Androgen Deprivation Therapy For Prostate Cancer Can Cause Osteoporosis

Androgen deprivation therapy is a common and effective treatment for advanced prostate cancer. However, among other side-effects, it can cause significant bone thinning in men on long-term treatment.

A new study¹ by Vahakn Shahinian and Yong-Fang Kuo from the Universities of Michigan and Texas respectively, finds that although bone mineral density testing is carried out on some men receiving this therapy, it is not routine. They did note, however, that men were significantly more likely to be tested when they were being cared for by both a urologist and a primary care physician. Their paper² appears in the Journal of General Internal Medicine, published by Springer.

Androgen deprivation therapy cuts off the production of testosterone by the male testes. This prolongs the life of men with advanced prostate cancer, often by years. However, the therapy can cause osteoporosis which carries an increased risk of fracture. There are treatments available which can help reduce the extent of osteoporosis suffered. Despite recommendations for bone mineral density testing being incorporated into practice guidelines in 2002, it still does not seem to be carried out frequently enough.

In order to ascertain current levels of testing, the researchers looked at the medical records of over 80,000 men with prostate cancer in a Medicare claims database between 1996 and 2008. Although they noted that the levels of bone mineral density testing had increased over those years, only just over 11 percent of men received a test for osteoporosis in the last year studied.

According to the authors, "The absolute rates of bone mineral density testing remain low, but are higher in men who have a primary care physician involved in their care." Levels of testing were lowest in men being cared for by just a urologist alone.

The authors emphasize that bone care is not within the usual remit of most urologists and, as such, may be outside their comfort zone for diagnosis and management. Urologists are not alone in this, though, as breast and colorectal cancer patients also tend to fare better with the involvement of a primary care physician in addition to their oncologist.

It would therefore appear important to derive a system whereby primary care physicians remain involved in the care of men with prostate cancer. In addition, urologists need to be made more aware of the risk to bones and men starting androgen deprivation therapy need to know to ask about the test.

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Broken Bones Mended With Stem Cells And Plastic

New bone tissue grown from patients' own stem cells that attach themselves to an implanted, rigid lightweight plastic "scaffolding" which gradually degrades and is replaced as new bone grows, could soon be healing shattered limbs, according to a new research report.

The degradable polymer material is the result of a seven-year collaboration between the Universities of Southampton and Edinburgh. The researchers report their work in a paper published in the journal Advanced Functional Materials.

In their background information they note how bone tissue regeneration is often needed after trauma, where "substantial bone or cartilage loss may be encountered", and this drives researchers to develop new biomaterials, especially those that can form a 3D structure.

Their new material is "strong enough to replace bone and is also a suitable surface upon which to grow new bone," says study author Mark Bradley, a professor in the University of Edinburgh's School of Chemistry, in a statement.

Using what the statement describes as a "pioneering technique", Bradley and colleagues created and experimented with hundreds of candidates before settling on a material that was robust, lightweight, and able to support bone stem cells.

The new technique, called "solvent blending", is a process that "avoids complications associated with conventional thermal or mechanical polymer blending or synthesis, opening up large areas of chemical and physical space, while potentially simplifying regulatory pathways towards in vivo application," they write.

The material they finally settled on is a polymer blend of three types of manmade and natural plastics and can be inserted into broken bones to encourage real bone to re-grow.

The polymer blend is like a scaffold made of honeycomb that allows blood to flow through it. Stem cells from the patient's bone marrow that are in the blood attach themselves to the scaffold and grow new bone tissue.

As time goes on, the material degrades, allowing the re-grown bone to replace it.

The researchers have already tested it in the lab and in animals, and are now looking to move into human clinical testing.

Bradley says:

"We are confident that this material could soon be helping to improve the quality of life for patients with severe bone injuries, and will help maintain the health of an ageing population."

His colleague and co-author Richard Oreffo, Professor of Musculoskeletal Science at the University of Southampton, says:

"Fractures and bone loss due to trauma or disease are a significant clinical and socioeconomic problem. This collaboration between chemistry and medicine has identified unique candidate materials that support human bone stem cell growth and allow bone formation. Our collaborative strategy offers significant therapeutic implications."

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Prices For Hip Replacement In US Vary Hugely

A study that used "secret shopper" techniques to find out the price of a hip replacement in hospitals across the US finds a huge variation in price, by as much as a factor of ten, with many hospitals contacted not able to give an estimated price.

Reporting in the 11 Feburary online issue of JAMA Internal Medicine, researchers at the University of Iowa (UI) Health Care and Iowa City VA Medical Center say their findings highlight the difficulties American consumers face when trying to obtain prices for a common surgical procedure.

Consumers can get their hands on information about hospital quality reasonably easily in the US, but information on pricing is much harder to come by, according to the study, which suggests efforts to achieve greater transparency in pricing have largely been ineffective.

Lead author Jaime Rosenthal says in a statement:

"There have been many initiatives to increase pricing transparency, including state and federal laws, and still many hospitals are unable to provide price information for a common procedure."

Rosenthal, currently a senior at Washington University in St. Louis, conducted the research as a summer project at UI Carver College of Medicine.

For their study, the researchers randomly selected two hospitals from each state of the US, plus the District of Columbia, that performed total hip replacements. They also included 20 top orthopedic hospitals from the U.S. News & World Report rankings.

To find out what the hospitals would charge, Rosenthal pretended to be enquiring on behalf of a fictitious patient, a 62-year-old grandmother with no health insurance who would be paying for the procedure herself.

Rosenthal asked each hospital to provide the lowest "complete" price (that is physician plus hospital fees) for an elective total hip replacement.

When the hospital was only able to give an estimate for the hospital fee and not the physician fee, the researchers contacted an orthopedic surgery affiliated to the hospital to get an estimate of the physician fee.

The researchers contacted each hospital up to five times to get a quote.

The results show that 40% of the top-ranked orthopedic hospitals and 36% of those not in the top rankings were not able to provide an estimated price for a total hip replacement.

Plus, of those that could give an estimate, there was a tenfold difference between the lowest at $11,100 and the highest at $125,798.

Rosenthal describes the variation as "striking", particularly as they "tried to give each hospital identical information in terms of what the procedure would require".

Only 9 of the 20 top-ranked hospitals (45%) and 10 of the ones not in the top ranking (10%) were able to give a completed bundled price for the procedure.

The researchers were able to compile complete prices for another 3 top-ranked (15%) and 54 non-top-ranked (53%) by contacting the hospitals and the affiliated physician surgeries separately.

Putting these results together, the complete price ranged from $12,500 to $105,000 at top-ranked hospitals and from $11,100 to $125,798 at non- top-ranked hospitals.

The researchers couldn't find any specific hospital characteristics or reasons for why the higher prices were higher and the lower ones were lower, although they concede that their study only sampled a small number of hospitals.

Senior author Peter Cram, UI associate professor of internal medicine and director of the Division of General Internal Medicine, says:

"A big finding was the absolutely huge variation in price estimates."

"We believe that our results highlight the reality that hospitals have a very hard time knowing their own prices," he adds.

Rosenthal says the huge range in prices that they found suggests a "savvy" consumer would be able to shop around and make some significant savings.

"Our study suggests that it is important for consumers to ask for information about the cost of medical care and procedures and to be persistent," urges Rosenthal, adding that the message for policy makers and hospital managers is that they have a long way to go to improve their pricing transparency.

In an accompanying invited commentary, policy researchers Andrew Steinmetz and Ezekiel Emanuel of the University of Pennsylvania in Philadelphia, liken the current state of the US healthcare system to that of the retail car industry in the 1950s, where prices varied hugely among dealers, depending on what "exorbitant" charges were added for shipping, "preparation fees", and other spurious reasons without the buyer's knowledge.

"There is no justification for the inability to report a fee estimate, or a 12-fold price variation for a common elective procedure like a hip replacement," they write, predicting that eventually, healthcare providers will be travelling down the same path as the one car dealers were forced to take, with federal laws brought in to get them to disclose full pricing information.

Funds from the National Institutes of Health helped pay for the study.

In November 2012, a surgeon with the Loyola University Health System described using a new hip replacement strategy, an anterior approach technique, that allows the patient to experience less pain, have a quicker recovery, and improved mobility.

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What Is Inflammation? What Causes Inflammation?

Inflammation is the body's attempt at self-protection; the aim being to remove harmful stimuli, including damaged cells, irritants, or pathogens - and begin the healing process.

When something harmful or irritating affects a part of our body, there is a biological response to try to remove it, the signs and symptoms of inflammation, specifically acute inflammation, show that the body is trying to heal itself. Inflammation does not mean infection, even when an infection causes inflammation. Infection is caused by a bacterium, virus or fungus, while inflammation is the body's response to it.

The word inflammation comes from the Latin "inflammo", meaning "I set alight, I ignite".

Inflammation is part of the body's immune response. Initially, it is beneficial when, for example, your knee sustains a blow and tissues need care and protection. However, sometimes inflammation can cause further inflammation; it can become self-perpetuating. More inflammation is created in response to the existing inflammation.

According to Medilexicon's medical dictionary, Inflammation is:

"A fundamental pathologic process consisting of a dynamic complex of histologically apparent cytologic changes, cellular infiltration, and mediator release that occurs in the affected blood vessels and adjacent tissues in response to an injury or abnormal stimulation caused by a physical, chemical, or biologic agent, including the local reactions and resulting morphologic changes; the destruction or removal of the injurious material; and the responses that lead to repair and healing.

The so-called cardinal signs of inflammation are rubor, redness; calor, heat (or warmth); tumor, swelling; and dolor, pain; a fifth sign, functio laesa, inhibited or lost function, is sometimes added. All these signs may be observed in certain instances, but none is necessarily always present."

Plaque in coronary artery disease linked to inflammation - scientists from Stanford University, California, linked 25 new genetic regions to coronary artery disease. They found that people with coronary artery disease, the leading cause of death globally, are most likely predisposed to the disease because they have gene variants linked to inflammation.

Inflammation helps wounds heal

Our immediate reaction to a swelling is to try to bring it down. Bearing in mind that inflammation is an essential part of the body's attempt to heal itself, patients and doctors need to be sure that the treatments to reduce swelling are absolutely necessary and to not undermine or slow down the healing process.

