Ask Dr KK:How often to repeat BMD test for osteoporosis?

• Assessment of fracture risk in all adults is important.

• BMD-independent risk factors are advanced age, previous fragility fracture, glucocorticoids, risk of falls, smoking, alcohol, and family history of fracture. 

• Screen with BMD in all women 65 years of age and older

• Screen with BMD in postmenopausal women less than 65 years if one of the above risk factors is present

• Do not perform 

• routine BMD measurements in premenopausal women 

• Do not perform routine BMD measurements in all men.

• Measure BMD in men who have clinical manifestations of low bone mass, such as radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height, as well as in those on long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, hyperthyroidism, and intestinal disorders

• For screening BMD use DXA

• Go for DXA of hip and spine

• Measurement of the hip alone could be sufficient in older individuals. 

• In women and men with low bone mass (T-score -2.00 to -2.49) at any site or who have risk factors for ongoing bone loss (steroid use, hyperparathyroidism) do follow-up BMD every two years as long as the risk factor persists 

• In women 65 + years at baseline with low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for accelerated bone loss, go for follow-up DXA in three to five years

• In women 65 years + of age with normal or slightly low bone mass (T-score -1.01 to -1.49) at baseline and no risk factors for accelerated bone loss go for follow-up DXA in 10 to 15 years 

• A 65-year-old woman with a femoral neck BMD T-score of -1.01 to -1.49 and no clinical risk factors for fracture has 10-year absolute risk of hip fracture of only 0.9 percent.[Source Uptodate] 

#AskDrKK: Can a patient with deep vein thrombosis fly?

#DrKKAnswers:

1.  Prolonged travel confer a 2- to 4-fold increase in risk of venous clots, a phenomenon that has been termed the "economy class syndrome" when applied to air travel.

2.  The risk is one per 100 million passengers for travel distances <5000 km (3100 miles) and 4.8 per million passengers at travel distances greater than 10,000 km (6200 miles).

3. There is an increased risk of venous clots among patients who fly longer than eight hours or further than 5000 kilometers. The risk increases by 26 percent for every two hour increment of air travel time.

4.The absolute risk of a first episode of venous clot is 1 in 4600 air flights.

5.This risk is higher for those with risk factors. Risk is increased in individuals with recent major surgery, including hip or knee arthroplasty within six weeks, increased age, obesity, prior venous clots, use of oral contraceptives, heart failure, hereditary thrombophilia)

6. Prolonged air travel may pose an even higher thrombotic risk in those with two or more risk factors for VTE.

7. In previously healthy patients who travel at least eight hours per flight (median duration 24 hours), duplex ultrasonography reveal an asymptomatic venous clots in 10 percent.

8. Blood thinners for high risk patients can decrease risk.

9.There are a number of maneuvers that travelers can use that may be beneficial during extended travel times (ie, flights of greater than six to eight hours duration). These include

• Moving about every hour or two
•  Request bulkhead seating
•  Refraining from smoking
•  Avoidance of constrictive clothing
•   Flexing and extended the ankles and knees periodically; avoidance of leg crossing; frequent changes of position while seated
• Adequate consumption of fluids to avoid dehydration
• Avoidance of agents favoring immobility (eg, sedative drugs, alcoholic beverages)
• Use of below-knee stockings

10.Compression stockings can decrease the incidence of DVT associated with prolonged flights.

11.Among patients considered to be at high risk for clots, use of properly fitted, below-knee graduated compression stockings (12 to 30 mmHg at the ankle) or one prophylactic dose of low molecular weight heparin a few hours before the flight may be protective. Aspirin is not effective in this setting.

 Maintain normal schedule using the time of the patient's home country (best for short trips; may help to keep a watch on home time).

Gradually adjust schedule by an hour or two daily, until medication is taken according to local time.

Abruptly change schedule so medication is immediately taken according to local time (may lead to extended delays between doses; not to be used with insulin).

 Screening questions

1.      Length of the journey

2.      History of tolerating prior air travel

3.      Conditions of the destination, eg, altitude, public health risks, and access to medical care.

Individuals with a medical condition that could lead to inflight illness, injury, or risk to other passengers may be required by the airline to have a medical certificate from their clinician. The certificate should state that the patient is currently stable and fit for air travel, and, if applicable, not contagious.

#AskDrKK: Can patients with low Hb fly?

#DrKKAnswers:
1. Patients with hemoglobin below 8.5 g/dL generally should be given supplemental oxygen, unless the anemia is known to be well compensated.
2. Anemic patients are at risk for lightheadedness and loss of consciousness during flight, even with minimal exertion, eg, walking to the lavatory.
3. The relative hypoxia in the cabin poses a particular risk to patients with sickle cell anemia. Such patients should use supplemental oxygen and be kept well hydrated.
4. Those with sickle cell trait are not considered at risk for flights at normal altitudes under usual conditions.

#AskDrKK: Are heart patients fit to fly?

#DrKKAnswers: 

Patients with uncomplicated heart attack, or those who have undergone uncomplicated percutaneous coronary interventions should not fly until at least two to three weeks have passed and they are tolerating their usual daily activities.

Travel in the week immediately after coronary stent placement should be avoided, due to the high risk of acute stent thrombosis during this time.

Following a heart attack, a stress test is recommended in all low-risk patients.

Patients with heart attack complicated by severely depressed cardiac function or an untoward event during treatment should not fly until two weeks after they are deemed medically stable.

