Stroke survivors should be screened and treated for osteoporosis

Results from the Ontario Stroke Registry suggest that recent stroke survivors are not always screened and treated for osteoporosis, which puts them at increased risk of fractures.  

The study examined data from more than 16,000 stroke survivors aged 65 years and older who either had visited the emergency department or had been hospitalized for strokes between 2003 and 2013 in Ontario, Canada.

Only a very small number of patients (5.1%) overall were screened for osteoporosis. One year after their stroke, only 15.5% of them had been prescribed medications to prevent fractures.

Female sex, pre-stroke osteoporosis and post-stroke falls and fractures were associated with increased rates of osteoporosis pharmacotherapy.

Stroke survivors are at high risk of falls, which may lead to fractures. This risk is up to four times greater than in healthy people. Hence, they should undergo screening bone mineral density test to identify those at risk of fractures after stroke and then be treated to prevent bone loss and fractures.

(Source: Stroke, April 25, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Postmenopausal women at high risk of fractures should be treated for osteoporosis

Osteoporosis is often a silent disease and is responsible for minimal trauma fractures in the hip, spine and ribs later in life.

In contrast to senile osteoporosis, osteoporosis occurs much more in the spine in postmenopausal osteoporosis, which is a cancellous bone.  In senile osteoporosis, bones are 50-50, cancellous as well as cortical.  Osteoporosis occurs both in the spine and hip. The commonest fractures in osteoporosis are spine fractures in postmenopausal women followed by fractures in hip and wrist.

The Endocrine Society has published new clinical practice guidelines on the management of osteoporosis in postmenopausal women. The guidelines were presented at ENDO 2019, its annual meeting in New Orleans, La.

Some key recommendations from the guidelines include:

·         Postmenopausal women at high risk of fractures, especially those who have experienced a recent fracture, should receive pharmacological therapies, as the benefits outweigh the risks.

·         Initial treatment with bisphosphonates to reduce fracture risk.

·         Reassess fracture risk after 3-5 years in women taking bisphosphonates.

·         Women who remain at high risk of fractures should continue therapy, while those who are at low-to-moderate risk of fractures should be considered for a “bisphosphonate holiday.”

·         Using denosumab as an alternative to bisphosphonates for the initial treatment of high-risk individuals.

·         Daily calcium and vitamin D supplementation for postmenopausal women at high risk of fracture with osteoporosis who cannot tolerate bisphosphonates, estrogen, selective estrogen response modulators (SERMs), denosumab, tibolone, teriparatide and abaloparatide.

·         Monitor bone mineral density by DEXA spine and hip in postmenopausal women with a low bone mineral density and at high risk of fractures every 1 to 3 years to evaluate response to treatment.

(Source: Endocrine Society News Release, March 25, 2019; J Clin Endocrinol Metab. May 2019;104(5)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

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] 

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

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] 

Punishment to Rapist

1.       One needs to distinguish between Paraphiliac and non-paraphiliac rapists. Paraphiliac rapists have excessive sexual desire. Paraphiliac offenders commit sex offences because they are sexually aroused by the act. On the other hand, non-paraphiliac sex offenders are instigated by violations or ego-hurt or for taking revenge.

2.       False allegations of rapes can occur in situations like: if one of the partners in live-in relationship refuses to marry, if two consensual partners are caught in the sexual act by the society, someone exploits secrete of the other person.

3.       Under the influence of alcohol one loses intellect and may end up in raping somebody if instigated.

4.       Chemical castration is reversible and the effect of the injection lasts only 3-6 months. The injections are costly and need to be given by medical doctors.

5.       Chemical castration in the long run leads to thinning of the bone (osteoporosis), feminine characteristic and increased tendency for cardiovascular diseases.

6.       Chemical castration drugs are not safe and healthy.

7.     In long run influential people convicted for chemical castration will start paying bribes to doctors and get a water injection in place of chemical castration injection.