The first stage of inflammation is often called irritation, which then becomes inflammation - the immediate healing process. Inflammation is followed by suppuration (discharging of pus). Then there is the granulation stage, the formation in wounds of tiny, rounded masses of tissue during healing. Inflammation is part of a complex biological response to harmful stimuli. Without inflammation, infections and wounds would never heal.

Neuroscientists at the Lerner Research Institute at the Cleveland Clinic in Ohio found that inflammation actually helps to heal damaged muscle tissue. Their findings clash with how sportspeople with inflammation are treated - health professionals always try to control the inflammation to encourage healing. The researchers say their findings may lead to new therapies for acute muscle injuries caused by freeze damage, medications, chemicals and trauma.

Lan Zhou, M.D., Ph.D., said that patients should be very closely monitored when therapies to combat inflammation are used to make sure that the benefits of inflammation are not completely eliminated.

Inflammation is part of our innate immunity

Our innate immunity is what is naturally present in our bodies when we are born, and not the adaptive immunity we get after an infection or vaccination. Innate immunity is generally non-specific, while adaptive immunity is specific to one pathogen:

Whooping cough vaccine - example of immunity being specific to one pathogen

After being vaccinated for whooping cough (pertussis), we develop immunity to Bordetella pertussis or Bordetella parapertussis, types of bacteria that cause pertussis. This is an example of adaptive immunity - the immunity was not there before receiving the vaccine.

Inflammation is seen as a mechanism of innate immunity.

What is the difference between chronic inflammation and acute inflammation?

Acute inflammation - starts rapidly (rapid onset) and quickly becomes severe. Signs and symptoms are only present for a few days, but in some cases may persist for a few weeks.

Examples of diseases, conditions, and situations which can result in acute inflammation include: acute bronchitis, infected ingrown toenail, sore throat from a cold or flu, a scratch/cut on the skin, exercise (especially intense training), acute appendicitis, acute dermatitis, acute tonsillitis, acute infective meningitis, acute sinusitis, or a blow.

Chronic inflammation - this means long-term inflammation, which can last for several months and even years. It can result from:

• Failure to eliminate whatever was causing an acute inflammation
• An autoimmune response to a self antigen - the immune system attacks healthy tissue, mistaking it (them) for harmful pathogens.
• A chronic irritant of low intensity that persists

Examples of diseases and conditions with chronic inflammation include: asthma, chronic peptic ulcer, tuberculosis, rheumatoid arthritis, chronic periodontitis, ulcerative colitis and Crohn's disease, chronic sinusitis, and chronic active hepatitis (there are many more).

Our infections, wounds and any damage to tissue would never health without inflammation - tissue would become more and more damaged and the body, or any organism, would eventually perish.

However, chronic inflammation can eventually cause several diseases and conditions, including some cancers, rheumatoid arthritis, atherosclerosis, periodontitis, and hay fever. Inflammation needs to be well regulated.

What happens during acute inflammation?

Within a few seconds or minutes after tissue is injured, acute inflammation starts to occur. The damage may be a physical one, or might be caused by an immune response.

Three main processes occur before and during acute inflammation:

• Arterioles, small branches of arteries that lead to capillaries that supply blood to the damaged region dilate, resulting in increased blood flow


• The capillaries become more permeable, so fluid and blood proteins can move into interstitial spaces (spaces between tissues).


• Neutrophils, and possibly some macrophages migrate out of the capillaries and venules (small veins that go from a capillary to a vein) and move into interstitial spaces. A neutrophil is a type of granulocyte (white blood cell), it is filled with tiny sacs which contain enzymes that digest microorganisms. Macrophages are also a type of white blood cells that ingests foreign material.
  
  Klaus Ley, M.D., a scientist at the La Jolla Institute for Allergy & Immunology, reported in a study published in Nature that neutrophils are the human body's first line of defense; they are the main cells that protect us from bacterial infections. Their protective function is a positive one, however, they also have inflammatory properties that may eventually lead to heart disease and several autoimmune diseases, such as lupus. Effectively manipulating neutrophils is vital in disrupting inflammatory diseases.

When our skin is scratched (and the skin is not broken), one may see a pale red line. Soon the area around that scratch goes red, this is because the arterioles have dilated and the capillaries have filled up with blood and become more permeable, allowing fluid and blood proteins to move into the space between tissues.

Edema - the area then swells as further fluid builds up in the interstitial spaces.

The five cardinal signs of acute inflammation - "PRISH"

An ingrown toenail with the five PRISH signs; pain, redness, immobility, swelling and heat



• Pain - the inflamed area is likely to be painful, especially when touched. Chemicals that stimulate nerve endings are released, making the area much more sensitive.
• Redness - this is because the capillaries are filled up with more blood than usual
• Immobility - there may be some loss of function
• Swelling - caused by an accumulation of fluid
• Heat - as with the reason for the redness, more blood in the affected area makes it feel hot to the touch

The five classical signs of inflammation

Although Latin terms are still used widely in Western medicine, local language terms, such as English, are taking over. PRISH is a more modern acronym which refers to the signs of inflammation. The traditional Latin based terms have been around for two thousand years:

• Dolor - Latin term for "pain"
• Calor - Latin term for "heat"
• Rubor - which in Latin means "redness"
• Tumor - a Latin term for "swelling"
• Functio laesa - which in Latin means "injured function", which can also mean loss of function

Dolor, Calor, Rubor, and Tumor were first described and documented by Aulus Cornelius Celsus (ca 25 BC-ca 50), a Roman encyclopaedist. Celcius is famous for creating De Medicina, which is thought to be the only surviving section of a vast encyclopedia. De Medicina was the main source of medical reference in the Roman world for pharmacy, surgery, diet and some other medical fields.

Functio laesa - it is not clear who first described and documented the fifth sign. The majority of attributions have gone to Thomas Sydenham (1624-1689) an English physician and Rudolph Carl Virchow (1821-1902), a German doctor, biologist, politician and pathologist. Virchow is seen as one of the founders of social medicine.

These five acute inflammation signs are only relevant when the affected area is on or very close to the skin. When inflammation occurs deep inside the body, such as an internal organ, only some of the signs may be detectable. Some internal organs may not have sensory nerve endings nearby, so there is be no pain, as is the case with some types of pneumonia (acute inflammation of the lung). If the inflammation from pneumonia pushes against the parietal pleura (inner lining of the surface of the chest wall), then there is pain.

Acute and chronic inflammation compared

The lists below show the difference between chronic and acute inflammation regarding the causative agents, which major cells are involved, features regarding onset, duration, and outcomes:

Acute Inflammation

• Causative agents - harmful bacteria or injury to tissue
• Major cells involved - mainly neutrophils, basophils (in the inflammatory response), and eosinophils (response to parasites and worms), and mononuclear cells (macrophages, monocytes)
• Primary mediators - eicosanoids, vasoactive amines
• Onset (when does the inflammation start) - straight away
• Duration - short-lived, only a few days
• Outcomes - the inflammation either gets better (resolution), develops into an abscess, or becomes a chronic inflammation

Chronic inflammation

• Causative agent - non-degradable pathogens that cause persistent inflammation, infection with some types of viruses, persistent foreign bodies, overactive immune system reactions
• Major cells involved - Macrophages, lymphocytes, plasma cells (these three are mononuclear cells), and fibroblasts
• Primary mediators - reactive oxygen species, hydrolytic enzymes, IFN-γ and other cytokines, growth factors
• Duration - from several months to years
• Outcomes - the destruction of tissue, thickening and scarring of connective tissue (fibrosis), death of cells or tissues (necrosis)

Sleep quality and duration impacts on inflammation risk

Scientists at Emory University School of Medicine in Atlanta, Georgia, found in a study that sleep deprivation or poor sleep quality raise inflammation, which in turn increase the risk of developing heart disease and stroke.

The team gathered data on 525 middle-aged volunteers who had completed the Pittsburgh Sleep Quality Index (PSQI) questionnaire, which asked detailed questions about sleep quality and duration.

They tested the participants' levels of various inflammatory markers, and then tried to see whether they could link them to quality and duration of sleep. The authors concluded:

"The researchers concluded that: "Poor sleep quality, and short sleep durations are associated with higher levels of inflammation."

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Simple, Inexpensive Way To Improve Healing After Massive Bone Loss Could Help With Battlefield Injuries

Bones are resilient and heal well after most fractures. But in cases of traumatic injury, in which big pieces of bone are missing, healing is much more difficult, if not impossible. These so-called "large segmental defects" are a major clinical problem, and orthopaedic surgeons struggle to treat them, especially among the military in places like Afghanistan.

Now research led by investigators at Beth Israel Deaconess Medical Center (BIDMC) offers surgeons a new approach. Described on-line in today's issue of the Journal of Bone and Joint Surgery, the results confirm that the bone healing process of large segmental defects is exquisitely sensitive to its mechanical environment and suggests that "reverse dynamization," a straightforward and inexpensive process, could help speed healing of these traumatic injuries.

"Bones are greatly influenced by their mechanical environment, which is why casts, rods, plates and screws are typically used to heal fractures - with a great deal of success," explains senior author Christopher Evans PhD, Director of the Center for Advanced Orthopaedic Studies at BIDMC. "But until now, no one has examined the relevance of the mechanical environment to the healing of large segmental bone defects."

According to the American Association of Orthopaedic Surgeons (AAOS), these injuries are one of the most demanding surgical challenges faced by orthopaedic trauma surgeons. Often as large as 20 centimeters in length, large segmental defects can be complicated by regional soft-tissue loss, reduced vascularity, regional scarring and infection. The AAOS notes that an increased number of missions being conducted on foot in Afghanistan has led to an increase in this type of combat blast injury.

Changing levels of stiffness during bone healing is known as "dynamization." During standard dynamization, bone is first held rigidly in place by a mechanical intervention, or fixation device. Once healing has begun, the stiff rigidity is loosened to allow movement. "An 'external fixator' is placed on the outside of the skin and usually has a 'cross-bar' that determines the level of rigidity and can be adjusted to allow more or less motion," explains Evans, who is also the Maurice Edmond Mueller Professor of Orthopaedic Surgery at Harvard Medical School. Evans and his colleagues thought that how firmly or loosely injured bone is held together by mechanical interventions - casts, rods, plates and screws - could impact these large segmental bone defects, just as it does for more minor fractures - but with one big difference. The scientists changed stiffness levels in the opposite order - hence, "reverse dynamization."