Unstable angina is a contraindication to air travel.

Stable angina is generally well tolerated during flight.

Severe decompensated congestive heart failure (CHF) is a contraindication to flight.

Patients with class III or IV New York Heart Association CHF should be carefully assessed to determine whether they will need inflight oxygen.

Symptomatic valvular heart disease is a relative contraindication to airline travel.

Medically stable patients with pacemakers and implantable cardioverter-defibrillators are at low risk for inflight emergencies. They should carry a pacemaker card along with a copy of the most recent ECG done with and without a magnet.

There is no evidence that airline electronics or airport security devices interfere with implanted pacemakers or ICDs.

There is a theoretical risk that the ICD might detect the alternating magnetic field created by the handheld wand, which could lead to an inadvertent shock or inhibition of the ICD's pacemaker output. Thus, patients with ICDs should request a hand search.

#AskDrKK: Can a patient fly after surgery?

#DrKKAnswers:

1. Patients with significant comorbidities, pulmonary surgery, or postoperative anemia are at greater risk during flight and should be carefully assessed.

2. General anesthesia is not usually a concern, but postspinal headache has been reported seven days after a spinal anesthetic, possibly because changes in cabin pressure induced a dural leak.

3. Invasive procedures introduce air into isolated body cavities that could expand at altitude in a pressurized cabin and cause barotrauma.

4. Patients should postpone air travel until at least 10 to 14 days after most surgical procedures. This delay should provide enough time for air in the intrathoracic, intraabdominal, or other cavities to be resorbed, and reduces the risk for barotrauma.

5. Laparoscopic abdominal procedures are less often associated with ileus than open procedures. The carbon dioxide introduced into the peritoneum during the procedure rapidly diffuses into the tissues, and patients can usually fly the next day if they do not have bloating.

6. Patients who have undergone a colonoscopy with polypectomy should wait at least 24 hours before flying because of the large amount of gas often present in the colon and the risk of bleeding or perforation at the polypectomy site.

7. Patients with colostomies are not at increased risk inflight, but increased fecal output resulting from intestinal distention may occur. A larger bag or frequent changes may be necessary.

#AskDrKK: Can a patient with respiratory infection fly?

#DrKKAnswers:

1. Active or contagious respiratory infections (eg, TB, Pneumonia) are a contraindication to air travel, until there is objective evidence of effective treatment (ie, negative cultures) and the patient is clinically stable.

2. A sore throat, upper respiratory infection, cold, can cause blockage of the Eustachian tube making it difficult to equilibrate the air pressure in the middle ear during descent. This can lead to a number of problems including pain, vertigo, and tympanic membrane rupture.

3. Patients with sore throat who cannot avoid flying may benefit from an oral decongestant
(pseudoephedrine) and a nasal spray containing a vasoconstrictor used 30 minutes before descent.

4. Patients should avoid alcoholic beverages and drink plenty of fluids to ensure hydration and to keep secretions thin and easier to clear.

#AskDrKK:Can a patient with nasal and sinus disease fly?

#DrKKAnswers:
1. Commercial air travel is contraindicated for patients with severe sinusitis, large obstructing polyps, recent nasal or facial surgery, or severe recurrent epistaxis (nasal bleed).
2. Such conditions can obstruct sinus opening preventing pressure equilibration and predisposing to extension of disease into the eye and brain.
3. For patients with allergic rhinitis, oral anti allergics and nasal steroids are helpful.

#AskDrKK:Can a patient with lung problem fly?

#DrKKAnswers:
1. Patients with significant cardiopulmonary disease can be severely compromised by even the small degree of hypoxia (low oxygen) that occurs aboard commercial flights.
2. Patients with severe, unstable asthma and those who have required recent hospitalization should not fly.
3. Asthmatics who do fly should carry on their person a beta-2 selective adrenergic agonist metered dose inhaler and spacer, and a course of oral steroids.
4. Patients with cystic fibrosis, bronchiectasis, or comparable diseases should be provided with appropriate antibiotic and secretion-clearing medications to be used before and during flight. They should stay well hydrated, and use inflight oxygen, if indicated.
5. A pneumothorax is an absolute contraindication to air travel.

#AskDrKK:Can a patient with mental illness fit to fly?

#DrKKAnswers:

Patients with psychiatric disorders that predispose to violent, disruptive, unsafe, or unpredictable behavior should not travel by air, nor should patients at risk for alcohol or drug withdrawal

#AskDrKK:Can a diabetic fly?

#DrKKAnswers
1. Diabetic patients generally tolerate travel without difficulty.
2. One should wear a medical alert bracelet.
3. Preflight planning is important to ensure ready access to simple sugars and insulin, and to adjust insulin dosing schedules.
4. As a general rule, when traveling east the day is shortened and less insulin may be needed; when traveling west the day is lengthened and more insulin may be needed.
5. Insulin will denature if exposed to extreme cold and should not be checked.
6. As per American Diabetes Association, unrefrigerated insulin remains usable for up to one month if kept at temperatures below 30ºC (86ºF).

#AskDrKK: Can a person with fracture fly?

#DrKKAnswers:


1. Patients with full-leg casts, for safety reasons, may be required to travel by stretcher, purchase an extra seat, or fly business or first class.

2. Casts applied within 48 hours should be split lengthwise along each side ( bivalved) to avoid injury from the expansion of air trapped between the skin and the cast if the limb swells.

3. Pneumatic splints should be partially deflated to avoid rupture from expanding gas.