8.       Chemical castration does not mean dissolving the male organ with a chemical. It only means reducing the blood testosterone levels to that of pre-puberty levels.

9.        Non-injectible oral drugs which block the action of testosterone are costlier and need to be taken every day. Therefore, they cannot be a part of chemical castration as punishment.

10.       Surgical removal of testis will remove sexual desire permanently and the same can only be given as a punishment in patients who are spending life-term in the prison.

11. Depoprovera is another injection which can be given every three months to patients with paraphiliac sexual abnormality.

12. Deprivation of sex and non-fulfillment of sexual desires is one of the main causes of rapes.

13.   If female commercial sex workers are banned in the society, the incidents of rape will increase as sexually deprived people with strong sexual urges will end up raping the minors.

 14.  People under the influence of alcohol and drugs will keep raping the girls if not treated and counseled in time. 

 Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India and National Vice President Elect IMA

#AskDrKK: What are the risk factors for osteoporosis in men

As per American Academy of Orthopaedic Surgeons the risk factors are

1.     Drinking excessive amounts of alcohol or using tobacco.

2. Not exercising regularly.
3. Having a low body-mass index.
4. Getting insufficient vitamin D and calcium.
5. Taking certain medications, including anticonvulsants, oral glucocorticoids or heparin.
6. Getting older.
7. Having a family history of fractures related to fragile bones.
8. Certain health conditions, including asthma, thyroid disorders or rheumatoid arthritis.
9. Having low levels of certain hormones, including testosterone or estrogen.

HCFI Update:20 minutes of sunlight and a glass of milk can keep osteoporosis at bay

Osteoporosis and vitamin D deficiencies are the two new epidemics of the society said Padma Shri and Dr B C Roy National Awardee Dr KK Aggarwal, President Heart Care Foundation of India and MTNL Perfect Health Mela.

Drinking less milk, quitting sunlight exposure and omitting the traditional aerobic indoor games are few reasons for the new epidemic. Younger professionals also stay indoors with practically no sunlight exposure. This is especially true for medical residents.

Here are few tips to prevent osteoporosis and strengthen the bones:

1. One should stop smoking as it increases bone loss.
2. Eat a calcium-rich diet: The aim should be to get 1,500 milligrams of calcium a day in postmenopausal woman or a man over age 65. Good dietary sources of calcium include dairy products, tofu and other soy products; orange juice fortified with calcium, canned salmon with the bones, and cooked spinach. The alternative is to take calcium supplements.
3. Get enough vitamin D: Vitamin D levels are influenced by how much sunlight one gets.  Levels tend to decrease in older adults, especially in winter and in people who are unable to leave their home. One should consider taking a supplement to make sure one gets the recommended daily amount. 
4. Get exposure to sunlight of at least 20 minutes per day. The exposure should at least be of 20 minutes every day for a month in a year.
5. Get enough protein in diet: An adequate intake of protein in diet, combined with an adequate intake of Ca helps increase bone density. One should aim for about 12% of calories to come from proteins such as legumes, poultry, seafood, meat, dairy products, nuts and seeds. However, too much protein with too little Ca can be harmful.
6. Weight-bearing exercises: These are activities such as walking, jogging and stair climbing that one should do on the feet, with your bones supporting your weight. They work directly on the bones of the legs, hips and lower spine to slow mineral loss.
7. Weightlifting exercises: These exercises are also called resistance training or strength training. They strengthen muscles and bones in the arms, chest and upper spine. They can work directly on the bones to slow minerals loss.
8. Get adequate vitamin K: This vitamin may be helpful in enhancing bone strength. Green leafy vegetables are the best sources of vitamin K. If one is taking a blood thinner he or she should check with the doctor. 
9. Avoid excessive alcohol: Women should limit alcohol consumption to less than one ounce a day and men should limit it to less than two ounces.
10. Limit cola drinks: People who have high cola intake often have lower bone density.