"Our laboratory has a lot of experience with a rat model of segmental defect healing, and we noticed that during the healing process, the defect first fills with cartilage, and then the cartilage turns to bone," says Evans. Technically known as "endochondral ossification" this process is well documented to occur in fracture healing. 'We knew from other previous work that the early formation of cartilage is helped when mechanical fixation is loose. We also knew that a subsequent increase in fixator stiffness would provide the rigidity needed for the ingrowth of blood vessels and other aspects of healing." Evans and his coauthors hypothesized that a period of loose "fixation" followed by a period of stiffened "fixation" would accelerate healing of large segmental defects. "If bones are allowed to move slightly, cartilage will form in the defect," he adds. "If the area is then held rigidly in place, the new cartilage will then turn to bone."

The team constructed external fixators capable of providing varying degrees of stiffness during the healing process. By implanting a growth factor called bone morphogenetic protein-2 on a collagen sponge, the scientists initiated healing of segmental defects in the femurs of 60 rats. Groups of the animals were then allowed to heal with either low-, medium-, or high-stiffness fixators. Healing also took place under conditions of reverse dynamization, in which the stiffness levels were changed from low to high after a period of two weeks. After eight weeks, the researchers assessed healing using various measures including radiographs, microscopic analyses, and mechanical tests.

The investigators found that when they looked only at unchanging stiffness, the low-stiffness fixator produced the best healing; however, by comparison, the reverse dynamization provided considerable improvement, leading to a marked acceleration in the healing process by all tests. Also, notes Evans, the bone mineral content and bone area of the defects healed by reverse dynamization were closer to normal, and the healed bone had greater mechanical strength.

"Our study confirms the exquisite sensitivity of bone healing to its mechanical environment," he notes. The next step, says Evans, will be to see if this therapy works in large animals, while also gathering more information about the biological mechanisms that are at play. But, he adds, moving these findings into a clinical setting should be relatively straightforward. "The nice thing about this approach is that it's simple and could be rapidly translated to human use if our proposed large-animal studies are successful. The regulatory hurdles should be minor." Furthermore, he adds, reverse dynamization might also be applicable to other situations for which bone healing is problematic. "Sometimes in smokers or individuals with diabetes, fractures heal poorly," he notes, adding that the same can be true when an infection is present.

Reverse dynamization is also an attractive option in terms of cost. "Often, strategies devised in the lab to solve clinical problems are far too complex and expensive to be translated into meaningful clinical use," notes study coauthor Mark Vrahas, MD, Chief of the Harvard Orthopaedic Trauma Service. "But if the promise of this strategy holds out, it will be inexpensive enough to be used even in developing countries, where the burden of severe injuries are particularly high."

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Chocolate 'Causes Weak Bones'

"Eating chocolate could lead to weaker bones," reported the Daily Express today. The Daily Telegraph also covered a new study that has shown that women who ate chocolate every day had less dense bones than those who ate it less than once a week. The Daily Mail quotes the lead researcher as saying, "These findings could have important implications for prevention of osteoporotic fracture."

The research behind this claim is a cross-sectional study, which by virtue of its design, cannot prove that chocolate consumption causes low bone density in women. Other diet, lifestyle, or environmental factors could have caused the decreased bone density. This finding was also only in women over 70 and so cannot apply to younger women or men. Studies with more robust designs would be needed to confirm this association.

Where did the story come from?

Dr Jonathan Hodgson and colleagues from the Royal Perth Hospital Unit carried out the research. The study was supported by a research grant from Healthway Health Promotion Foundation of Western Australia and from the National Health and Medical Research Council of Australia. The study was published in the : American Journal of Clinical Nutrition.

What kind of scientific study was this?

The study was a cross-sectional study of Australian women aged over 70 who had participated in a five-year randomised controlled trial of calcium supplementation to prevent osteoporotic fractures. For this latest publication, the authors looked at the data available on women's chocolate consumption and bone density measurements at the end of the original study (i.e. at five years).

Although 1,460 women were included in the original study, only 1,001 were included in this cross-sectional study. This was primarily because the researchers excluded women who were not able to walk. The women's chocolate intake and overall diet (including beverages) was assessed through a questionnaire. Bone density and strength measurements were made using three different imaging techniques (ultrasound, computed tomography, X-ray absorptiometry) at three different body sites (the heel, the shin and the hip).

The researchers then used statistical methods to explore whether there was a link between total chocolate intake (including solid chocolate and "chocolate containing beverages") and bone density and strength. In their analysis, they took into account other factors that may affect this relationship, including age, BMI, smoking status, physical activity, and other dietary factors.

What were the results of the study?

Increased chocolate consumption was associated with lower mean bone density at all the measured sites. When the researchers took into account other factors, such as age, BMI and lifestyle, that could potentially affect this relationship, they found that some of these relationships (e.g. when bone density and strength were measured in the shin) were no longer significant.

What interpretations did the researchers draw from these results?

The researchers conclude that this is the first study to investigate the relationship between chocolate intake and bone structural measurements. They say that although further studies are needed to confirm the findings, their study raises concerns that frequent chocolate consumption may increase the risk of osteoporosis and bone fracture.

What does the NHS Knowledge Service make of this study?

This study has weaknesses that are due to the nature of the study design. The authors themselves say that "additional cross-sectional and longitudinal studies are needed to confirm these observations".

- Although the study took into account the effects of some factors that could influence the association, there are likely to be others that were not considered. On this point, the researchers say that it is possible that chocolate is a surrogate for some other factor (diet, lifestyle, or environmental) which was not considered or was measured inadequately and therefore chocolate may not be responsible for the observed relation.

- The researchers excluded about 200 women who were not able to walk. This would have introduced a bias if those women had different patterns of chocolate intake and bone density than those who were included. - The consumption of solid chocolate and "chocolate containing beverages" was combined in their measure of chocolate intake. The study then was not only about "eating" chocolate as the papers have imply.

- The researchers analysed chocolate consumption at one time point (at five years). Although the researchers assessed the persistence of chocolate intake (by comparing intake at year one and year five), they did not use this figure in their analyses. They also did not assess this for "chocolate containing beverages".

- The study was in women aged over 70 and the findings will not apply to younger women (premenopausal or not) or to men.

Until prospective studies confirm a harmful link between chocolate consumption and bone health, women should not be unduly concerned by the results of this study. Because of its high fat and sugar content, chocolate should be consumed in sensible amounts.

Links to the headlines

Eating chocolate could give you weaker bones. The Daily Telegraph
Can a daily bar of chocolate cause brittle-bone disease? Daily Mail

Links to the science

Chocolate consumption and bone density in older women.

This news comes from NHS Choices

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Essentials Of Orthopaedic Nurse Care

Orthopaedic Nursing

An orthopaedic nurse is a specialty nurse trained in orthopaedic problems such as fractures and is an expert in neurovascular status monitoring, traction, casting and continuous motion therapy. More than 350,000 hip fractures occur in the United States every year (Watters, 2006). Nurses' skills, interventions, attitudes, communication and continuity of care constitute the essential components of orthopaedic nurse care .

Patient satisfaction measures assist nurses in the evaluation of effectiveness of their practice and assist the process of improvement of established orthopaedic practice methods (Wu et.al, 2000). Technical advances in the field of orthopaedics like Radiography, Computed Tomography, and Magnetic Resonance Imaging have not only led to improved diagnosis and evaluation of orthopaedic diagnosis but also innovative treatment options like Vertebroplasty, Bupivacaine Infiltration, Total Disc Replacement Arthroplasty, Unicompartmental Knee Arthroplasty, The Titanium Rib, Toe-to-Hand Transplantation Surgery, The Scandinavian Total Ankle Replacement (STAR), Mechanical Devices for Lateral Transfers and Kyphoplasty. Thus, orthopaedic nurse should have the essential training and skills in the latest innovations in the field.

Nursing Skills and Interventions

Nursing intervention begins with the assessment of the patient after a traumatic event, determination of the mechanism of injury, assessment of the injured or fracture site, confirmation of the exact injury, identification of potential complications, and assessment of the patient's social and professional status to identify potential problems that might affect treatment and challenge and are important as a cause for morbidity and mortality (Kobziff, 2006).Fractures of the forearm in an adult may involve the ulna, the radius, or both and it is better to xray the entire upper extremity in most upper-limb injuries (Altizer, 2003).

Spinal cord injuries are devastating events, and they are particularly tragic when they affect children or adolescents (Vogel et.al, 2004).Nurses should provide interventions preoperatively, intraoperatively, and postoperatively to avoid potential complications (Harvey, 2005).Preoperative interventions include a thorough assessment of the patient history and screen for hypertension or other problems in order to avoid possible intraoperative and postoperative complications. Intraoperative interventions include insertion of a urinary catheter, prophylactic administration of antibiotics and inflammation of tourniquets. Postoperative care is equally important at the surgery itself. An effective postoperative nurse care can decrease the patient's pain and decrease vasospasm in replantation surgeries ( Michalko and Bentz, 2002 ).


Compartment syndrome is a common complication in fracture, sprain, or orthopaedic surgery. Early identification of the symptoms can prevent the loss of a limb (Altizer, 2004).Pulse oximetry provides one of the best objective ways to monitor arterial blood flow. Patient monitoring is done hourly during the first 24 hours and then every 2 hours during the second 24-hour period after a surgery. This intense monitoring frequently is done in the ICU. Antibiotic chemotherapy is usually recommended for 5 days, but is always determined by the wound intensity. Bed rest minimizes vasospasm. Intake of chocolate, caffeine, and nicotine in any form is strictly prohibited in the postoperative period to avoid induction of vasospasm that could impede blood flow. Patient-controlled analgesia (PCA) has been recommended for pain relief with relatively few side effects. But, IV PCA has been shown to cause respiratory depression (Brubakken and Shippee, 2004). Continuous low-dose infiltration of a local anesthetic into the postoperative wound incision for a 48-hour period has been shown to diminish the need for narcotics or other analgesics to reduce postoperative pain (Pulido et.al, 2002). The use of a mechanical device for the lateral transfer has been shown to give comfort to the patients (Pellino et.al, 2006).

