Correction to: Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures.

The article 'Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures',written by J. A. Kanis, was originally published Online First without Open Access. After publication in volume [#], issue [#] and page [#-#], the author decided to opt for Open Choice and to make the article an Open Access publication.

Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures.

Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures. INTRODUCTION: The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach. METHODS: Clinical perspective and updated literature search. RESULTS: The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis. CONCLUSIONS: A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.

Chylothorax complicating closure of the ductus arteriosus: the second case.

Chylothorax is a possible complication of intrathoracic surgery. The diagnosis of postoperative chylothorax is easy; however, the treatment can cause problems of management because of the lack of consensus. In children, the most common causes of postoperative chylothorax are the cures for congenital heart diseases. We report the case of a two-year-old child, presenting with a chylothorax following surgery of the ductus arteriosus. Our case illustrates the treatment that must first include medical measures without delaying the surgery. The risk is the installation of nutritional and immune deficiency.

Middle East and North Africa consensus on osteoporosis.

With the increasing life expectancy, osteoporosis is becoming a major worldwide health problem. The magnitude of the disease may become larger in developing countries, more particularly in the Middle East region where the prevalence of low bone mass is higher than in western countries. Although several local organizations and countries have developed guidelines for osteoporosis, no previous regional guidelines have been developed encompassing all Middle-Eastern and North African countries. The present document reviews all the regional published data on bone mineral density, risk factors, fracture prevalence and vitamin D status. It also gives simple recommendations applicable to all these countries. This document was endorsed by leading members of all the different regional countries including, Iran, Egypt, Tunisia, Jordan, Palestine, Syria, Iraq, Libya, Oman, Kuwait, Saudi Arabia and Bahrain.

The spinal curvature irregularity index independently identifies vertebral fractures.

INTRODUCTION AND HYPOTHESIS: The spinal curvature irregularity index (SCII) is a quantitative measure of the irregularity of the spinal curvature. We evaluated the predictive ability of SCII to identify subjects with vertebral fractures (VF). METHODS: Vertebral heights were measured by quantitative vertebral morphometry in 461 Lebanese women 20-89 years of age and VFs were ascertained by the grade 1 Eastell method. SCII scores were log-transformed and expressed as Z-SCII, the number of standard deviations above or below the mean ln(SCII) of young patients without VF. Univariate and multivariate binary logistic regression models were used to identify clinical predictors of VF. RESULTS: Women with a higher SCII were more likely to have prevalent VF. A higher SCII was associated with a greater prevalence of VF within each category of femoral neck BMD (normal, osteopenia, osteoporosis). In univariate analysis, predictors of VF included Z-SCII (odds ratio, OR: 2.21, 95% CI: 1.80-2.71) and femoral neck T-score (OR: 1.35, 95% CI: 1.12-1.63). In multivariate analysis, predictors of VF were: Z-SCII (OR: 1.54, 95% CI: 1.02-2.32), femoral neck T-score (OR: 1.41, 95% CI: 1.11-1.78) and age(3) (OR: 1.40, 95% CI 1.10-1.82). At a cutoff SCII of 9.5%, the sensitivity and specificity of SCII for VF were 71 and 64% respectively, and higher SCII cutoffs identified VFs with greater specificity. CONCLUSION: The SCII is a robust, simple and independent indicator of the presence of VFs.

Use and misuse of aspirin in rural Ethiopia.

OBJECTIVES: To investigate ability to distinguish simple analgesics, to document misconceptions about aspirin use, and to identify strategies to diminish potentially harmful aspirin use in Ethiopia. DESIGN: Qualitative study (eight focus group discussions) used to inform cross-sectional survey. SETTING: Butajira, a small town in southern Ethiopia, and surrounding rural areas. PARTICIPANTS: Purposively selected informants for focus groups; random sample of urban and rural residents for cross-sectional survey. MAIN OUTCOME MEASURES: Ability to distinguish aspirin from paracetamol; proportion using aspirin; proportion aware of common risks of aspirin. RESULTS: Questionnaires were completed by 204 of the 250 residents sampled (82% response). Three-quarters of survey participants knew the difference between aspirin and paracetamol. Aspirin was used by 7.3% of respondents, and was mainly taken for headache and fever. In focus group discussions there was a suggestion that aspirin was considered particularly useful for children. There was very low awareness of the risks of using aspirin in children (2.5% unprompted, 18.6% prompted) or in people with asthma (1% unprompted, 5.9% prompted). Aspirin is cheap and widely available in urban and rural areas. CONCLUSION: Awareness of the risks of aspirin use by children and in asthma is extremely low in this rural Ethiopian setting. Medications are purchased with minimal packaging by a population with low literacy. Drug dispensers and vendors must be trained to convey simple verbal warnings about aspirin use.

Osteoporosis: combination therapy for better or worse.

Osteoporosis is a condition that is associated with an increased susceptibility for fractures. In the past few years, several drugs have become available that can reduce the incidence of fractures in patients with osteoporosis. Since these drugs work through different cellular mechanisms, combining agents of different classes may have an additive or multiplicative effect on fracture risk reduction. Combination treatments that have been evaluated in clinical trials include bisphosphonates with estrogen, raloxifene or PTH/ bisphosphonates and PTH/ estrogen. In general, these trials have shown increases in bone mineral density over that observed with each agent alone. However, whether anti-fracture efficacy is improved, or worsened remains to be established. This article reviews the combination treatments that have been evaluated in clinical trials, with a discussion of the potential benefits and risks that those treatments entail. Integrating safety and cost issues will eventually determine whether those combinations will become the standard of care.

A study of ethylene glycol exposure and kidney function of aircraft de-icing workers.

Ethylene glycol levels were measured in 154 breathing zone air samples and in 117 urine samples of 33 aviation workers exposed to de-icing fluid (basket operators, de-icing truck drivers, leads and coordinators) studied during 42 worker-days over a winter period of 2 months at a Montreal airport. Ethylene glycol as vapour did not exceed 22 mg/m3 (mean duration of samples 50 min). Mist was quantified at higher levels in 3 samples concerning 1 coordinator and 2 basket operators (76-190 mg/m3, 45-118 min). In 16 cases workers' post-shift or next-morning urine contained quantities of ethylene glycol exceeding 5 mmol/mol creatinine (up to 129 mmol/mol creatinine), with most of these instances occurring in basket operators and coordinators, some of whom did not wear paper masks and/or were accidentally sprayed with de-icing fluid. Diethylene glycol was also found in a few air and urinary samples at levels around one tenth those of ethylene glycol. Urinary concentrations of albumin, beta-N-acetyl-glucosaminidase, beta-2-microglobulin and retinol-binding protein were measured and compared over various periods, according to subgroups based on exposure level and according to the frequency of extreme values. These analyses did not demonstrate acute or chronic kidney damage that could be attributed to working in the presence of ethylene glycol. In conclusion, this study does not suggest important health effects of exposure to de-icing fluid in this group of workers. Potential for overexposure exists, however, in certain work situations, and recommendations on preventive measures are given. In addition, these results suggest that other routes of absorption than inhalation, such as the percutaneous route, may be important and that urinary ethylene glycol may be a useful indicator of exposure to ethylene glycol.