Though most patients treated with casts do not have any significant orthopaedic problems, it is important to emphasize cast care instructions to young patients and their parents to alleviate itching, such as blowing cool air under the cast to reduce the risk of serious infectious complications (Carmichael, 2006).Tracking outcomes of interventions provides a systematic method of monitoring effectiveness and efficiency. The nurse should evaluate and choose appropriate measurement tools, and understand the clinical meaning of measurements to successfully employ these instruments (Resnik and Dobrykowski, 2005).

Nurse attitudes

Attitudes of nurses caring for orthopaedic patients affect the quality of care provided. A recent research on positive and negative attitudes of such nurses has shown that knowledge deficits shape most of the negative attitudes (Mary et.al, 2000). The cultural background of nurses also has an influence on the attitudes and there are reports of nurse's disagreements with patient's self-report, especially in pain assessment (Harper et.al, 2007).

Communication

Patient education is a critical component of orthopaedic nursing that requires nurse communication to maintain optimum independence and quality of life (Oldaker, 1992). A randomized controlled trial study with sixty six young adolescents to evaluate the effects of coping instruction and concrete-objective information on adolescents' postoperative pain and focus on potential applications of these interventions for orthopaedic nursing practice has shown that nurse interventions that direct adolescent patients' attention to learning coping strategies reduce the postoperative pain in such patients (LaMontagne et.al, 2003). The gender, age and health condition also influences the communication. For example, it is difficult to communicate to or assess an old patient whose 'hearing capacity would be at a reasonably low level or whose perception has diminished due to aging. Nonverbal verbal communications do occur in nurse-patient communication. (Wilma, 1999).

Continuity of care

It may take several months of intense physical or occupational therapy for the patients to regain optimal function, especially after complicated orthopaedic surgical procedures like toe-tohand transplants. In such surgical procedures progressive joint mobilization, usually begins on the seventh to tenth postoperative day and Progressive resistive exercises are begun 4 weeks later to increase strength.

A recent conference convened to explore the strengths and weakness of the current continuum of care, develop recommendations for addressing problems in the system, and devise strategies for implementing the recommendations has brought out recommendations in four broad categories: Communication/Continuum of Care, Reimbursement, Prevention/Education, and Research Initiatives. A study examining the risk factors for falls and the effectiveness of physical therapy interventions to decrease the risk of falls in a community dwelling population has shown that an appropriately designed physical therapy intervention in the form of an exercise program can decrease the risk for falls among a community-dwelling aging population identified as having an increased risk of falls (Robinson et.al, 2002). Massage therapy has been shown to be safe and effective for orthopaedic patients with low back problems and potentially beneficial for patients with other orthopaedic problems. Massage therapy appears to be safe, to have high patient satisfaction, and to reduce pain and dysfunction (Dryden et.al, 2004).

Conclusion

There is a critical need to incorporate the use of latest technological innovations like guided imagery (Antall and Kresevic, 2004) and bone morphogenetic proteins (Boden, 2005) into all nursing curricula to improve the skills, interventions, communication and attitudes of orthopaedic nurses so that nurses can develop the expertise to act as patient educators and advocates in the use of these interventions. Early identification of the care problem is vital in orthopaedic nursing.

References

-- Carmichael, Kelly D.; Goucher, Nicholas R. (2006). Orthopaedic Essentials. Orthopaedic Nursing. 25(2):137- 139.

-- Carol V. Harvey (2005). Spinal Surgery Patient Care. Orthopaedic Nursing. 24 (6). 426 - 440.

-- Cindy Pfeiff (2006). The Scandinavian Total Ankle Replacement (STAR). Orthopaedic Nursing.25 (1):30 - 33.

-- Courtney, Mary, Tong, Shilu, Walsh, Anne (2000). Acute-care nurses' attitudes towards older patients: A literature review. International Journal of Nursing Practice. 6(2):62-69.

-- Elwin R. Tilson et .al (2006). An Overview of Radiography, Computed Tomography, and Magnetic Resonance Imaging in the Diagnosis of Lumbar Spine Pathology. Orthopaedic Nursing.25 (6): 415 - 420

-- Gloria F. Antall (2004). The Use of Guided Imagery to Manage Pain in an Elderly Orthopaedic Population. Orthopaedic Nursing. 23(5): 335 - 340.

-- Harper, Phil, Ersser, Steven and Gobbi, Mary (2007) How military nurses rationalize their postoperative pain assessment decisions. Journal of Advanced Nursing, 59, (6), 601-611.

-- Heather Chong (2004). Innovations: The Titanium Rib: Creating Room to Grow. Orthopaedic Nursing. 23(5): 348 - 349.

-- Jim Hanna et.al (2007). Kyphoplasty: A Treatment for Osteoporotic Vertebral Compression Fractures. Orthopaedic Nursing.26 (6):342 - 346.

-- Julie Hummer-Bellmyer (2002). The Collaborative Role of the Perioperative Nurse Practitioner in Assessing Perioperative Patients. Orthopaedic Nursing. 21(1): 29- 44.

-- Kathleen A. Gross (2002). Vertebroplasty A New Therapeutic Option. Orthopaedic Nursing. 21(1): 23-29.

-- LaMontagne, Lynda; Hepworth, Joseph T.; Salisbury, Michele H.; Cohen, Frances. Effects of Coping Instruction in Reducing Young Adolescents' Pain after Major Spinal Surgery. Orthopaedic Nursing. 22(6):398- 403.

-- Linda Altizer (2003). Forearm and Humeral Fractures. Orthopaedic Nursing. 22 (4): 266 - 273. Lawrence C. Vogel et.al (2004). Unique Issues in Pediatric Spinal Cord Injury. Orthopaedic Nursing. 23(5): 300-308.

-- Lydia Kobziff (2006). Traumatic Pelvic Fractures. Orthopaedic Nursing. 25(4):235 - 241.

-- Mary E. Hagle et.al (2004). Respiratory Depression in Adult Patients with Intravenous Patient-Controlled Analgesia. Orthopaedic Nursing. 23(1): 18-27.

-- Mary Faut Rodts (2004). Total Disc Replacement Arthroplasty. Orthopaedic Nursing. 23(3): 216-219.

-- Maryann Godshall (2006). Toe-to-Hand Transplantation Surgery. Orthopaedic Nursing. 25(1):13 - 19.

-- Watters CL, Moran WP (2006). Hip fractures--a joint effort. Orthop Nurs. 25(3):157-65.

-- Wilma M.C.M et.al (1999). Non Verbal behaviour in nurse elderly patient communication. Journal of Advanced Nursing 29: 808.

-- Wu ML, Courtney M, Berger G (2000). Models of nursing care: a comparative study of patient satisfaction on two orthopaedic wards in Brisbane. Aust J Adv Nurs.; 17(4):29-34.

Journal of Nursing

Journals belonging to the American Society of Registeres Nurses

The American Society of Registered Nurses (ASRN) was founded in May 2003 for the purpose of bringing together professional nurses interested in creating a nursing "society" which is defined as "A group of humans broadly distinguished from other groups by mutual interests, participation in characteristic relationships, shared institutions, and a common culture".

This new Society brings together nurses from all fields of inquiry, regions, and specializations both inside and outside academe in order to expand the study and practice of nursing, and offer support, resources, education, and distinction to its members. The Society serves nurses in all 50 states as well as across the globe.

ASRN represents a community for all nursing voices. We invite registered nurses, international professionals, and new graduates to discover ASRN. Our goal is to advance nursing as a science and profession.

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Achilles Tendon Surgery Advances Speed Recovery

Many Achilles tendon surgery patients are getting back on their feet faster, thanks to new procedures and techniques.

The introduction of tissue graft products, bone anchors, radio frequency treatments and new arthroscopic procedures provides patients with less invasive treatments and speedier recovery times. More than 1,000 foot and ankle surgeons are learning about the latest treatments and techniques for foot and ankle conditions at the American College of Foot and Ankle Surgeons (ACFAS) 66th Annual Scientific Conference in Long Beach this week.

"Whether it's getting back to work faster, or getting back to marathon training, these surgical advances will shorten recovery times for many types of patients," says Des Moines, Iowa foot and ankle surgeon Michael S. Lee, DPM, FACFAS. Lee serves on the ACFAS board of directors.

The Achilles tendon connects the calf muscle to the heel bone in the back of the leg and facilitates walking. The most common Achilles condition is tendonitis, an inflammation of the tendon. Most tendonitis cases can be successfully treated with non-surgical methods such as rest, ice, anti-inflammatory medications and physical therapy.

But some tendonitis patients develop scar tissue on the tendon, or their tendon fibers weaken and develop microscopic tears, a condition called Achilles tendonosis. Fixing these problems can require invasive surgery and weeks to months of recovery.

Recently-introduced radio frequency technology can slash recovery time for some patients by using radio waves to stimulate healing in the tendon. The procedure requires smaller incisions to insert the wand-like radio frequency device. Smaller incisions mean less damage to skin and muscle, less pain, and lower risk of surgical infections. Patients recover faster.

Overuse, especially in athletes, can cause the Achilles tendon to tighten and pull so hard on the heel bone that a bone spur, or bump, develops. Shoes can rub against the spur and cause pain. In addition, a painful fluid-filled sac called a bursa can develop between the heel bone and the tendon. Traditionally, correcting this tightness involved severing the tendon, removing the bone spur or bursa, and then reattaching the tendon.

New arthroscopic techniques can provide a minimally invasive option to removing bone spurs and bursas without significant damage to the Achilles tendon. When the tendon does have to be surgically detached, new bone anchor constructs (screws that are drilled into the heel bone to secure the tendon and tissues) can reattach the tendon, minimizing the chance of a potentially painful knot on the back of the heel.

Achilles tendon ruptures are the most serious Achilles injuries. Most patients require surgery to decrease the likelihood of a re-rupture. Various techniques are available, and increasingly may include tissue grafts used as a bridge to link the severed tendon lengths. The graft provides a scaffold on which new tissue grows, increases the overall strength of the repair, and is usually absorbed by the body within a year.

Go to the ACFAS consumer Web site, http://FootPhysicians.com, for more information on Achilles tendon conditions.

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Once-Yearly Reclast(R) Demonstrates Highly Significant Fracture Risk Reductions In The Treatment Of Postmenopausal Osteoporosis, New Study Shows

New Phase III data presented for the first time demonstrated that the investigational treatment Reclast(R)^ (zoledronic acid) 5 mg was highly effective in reducing the incidence of bone fracture in women with postmenopausal osteoporosis across the most common fracture sites -- hip, spine and non-spine^^ -- with sustained effect over three years.(1) Further data demonstrated that postmenopausal osteoporosis patients currently taking oral alendronate can be directly switched to Reclast and maintain beneficial bone effects for a full 12 months after a single dose.(2) These studies were presented today at the annual meeting of the American Society of Bone and Mineral Research (ASBMR) in Philadelphia.

Postmenopausal osteoporosis (osteoporosis) is a serious condition affecting millions of women worldwide.(3) An estimated one out of every two women over age 50 with osteoporosis will suffer an osteoporotic fracture in her lifetime.(4) Of those women age 65 years or older who fracture a hip, 21% will die within one year.(5) Reclast is the only once-yearly bisphosphonate treatment being studied for the treatment of osteoporosis.

An interim analysis encompassing 99% of the data from the now completed three-year HORIZON Pivotal Fracture Trial showed that patients treated with Reclast experienced a 70% risk reduction in new spine fractures (p<0.0001) and a 40% risk reduction in hip fractures (p=0.0032) over three years compared to placebo. This met the study's two primary endpoints. Additionally, the study met all secondary endpoints including risk reduction in clinical spine fractures and non-spine fractures.

In the study, the overall incidence of adverse events experienced with Reclast was comparable to placebo. The most common adverse events associated with Reclast were the following post-dose symptoms: fever, muscle pain, flu-like symptoms, headache, and bone pain, the majority of which occurred within the first three days following Reclast administration. The majority of these symptoms resolved within the first three days of the event onset. The incidence decreased markedly with subsequent doses of Reclast. Analysis of key safety parameters, including kidney and jaw safety, found Reclast to be comparable to placebo.(1)

"The efficacy and safety data show that for the first time women may have the option of a once yearly treatment for osteoporosis," stated Dr. Dennis Black, the study steering committee chair from University of California, San Francisco. "The results show that Reclast effectively protects women against fractures including those of the hip, which can be devastating."


Additional Phase III data presented at the meeting from a study of 225 women with osteoporosis demonstrated that patients treated with weekly Fosamax therapy can directly switch to Reclast. In the study, the beneficial effects of alendronate on bone mineral density levels in postmenopausal women were maintained for 12 months after a single infusion of Reclast, and, at 12 months, bone mineral density values for patients randomized to receive Reclast were similar to bone mineral density values for patients randomized to continued treatment with alendronate, meeting the study's primary endpoint. In patients taking Reclast, bone turnover remained within the normal pre-menopausal range at 12 months after an infusion.(2) The most common adverse events reported in this study were similar to those observed in the pivotal fracture trial.(1,2,6)

Furthermore, two separate studies of women being treated for osteoporosis have shown that a majority preferred a once-yearly infusion to a once-weekly pill.(7,8)

"We believe once-yearly Reclast may offer advantages for the millions of women suffering from osteoporosis and potentially provide the most comprehensive protection across the most common osteoporotic fracture sites," said James Shannon, MD, Global Head of Development at Novartis Pharma AG.

Reclast In Post-Menopausal Osteoporosis: Study Designs

The Health Outcomes and Reduced Incidence with Zoledronic acid Once yearly (HORIZON) Pivotal Fracture Trial is a multi-national, multi-center, randomized, placebo-controlled trial of 7,736 women. The study evaluated the potential of a once-yearly infusion of Reclast to decrease the risk of fracture in postmenopausal women with osteoporosis. Primary endpoints were incidence of new vertebral fractures and hip fractures at three years compared to placebo. All study participants received elemental calcium (1000 to 1500 mg per day) and vitamin D (400 to 1200 IU per day).

The second Phase III Reclast study presented at ASBMR investigated the safety and efficacy of treating patients with Reclast who were previously taking Fosamax. This randomized, double-blind, double-dummy, multi-center trial compared a single infusion of 5 mg Reclast vs. continuation of therapy with oral alendronate weekly for 52 weeks. The study included postmenopausal women with low bone mineral density (n=225). The women must have been treated with Fosamax for at least one year prior to randomization. The primary endpoint of the study was percent change in lumbar spine bone mineral density from baseline to one year.

About Reclast

Reclast is being studied worldwide in a series of multi-national and multi-center clinical trials program called HORIZON. This clinical development program studies a once-yearly dosing with Reclast for osteoporosis. It also includes studies in the prevention of clinical fractures following a hip fracture in men and women, male osteoporosis, corticosteroid-induced osteoporosis, prevention of osteoporosis, treatment of Paget's disease of the bone, and the treatment of osteogenesis imperfecta in children. Approximately 13,000 patients have participated in the ongoing HORIZON program in more than 400 trial centers worldwide. The HORIZON program is one of the most comprehensive drug evaluation programs ever undertaken in the area of metabolic bone diseases.

Zoledronic acid 5mg, under the brand name Aclasta(R), has been approved in approximately 50 countries worldwide, including the EU and Canada, for the treatment of Paget's disease. The U.S. Food and Drug Administration (FDA) issued an "approvable letter" for Reclast for the treatment of Paget's disease of the bone in February 2006. The FDA requested additional data from the ongoing clinical trial program in osteoporosis. Novartis is working with the FDA to gain approval for this indication. Zoledronic acid, the active ingredient of Reclast, is also available under the brand name Zometa(R) for use in other indications.

About Postmenopausal Osteoporosis

Postmenopausal osteoporosis (PMO) is a serious condition affecting millions of women worldwide. Osteoporosis currently affects an estimated 50.7 million people in the UK, France, Germany, Italy, Spain, the USA and Japan.(3) Incidence of hip fracture in women is projected to rise by 240% worldwide by 2050, as populations grow and age.(9)

Disclaimer

The foregoing release contains forward-looking statements that can be identified by the use of terminology such as "may," "believe," "potentially," "potential," or similar expressions, or by express or implied discussions regarding potential regulatory filings, approvals or future sales for Reclast. Such forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause actual results with Reclast to be materially different from any future results, performance or achievements expressed or implied by such statements. There is no guarantee that Reclast will be approved by the U.S. Food and Drug Administration or any other regulatory authority for any indication in any market. Neither can there be any guarantee regarding potential future sales of Reclast. In particular, management's ability to ensure satisfaction of any health authorities' requirements is not guaranteed and management's expectations regarding commercialization of Reclast could be affected by, among other things, unexpected regulatory actions or delays or government regulation generally; unexpected clinical trial results, including new clinical data and additional analysis of existing clinical data; the company's ability to obtain or maintain patent or other proprietary intellectual property protection; competition in general; government, industry and general public pricing pressures; and other risks and factors referred to in Novartis AG's current Form 20-F on file with the Securities and Exchange Commission of the United States. Should one or more of these risks or uncertainties materialize, or should underlying assumptions prove incorrect, actual results may vary materially from those anticipated, believed, estimated or expected. Novartis is providing the information in this press release as of this date and does not undertake any obligation to update any forward-looking statements contained in this press release as a result of new information, future events or otherwise.

About Novartis

Novartis Pharmaceuticals Corporation develops, manufactures, markets and sells leading innovative prescription drugs used to treat a number of diseases and conditions, including those in the cardiovascular, metabolic, cancer, organ transplantation, central nervous system, dermatological, gastrointestinal and respiratory areas. The company's mission is to improve people's lives by pioneering novel healthcare solutions.

Located in East Hanover, New Jersey, Novartis Pharmaceuticals

Corporation is an affiliate of Novartis AG (NYSE: NVS) -. a world leader in offering medicines to protect health, treat disease and improve well-being. Our goal is to discover, develop and successfully market innovative products to treat patients, ease suffering and enhance the quality of life. Novartis is the only company with leadership positions in both patented and generic pharmaceuticals. We are strengthening our medicine-based portfolio, which is focused on strategic growth platforms in innovation-driven pharmaceuticals, high-quality and low-cost generics and leading self-medication OTC brands. In 2005, the Group's businesses achieved net sales of USD 32.2 billion and net income of USD 6.1 billion. Approximately USD 4.8 billion was invested in R&D. Headquartered in Basel, Switzerland, Novartis Group companies employ approximately 91,000 people and operate in over 140 countries around the world. For more information, please visit http://www.novartis.com.

References

1. Black DM, et al. Effect of once-yearly infusion of Zoledronic Acid 5 mg on spine and hip fracture reduction in postmenopausal women with osteoporosis: the HORIZON pivotal fracture trial. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

2. McClung M, et al. Single infusion of zoledronic acid 5 mg provides sustained benefits in BMD and biomarkers at 12 months in postmenopausal women with low bone mineral density and prior alendronate therapy. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

3. Decision Resources Inc. -- Dbase 9; Kanis JA, 2000 & Melton LJ, 1995.

4. National Institutes of Health Osteoporosis and Related Bone Diseases -- National Resource Center. Osteoporosis Overview. Department of Health and Human Services. Available at http://www.niams.nih.gov/bone/hi/overview.htm.

5. US Congress, Office of Technology Assessment, Hip Fracture Outcomes in People Age 50 and Over -- Background Paper, OTA-BP-H-120 (Washington, DC: US Government Printing Office, July 1994).

6. Recker R, et al. Bone histomorphetry demonstrates normal bone remodelling in postmenopausal women with osteoporosis/osteopenia switched from oral alendronate to IV zoledronic acid. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

7. Lindsay R, et al. A single zoledronic acid 5 mg infusion is preferred over weekly 70 mg oral alendronate in a clinical trial of postmenopausal women with osteoporosis/osteopenia. Presented at Sixth European Congress on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ECCEO), 15-18 March 2006, Vienna, Austria.

8. Omizio M, et al. A single infusion is preferred to oral weekly treatment in post-menopausal women with low bone mineral density previously treated with alendronate. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

9. Gullberg B, et al. World-wide projections for hip fracture. Osteoporosis Int 1997; 7:407-13.

Novartis Pharmaceuticals Corporation
http://www.novartis.com

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The Strength Of Strontium Ranelate - Protects Bones For At Least Five Years, Remodels Bone Architecture

In previous clinical trials strontium ranelate has proven effective in preventing fractures for up to three years. But according to new data presented today at the IOF World Congress on Osteoporosis in Toronto, Canada that window of opportunity can now be extended to at least five years.

Jean-Yves Reginster, Professor of Epidemiology, Public Health and Health Economics at the University of Liege, Belgium, reported (see conference Abstract No. OC24) that in the phase III Spinal Osteoporosis Therapeutic Intervention (SOTI) trial, strontium ranelate reduced the risk of new vertebral fractures by about 30 percent over four years. In the Treatment Of Peripheral Osteoporosis (TROPOS) trial, which has been running a little longer, those taking the drug for five years had about a 25 percent reduction in vertebral fractures and a 15 percent reduction in non-vertebral fractures, such as those of the thigh. "These results demonstrate, uniquely for anti-osteoporotic treatments, that strontium ranelate provides sustained efficacy over five years against both vertebral and non-vertebral fractures," said Reginster.

Because other existing treatments have not demonstrated such robust effects in prospective, pre-planned, double-blind, placebo-controlled studies, postmenopausal osteoporotic women stand to benefit from the proven efficacy and tolerability of strontium treatment, according to Reginster.

In two other studies presented at the IOF WCO this week, Georges Boivin and colleagues at the INSERM, Universite Claude Bernard, Lyon, France and J. Yebin Jiang and colleagues at the University of California and the University of Michigan Osteoporosis and Arthritis Lab report on just how strontium ranelate contributes to bone strength.

Boivin (see conference Abstract No. P310) reported that strontium is incorporated into new bone but does not make its way into older bone, which remains virtually free of strontium even after three years of treatment. His findings, based on high resolution X-ray microanalysis, also suggests that strontium does not affect the quality of the bone mineral, but it does affect the quantity. "We believe that the microarchitecture of bone is improved in those taking strontium ranelate. It appears that the bone mass is increased with a normal degree of mineralization," said Boivin. The best way to think of this is to imagine bone as a tube filled with styrofoam packing. On strontium ranelate, the nature of the packing does not change, but the amount of packing and how it fits together does.

That theory is supported by the findings of Jiang and colleagues, who reported (see conference Abstract No. OC40) that strontium does, in fact, rearrange bone architecture. Bone is made up of two different types of structure, a spongier honeycomb core and a harder outside layer called cortical bone. Jiang reported that the bone making up the honeycomb appears as flatter, plate-like mineral in samples taken from patients treated with strontium ranelate, whereas in control samples the bone appears as rod-like structures. He also reported that the outer cortical bone becomes thicker. "The three-dimensional changes in trabecular and cortical bone may improve bone mechanical strength, explaining the decreased risk for fracture in those on strontium ranelate treatment," said Jiang.


Both groups obtained their data by analyzing biopsies taken from those enrolled in the TROPOS, SOTI and also the STRATOS phase II clinical trials for strontium ranelate. Boivin and colleagues used high resolution X-ray microradiography to determine the degree of mineralization of pelvic bone samples. Jiang and colleagues used a sophisticated micro computerized tomography scanner, better known as a micro CAT scanner, to measure the three-dimensional structure of the bone, also taken from the pelvis. Boivin compared 35 samples taken from patients treated with various doses of strontium ranelate, with 22 samples taken from those given placebo. Jiang and colleagues measured similar numbers of samples, 20 from the treatment group and 21 controls.

Bisphophonates - Medicine that Keeps on Giving

Boivin's findings also suggest that because strontium is laid down at the surface of newly formed bone mineral, it may be rapidly cleared from the bone once treatment is stopped. Bisphosphonates, on the other hand, are released only very slowly from bone and continue to appear in the urine for years after treatment is stopped according to researchers from the Netherlands (see conference Abstract No. OC25). The finding should caution against prescribing the drugs for young girls who suffer from osteoporosis or brittle bone disorders such as osteogenesis imperfecta.

Bisphosphonates are the most widely prescribed treatment for those with, or at risk for, osteoporosis. Like strontium, bisphosphonates are incorporated into bone where they stop the bone mineral from being dissolved away. They are known to be slowly released from bone but just how long they remain imbedded in the mineral is uncertain. However, at the IOF WCO, Socrates Papapoulos and colleagues at Leiden University, report that the bisphosphonate pamidronate can still be detected in urine eight years after treatment has stopped.

"Up to now it has been hypothesized in the literature that bisphosphonates trapped in the bone are slowly released once therapy is stopped, but now we show for the first time that that phenomenon is real," said Papapoulous.

The researchers tested urine samples from 6 children who had been given pamidronate for 4-10 years. Urinary measurements were taken up to 13 years after treatment was suspended. Pamidronate was measurable in urine of all patients except one, who had received treatment for 6 years, and drug was measured 13 years after stopping treatment.

The long half-life of bone bisphosphonates probably explains why osteoporotic women who have taken bisphosphonates for a long time have reduced bone mineral loss after stopping treatment. But there is a small cloud to this silver lining-"we need to be cautious about administering bisphosphonates to young girls because there is very little data on the effects of these drugs on embryonic development," said Papapoulous.

Combination Therapy Packs One-Two Punch

Silvano Adami, University of Verona, Italy, and colleagues reported that women who have completed a course of another hormone therapy, parathyroid hormone, maintain better bone strength if they begin taking the Selective Estrogen Receptor Modulator (SERM) raloxifene once the parathyroid treatment has ended (see conference Abstract No. OC22).

"The results tell us that after a course of parathyroid treatment it is important to begin taking an anti-resorber, such as raloxifene, as soon as possible," said Adami.

Parathyroid hormone is one of very few therapies that actually stimulates bone formation but the treatment is limited to two years or less in most countries. This has left doctors and patients wondering what the best course of action is once the hormone therapy has ended. SERMs are compounds that mimic only some of the action of estrogen. As such, they have different efficacies and side effects to hormone replacement therapy.

Adami and colleagues measured bone mineral density in 329 women who had been on parathyroid for one year then switched to either raloxifene or a placebo for a subsequent year. The researchers found that at the end of the second year, women who followed the parathyroid therapy with the estrogen mimic had a 2.3% higher bone density at the hip than those who had taken a placebo after the hormone treatment.

The researchers are planning to continue this study to see how long the benefit of the sequential parathyroid/raloxifene therapy persists.

Problems with New Hormone Replacement Therapy

In the recent LIFT trial to measure the efficacy of the estrogen hormone replacement therapy tibolone. Steve Cummings, Director of the San Francisco Coordinating Center, University of California, San Francisco and lead investigator, reported that follow up analysis showed that women who had taken the drug had about half as many vertebral fractures as those who had taken placebo (see conference Abstract No.OC38).

However, this trial was halted due to increased incidence of stroke. "The increased risk of stroke was unexpected and will limit the use of tibolone for prevention of osteoporosis and fracture," said Cummings. He also suggested that women and physicians should weigh the benefits and risks and consider alternatives before prescribing tibolone for any indication.

Osteoporosis, in which the bones become porous and break easily, is one of the world's most common and debilitating diseases. The result: pain, loss of movement, inability to perform daily chores, and in many cases, death. One out of three women over 50 will experience osteoporotic fractures, as will one out of five men 1, 2, 3. Unfortunately, screening for people at risk is far from being a standard practice. Osteoporosis can, to a certain extent, be prevented, it can be easily diagnosed and effective treatments are available.

The International Osteoporosis Foundation (IOF) is the only worldwide organization dedicated to the fight against osteoporosis. It brings together scientists, physicians, patient societies and corporate partners. Working with its 170 member societies in 84 locations, and other healthcare-related organizations around the world, IOF encourages awareness and prevention, early detection and improved treatment of osteoporosis.

1 Melton U, Chrischilles EA, Cooper C et al. How many women have osteoporosis? Journal of Bone Mineral Research, 1992; 7:1005-10
2 Kanis JA et al. Long-term risk of osteoporotic fracture in Malmo. Osteoporosis International, 2000; 11:669-674
3 Melton LJ, et al. Bone density and fracture risk in men. JBMR. 1998; 13:No 12:1915

IOF World Congress on Osteoporosis, held every two years, is the only global congress dedicated specifically to all aspects of osteoporosis. Besides the opportunity to learn about the latest science and developments in diagnosis, treatment and the most recent socio-economic studies, participants have the chance to meet and exchange ideas with other physicians from around the world. All aspects of osteoporosis will be covered during the Congress which will comprise lectures by invited speakers presenting cutting edge research in the field, and 35 oral presentations and more than 680 poster presentations selected from 720 submitted abstracts. More than 70 Meet the Expert Sessions covering many practical aspects of diagnosis and management of osteoporosis are also on the program.

For more information on osteoporosis and IOF please visit: http://www.osteofound.org

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Opioid Use Linked To More Fractures And Even Death Among Elderly Patients

Elderly patients with arthritis who regularly take opioids for pain experience more undesirable and sometimes dangerous side effects than those on other painkillers, such as Coxibs and NSAIDs (non-steroidal anti-inflammatory drugs), researchers from Brigham and Women's Hospital, Boston, reveal in Archives of Internal Medicine.

Opioids are a class of drugs commonly prescribed for their painkilling (analgesic) properties. They include substances such as codeine, oxycodone, methadone, or morphine. They may be more easily recognized by the brand names, such as OxyContin, Kadian, Demerol, Percocet, Avinza, Percodan, Darvon, , Vicodin, and Lomotil.

The authors wrote:

"In the United States, one in five adults received a prescription for an analgesic in 2006, accounting for 230 million prescription purchases; however, the comparative safety of these drugs is unclear. Although the cardiovascular safety of nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) and selective cyclooxygenase-2 inhibitors (coxibs) has been called into question, there is little comparable information about the third major analgesic group, opioids."

Daniel H. Solomon, M.D., M.P.H., at Brigham and Women's Hospital, Boston and team set out to compare the safety of opioids, Coxibs and NSAIDs among 12,840 Medicare beneficiaries. They had all been given one or more of these painkillers between 1999 and 2005. By gathering data from an extensive claims database, the researchers worked out how many of them developed heart attacks, stroke, heart failure, gastrointestinal tract bleeding, bowel obstruction, liver toxicity, acute kidney injuries, and bone fractures.

They found that patients on opioids had a higher risk of experiencing adverse events compared to those on NSAIDs or Coxibs. Those on NSAIDs had the lowest risk.

The authors reported 101 fractures per 1,000 patients among those on opioids annually, compared to just 19 for those on Coxibs.

Cardiac risk was lower for those on NSAIDs compared to coxib or opioids users.

Opioid usage was linked to a higher risk of death or hospitalization than NSAID usage. Coxib users had the same risk as NSAID users.

21 per 1,000 NSAID users annually experience gastrointestinal tract bleeding, compared to 12 per 1,000 among coxib users.

The authors wrote:

"Analgesics are used daily by millions of people; however, current data do not allow patients or physicians to determine which type of agent is safest. We compared nsNSAIDs, coxibs and opioids across a wide range of specific safety events and several composite safety events. Although nsNSAIDs pose certain risks, these analyses support the safety of these agents compared with other analgesics. The recent concerns raised about opioid use in non-malignant pain syndromes appear warranted on the basis of these data."

In another article in the same journal (same issue), Dr. Solomon and team gathered data just on Medicare beneficiaries who took opioids for non-malignant pain for the period 1996-2005.

6,275 patients on five types of opioids - tramadol, propoxyphene, codeine, hydrocodone, and oxycodone - were compared for adverse events rates after 30 and 180 days.

Gastrointestinal adverse events risks were similar across all groups throughout the study period, the authors report. Cardiovascular events risk was similar across all groups after 30 days, but at 180 days those on codeine had significantly higher cardiovascular events risk.

When using hydrocodone as a reference point, tramadol users had a 79% lower risk of fracture and those on propoxyphene had a 46% lower risk.

The risk of death was 2.4 times higher among oxycodone users when compared to hydrocodone, and two times higher among codeine users.

The authors wrote:

"This study's findings do not agree with a commonly held belief that all opioids are associated with similar risk. The risks were not explained by the dosage being prescribed and did not vary across a range of sensitivity analyses. The risks were substantial and translated into numbers needed to treat that would be considered clinically significant. Our findings regarding cardiovascular risk were surprising and require validation in other data sets."

The authors stress that an experimental design is required to prove a cause-and-effect relationship between opioids and adverse events, rather than an observational one.."but these results should prompt caution and further study."

During a follow-up of a clinical trial, researchers found that approximately 189 days after patients had stopped taking Rofecoxib, their risk of cardiovascular events increased significantly. This was reported in a separate research letter published in the same journal.

"The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults"

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What Is Bone Cancer? What Causes Bone Cancer?

Bone cancer can be primary bone cancer or secondary bone cancer. Primary bone cancer started in the bone; the cancer initially formed in the cells of the bone, while secondary cancer started elsewhere in the body and spread to the bone. Examples of primary bone cancer include steosarcoma, Ewing sarcoma, malignant fibrous histiocytoma, and chondrosarcoma.

According to the National Cancer Institute, USA, it is estimated that by the end of 2010 there will have been 2,650 new cases and 1,450 deaths from cancer of the bones and joints. The National Health Service (NHS), UK, informs that primary bone cancer accounts for 1 in every 500 cancers in the United Kingdom. There are approximately 500 cases of bone cancer each year in the UK, making this kind of cancer a fairly rare one.

Primary bone cancer (tumor) - these can be divided into benign tumors - which can have a neoplastic (abnormal tissue growth), developmental, traumatic, infectious, or inflammatory cause - and cancers.

Examples of benign bone tumors include - osteoma, osteoid osteoma, osteochondroma, osteoblastoma, enchondroma, giant cell tumor of bone, aneurysmal bone cyst, and fibrous dysplasia of bone.

Examples of malignant primary bone tumors include: osteosarcoma, chondrosarcoma, Ewing's sarcoma, malignant fibrous histiocytoma, fibrosarcoma, and other sarcomas. Multiple myeloma is a blood cancer which may include one or more bone tumors. Teratomas and germ cell tumors are frequently located in the tailbone.

Osteosarcoma is the most common type of bone cancer. It usually develops in children and young adults. After leukemia and brian tumors, osteosarcoma is the third most common cancer among for children in the UK and the USA.

Ewing sarcoma usually develops in the pelvis, shin bone or thigh bone. 90% of patients develop this type of cancer when they are less than 20 years of age.

Chrondrosacroma usually develops in adults. It starts in the cartilage cells and moves on to the bone.

The outlook for a patient with malignant bone cancer depends mainly on whether it has metastasized (spread to other parts of the body). If the cancer is localized (has not spread), prognosis is usually good.

What are the signs and symptoms of bone cancer?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor notice. For example, pain may be a symptom while a rash may be a sign.

The patient initially experiences pain in the affected area. Over time the pain gets worse and continuous. In some cases the pain is subtle and the patient may not see a doctor for several months. The progression of pain with Ewing sarcoma tends to be faster than in most other bone cancers. Typically, bone cancer pain is deep, nagging and has a permanent character.

There may also be swelling in the affected area.

Often the bone will weaken, resulting in a significantly higher risk of fracture.

The patient may find he/she loses weight unintentionally.

A mass (lump) may be felt in the affected area.

Although much less common, the patient may also experience fever, chills and/or night sweats.

What are the causes of bone cancer?

Nobody knows in general what the causes of bone cancer are. Patients with chronic (long-term) inflammatory diseases, such as Paget's disease are at a significantly higher risk of developing bone cancer later on in life. However, nobody can explain why one person gets bone cancer while another one doesn't. It is not contagious - you cannot catch it from someone else.

The following groups of people may be at a higher risk of developing bone cancer (risk factors):

• Being a child or very young adult - most cases of bone cancer occur in children or young adults aged up to 20.
• Patients who have received radiation therapy (radiotherapy).
• People with a history of Paget's disease.
• People with a close relative (parent or sibling) who has/had bone cancer.
• Individuals with hereditary renoblastoma - a type of eye cancer that most commonly affects very young children.
• People with Li-Fraumeni syndrome - a rare genetic condition.
• Babies born with an umbilical hernia.

How is bone cancer diagnosed?

A GP (general practitioner, primary care physician) may order a blood test to rule out other possible causes for the patient's symptoms. The patient will then be referred to a bone specialist (orthopedic surgeon). The following diagnostic tests may be ordered:

• Bone scan: a liquid which contains radioactive material is injected into a vein. This material collects in the bone, especially in abnormal areas, and is detected by a scanner. The image is recorded on a special film.
• Computerized tomography (CT): the CT scanner uses digital geometry processing to generate a 3-dimensional (3-D) image of the inside of an object. The 3-D image is made after many 2-dimensional (2-D) X-ray images are taken around a single axis of rotation - in other words, many pictures of the same area are taken from many angles and then placed together to produce a 3-D image. It is a painless procedure. CT scans are commonly used to see whether the bone cancer has spread and where it has spread to.
• Magnetic resonance imaging (MRI): the device uses a magnetic field and radio waves to create detailed images of the body, which in this case would be a specific bone or part of a bone. Most MRI machines look like a long tube, with a large magnet present in the circular area. When beginning the process of taking an MRI, the patient is laid down on a table. Then depending on where the MRI needs to be taken, the technician slides a coil to the specific area being imaged. The coil is the part of the machine that receives the MR signal.
• Positron emission tomography (PET): a PET scan uses radiation, or nuclear medicine imaging, to produce 3-dimensional, color images of the functional processes within the human body. The machine detects pairs of gamma rays which are emitted indirectly by a tracer (positron-emitting radionuclide) which is placed in the body on a biologically active molecule. The images are reconstructed by computer analysis.
• X-rays: this type of scan can detect damage the cancer may have caused to the bone. It may also detect new (bone) cells that have started to form around the tumor. An x-ray does not provide enough data for a definitive diagnosis, but can help the surgeon decide whether further tests are recommended.
• Bone biopsy - a sample of bone tissue is extracted and examined for cancer cells. This is the most reliable way to diagnose bone cancer. A core needle biopsy involves inserting a long, thin needle into the bone and removing a sample, while an open biopsy involves making an incision in the target bone area and surgically removing a sample of tissue.

Staging the bone cancer Bone cancer is has different stages which describe its level of advancement.

• Stage I - the cancer has not spread out of the bone. The cancer is not an aggressive one.
  
• Stage II - same as Stage I, but it is an aggressive cancer.
  
• Stage III. Tumors exist in multiple places of the same bone (at least two).
  
• Stage IV. The cancer has spread to other parts of the body.

What is the treatment for bone cancer?

The type of treatment for bone cancer depends on several factors, including what type of bone cancer it is, where it is located, how aggressive it is, and whether it is localized or has spread. There are three approaches to bone cancer:

• Surgery
• Chemotherapy
• Radiotherapy (radiation therapy)

Surgery - the aim is to remove the tumor, all of it if possible, and some of the bone tissue that surrounds it. If some of the cancer is left behind after surgically removing the tumor it may continue to grow and eventually spread. Limb sparing surgery, also known as limb salvage surgery means that surgical intervention occurs without having to amputate the limb. The surgeon may take some bone from another part of the body to replace lost bone (bone graft), or an artificial bone may be put in. In some cases, however, amputation of a limb may be necessary.

Radiation therapy - also known as radiotherapy, radiation oncology and XRT. Approximately 40% of patients of all types of cancer undergo some kind of radiotherapy. It involves the use of beams of high-energy X-rays or particles (radiation) to destroy cancer cells. Radiotherapy works by damaging the DNA inside the tumor cells, destroying their ability to reproduce. Radiotherapy can be used for different reasons:

• Total Cure - to cure the patient by completely destroying the tumor.
• To alleviate symptoms - radiotherapy is often used to relieve pain in more advanced cancers.
• Neo-adjuvant radiotherapy (before surgery) - if a tumor is large, radiotherapy can shrink it, making it easier and less harmful to then surgically remove it.
• Adjuvant radiotherapy - given after surgery. The aim is to eliminate the cancer cells that remained behind.
• Combination therapy (radiotherapy combined with another type of therapy) - in some cases, chemoradiation - radiotherapy combined with chemotherapy - is more effective.

Chemotherapy - the use of chemicals (medication) to treat disease - more specifically, it usually refers to the destruction of cancer cells. Cytotoxic medication prevents cancer cells from dividing and growing. In general, chemotherapy has 5 possible goals:

• Total remission - to cure the patient completely. In some cases chemotherapy alone can get rid of the cancer completely.
• Combination therapy - chemotherapy can help other therapies, such as radiotherapy or surgery have more effective results.
• Delay/Prevent recurrence - chemotherapy, when used to prevent the return of a cancer, is most often used after a tumor is removed surgically.
• Slow down cancer progression - used mainly when the cancer is in its advanced stages and a cure is unlikely. Chemotherapy can slow down the advancement of the cancer.
• To relieve symptoms - also more frequently used for patients with advanced cancer.

What is phantom limb pain?

Also known as phantom limb syndrome - the patient feels sensations, often of pain, in a limb that has been amputated; the limb is no longer there. The brain still receives messages from the nerves that originally carried impulses from the missing arm or leg.

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What Is Sinusitis? What Causes Sinusitis?

Sinusitis comes from the Latin sinuo meaning "bend, wind, curve", and the Greek itis meaning "pertaining to". In medical English, the suffix "itis" means an "inflammation". According to Medilexicon`s medical dictionary, sinusitis is the "Inflammation of the mucous membrane of any sinus, especially the paranasal".

What are the sinuses?

Behind the bones of your face there are some hollow spaces, filled with air, which lead to the nose cavity - they are what we know as the sinuses. Your sinuses have the same mucous membrane lining as your nose does. The membrane produces a slimy secretion (mucus), keeping the nasal passages moist. The mucus traps dirt particles and germs.

There are four main sets of sinuses, they are all paired.

• In each cheekbone
  THE MAXILLARY SINUSES
  These are the largest sinuses, also the ones that most commonly are affected when a person has sinusitis.


• Above your eyes, either side of your forehead
  THE FRONTAL SINUSES


• Behind the bridge of your nose, between your eyes
  ETHMOID SINUSES
  Can also be broken down into anterior and posterior - front and back


• Between the upper part of your nose an behind your eyes
  SPHENOID SINUSES

What is sinusitis?

Sinusitis is an inflammation of the paranasal sinuses. Paranasal means adjacent to the naval cavities. The inflammation could be caused by an infection from a virus, bacteria or fungus. It may also be the result of an allergic or autoimmune reaction. An autoimmune reaction is when your immune system attacks the good parts of your body.

Doctors often refer to sinusitis as rhinosinusitis, because an inflammation of the sinuses nearly always occurs with inflammation of the nose (rhinitis).

Sinusitis can also be referred to the cavity is affects:

• Maxillary sinusitis - the patient feels pain or pressure in the cheek (maxillary) area. This can be experienced as toothache or headache.


• Frontal sinusitis - the patient feels pain and/or pressure behind or above the eyes (frontal sinus cavity). The pain will generally be experienced as headache.


• Ethmoid sinusitis - the patient feels pain and/or pressure behind or between the eyes. Usually as in the form of a headache.


• Sphenoid sinusitis - the patient usually feels pain or pressure in the top part (vertex) of the head.

Many experts believe that sinusitis is often linked to asthma and happens as part of a group of diseases which affect the respiratory tract - the one airway theory. As sinusitis may result in, or be part of a generalized inflammation of the airway, other symptoms such as a cough are generally associated with it.

How long does sinusitis last?

• Acute sinusitis - lasts up to a maximum of 4 weeks.
  
  Acute sinusitis is often caused by the common cold. However, it could be caused by bacteria, allergies, or a fungal infection. Treatment depends on what caused it. In the majority of cases home remedies are suitable treatments. However, if the sinusitis is persistent it can lead to serious infections and complications.
  
  Typically, with acute sinusitis, the patient's sinuses become inflamed and swollen. This stops the drainage and causes a build up of mucus. Doctors may refer to this as acute rhinosinusitis.
  
  If you have acute sinusitis may find it hard to breathe through your nose. The area adjacent to your eyes and nose may feel swollen and puffed up. You could also have throbbing facial pain and a headache. Sometimes a patient with acute sinusitis may have a fever. Treatment may include an antibiotic.


• Subacute sinusitis - lasts from 4 to 12 weeks
  
  This type of sinusitis represents a continuation of the natural progression of acute sinusitis that has not got better. Symptoms will be pretty much the same as with acute sinusitis, possibly less severe, but treatment may be different. Treatment may include an antibiotic.


• Chronic sinusitis - Lasts at least 12 weeks, or keeps coming back.
  
  Chronic sinusitis is usually caused by an infection. However, it can also be caused by nasal polyps (growths in the sinuses), as well as a deviated septum.
  
  As with acute and subacute sinusitis the sinuses become inflamed and swollen, causing blockage and mucus build up. Doctors often refer to this as chronic rhinosinusitis. The patient may find it hard to breathe through his nose. He may experience throbbing facial pain and a headache.
  
  At onset it is very hard for a doctor to know which one a patient is likely to have as the symptoms are very similar.

What are the signs and symptoms of sinusitis?

Acute Sinusitis signs and symptoms

If the patient has two or more of these symptoms, and/or thick, green or yellow nasal discharge he may be diagnosed with acute sinusitis.

• Facial pain and pressure
• Blocked nose
• Nasal discharge
• Poor sense of smell
• Congestion
• Cough
These symptoms may also be present
• A high temperature
• Halitosis (bad breath)
• Tiredness
• Toothache

Subacute sinusitis may have symptoms of acute or chronic sinusitis. Chronic Sinusitis signs and symptoms

The following signs and symptoms may have been present for at least 8 weeks

• Congested, puffy face
• Blocked nose
• Nasal cavity has pus
• A high temperature (fever)
• Nasal discharge
• Discolored postnasal drainage
• These symptoms may also be present
• Headache
• Halitosis (bad breath)
• Tiredness
• Toothache

What are the treatments for sinusitis?

In the majority of cases sinusitis will resolve itself without treatment. Many patients find that home treatments provide some relief. These treatments include some OTC (over-the-counter) medications.

• Steam inhalation - you breath in steam from a bowl of hot water - not boiling. The water may have some drops of menthol oil. Although patients do feel they experience some relief, this treatment has not been scientifically proven. Standing or sitting in a very steamy shower may sometimes provide the same effect.


• Nasal Irrigation - this is also known as sinus irrigation, sinus rinse, or sinus lavage. It is a home procedure that involves a salt water rinse to clear the nasal passages.


• Warm compress - if you apply a warm compress gently to the affected areas of your face you may have some relief of symptoms.


• Sleeping with your head raised - when you go to bed prop up some pillows so your head is higher than it usually is. This may reduce the amount of pressure around the sinuses and lower the discomfort and pain.


• Painkillers - if you take a painkiller that you would normally have to treat a headache, your fever may improve.


• Decongestant tablets - these may reduce swelling and allow the sinuses to drain.


• Decongestant sprays - these may have the same effect as tablets. However, do not use them for more than a week. The risk of making the blockage worse rises if you use decongestant sprays for prolonged periods. Ask your doctor or pharmacist for advice.

If none of these home remedies work after about a week, you should see your doctor. Your doctor may decide the sinusitis has been caused by a bacterial infection and prescribe antibiotics.

• Antibiotics - a review of clinical trials found that while antibiotics can provide small improvements in uncomplicated sinusitis cases, most patients recover without the drugs within two weeks. However, in patients with severe symptoms, like high fever, severe pain in cheeks and swelling of face, antibiotic treatment is justified. The most commonly prescribed antibiotics for sinusitis are:


• Beta-Lactams - these include penicillins, such as Amoxicillin (Amoxil, Polymox, Trimox, Wymox (or any generic formulations). These antibiotics work by interfering with the bacterial cell walls. As drug resistance grows, many of these types of medications have lost some of their effectiveness. Make sure you are not allergic to penicillins if you are prescribed these. Cephalosporins are also beta-lactams, and may include first generation (Keflex), cefadroxil (Duricef, Ultracef), and cephradine (Velosef), second generation cefaclor (Ceclor), cefuroxime (Ceftin), cefprozil (Cefzil), and loracarbef (Lorabid), and third generation cefpodoxime (Vantin), cefdinir (Omnicef) cefditoren (Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). Ceftriaxone (Rocephin). These are effective against a wide range of bacteria.
  
  If you are allergic to penicillin you may find cefpodoxime, cefdinir, and cefuroxime are effective for mild to moderate sinusitis.


• Macrolides and Azalides - these antibiotics attack the bacteria genetically. They are sometimes used with patients with mild to moderate symptoms who are allergic to penicillin. Included are such drugs as erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). These drugs are not effective against H. influenzae.
  
  These drugs also have anti-inflammatory properties, which might help patients with chronic sinusitis.


• Trimethoprim-Sulfamethoxazole - these are also useful alternatives to patients who are allergic to penicillin. Certain streptococcal strains, however, have developed resistance to these types of drugs. Allergic reactions can be severe. They should not be given to patients who have had infections after dental work.


• Fluoroquinolones (Quinolones) - these medications stop the bacteria from reproducing. Levofloxacin (Levaquin), sparfloxacin (Zagam), gatifloxacin (Tequin), and moxifloxacin (Avelox) are extremely effective against the common bacteria that cause sinusitis. They are commonly used to treat patients who have already taken antibiotics within six weeks. They are also commonly prescribed for patients who are allergic to beta-lactams.


• Lincosamide - also stops the bacteria from reproducing. Effective against S. pneumonia but not H. influenza.


• Tetracyclines - these drugs help stem the spread of bacteria, and include doxycycline, tetracycline, and minocycline. Patients may have side effects which include skin sensitivity to sunlight, sore throat sensation, and tooth discoloration.


• Ketolides - effective against antibiotic-resistant bacterial strains.

Video: Sinusitis Pathology (Para-nasal Sinus Anatomy)

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