The clinician's guide to prevention and treatment of osteoporosis.

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Home therapies to improve disability, activity, and quality of life in military personnel with subacute low back pain: Secondary outcome analysis of a randomized controlled trial.

BACKGROUND: Low back pain (LBP) is an urgent military health concern with implications for fitness, quality of life (QoL) and disability. PURPOSE: This secondary outcome analysis from a randomized controlled trial (RCT) was to determine if the addition of neuromuscular electrical stimulation core strength training (NMES) or progressive exercise (PEP)in conjunction with primary care management (PCM) was more effective than PCM alone. METHODS: This randomized controlled trial (RCT assigned 128 service members to the three intervention groups. The outcomes included changes in perceived disability (Oswestry Disability Index), health-related quality of life (SF-12v2), pain during activity (Clinical Back Pain Questionnaire), and daily steps walked in service members with subacute LBP. FINDINGS: Over a 9-week intervention, perceived disability, SF-12v2 physical component summary, and activity associated with pain improved in all groups. Home therapies were helpful to reduce perceived disability, QoL and pain during activity in service members with subacute LBP. DISCUSSION: These non-pharmacological options provide other home-managed approaches for those in the subacute LBP phase.

Diagnosis and Management of Hepatitis C Infection in Primary Care Settings.

Hepatitis C virus (HCV) infection is a significant health problem worldwide, and is the leading cause of cirrhosis, hepatocellular carcinoma, and liver transplantation in the United States. The management of HCV has changed significantly over the last 5 years, as treatments have become simpler and more efficacious. Medication efficacy is now greater than 90%, with a high barrier to resistance and few side effects. This review is a collaboration between primary care and hepatology providers to explore all aspects of HCV management: acute versus chronic HCV infection, transmission and testing, and diagnosis and treatment. Specific medications for the treatment of HCV infection are considered, and patient and medication factors including genotype, liver disease status, and comorbidities affecting medication choice are discussed. This is a new era for the management of HCV infection, and interested primary care physicians, family doctors, and general internists can be at the forefront of diagnosis, management, and treatment of HCV.

Identification and Management of Eating Disorders in Integrated Primary Care: Recommendations for Psychologists in Integrated Care Settings.

Eating disorders are associated with deleterious health consequences, increased risk of mortality, and psychosocial impairment. Although individuals with eating disorders are likely to seek treatment in general medical settings such as primary care (PC), these conditions are often under-detected by PC providers. However, psychologists in integrated PC settings are likely to see patients with eating disorders because of the mental health comorbidities associated with these conditions. Further, due to their training in identifying risk factors associated with eating disorders (i.e., comorbid mental health and medical disorders) and opportunities for collaboration with PC providers, psychologists are well-positioned to improve the detection and management of eating disorders in PC. This paper provides a brief overview of eating disorders and practical guidance for psychologists working in integrated PC settings to facilitate the identification and management of these conditions.

Cardiovascular Health Disparities in Underserved Populations.

African Americans are at increased risk for hypertension, hyperlipidemia, obesity, and diabetes, which contribute to the burden of cardiovascular disease (CVD). The disparities of CVD in underserved populations require targeted attention from primary care clinicians to eliminate. Primary care can provide this targeted care for their patients by assessing cardiovascular risk, addressing blood pressure control, and selecting appropriate intervention strategies. Using community resources is also effective for addressing CVD disparities in the underserved population.

Blood glucose levels and glycaemic burden in 76,341 patients attending primary care: Bittersweet findings from a 9-year cohort study.

AIMS: Diabetes care is principally applied in the primary care setting whereby we examined trends in glycaemic levels and goals and estimated avoidable glycaemic burden. METHODS: We retrieved glycated haemoglobin (HbA1C) results and glucose-lowering prescription records from a patient-based medical database during 2005-2013. There were 275,480 available HbA1C measurements from 76,341 individuals managed by 960 general practitioners from 321 clinics across Australia. Change in mean levels and glycaemic control over time were assessed according to sex, age and glucose-lowering therapy. The time that HbA1C levels exceeded 7% (53mmol/mol) in untreated (n=4888), non-insulin (n=11,534) and insulin treated (n=4049) patients was calculated as area under the curve (AUC) and months above threshold. RESULTS: Average age of patients was 62.1±15.1years (47.1% women). HbA1C levels decreased from 7.1% (54mmol/mol) in 2005 to 6.6% (49mmol/mol) in 2013 and the proportion of patients who achieved a HbA1C target of <7% improved by 16% in men (53-69%) and 21% in women (55-76%). HbA1C levels decreased with advancing age in men and increased with insulin treatment; correspondingly, HbA1C goal attainment increased and decreased, respectively. Avoidable glycaemic burden was 9.3±17.7months in untreated, 16.2±25.2months in non-insulin, and 26.8±34.6months in insulin-treated patients. CONCLUSIONS: Amid considerable improvements, many treated patients still do not attain HbA1C levels ≤7% and time spent above this threshold was delayed. Earlier and more vigorously intensified management may reduce lengthy periods of uncontrolled hyperglycaemia in primary care.

Epidemiology, severity, and treatment of chronic obstructive pulmonary disease in the United Kingdom by GOLD 2013.

OBJECTIVES: In 2013, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated the management strategy on COPD based on severity using a combined assessment of symptoms, degree of airflow limitation, and number of exacerbations. This study quantified prevalence and incidence of COPD in the United Kingdom and estimated disease severity by GOLD 2013 categories A/B (low risk) and C/D (high risk). METHODS: The Clinical Practice Research Datalink was used to identify COPD patients ≥40 years. Patient characteristics were described, and prevalence was calculated on December 31, 2013. Five-year incidence (2009-2013) was estimated, with rates standardized using 2011 UK population age and sex. To classify patients by GOLD categories, spirometry results, the modified British Medical Research Council grade, and history of exacerbations were used. RESULTS: The prevalent cohort comprised 49,286 patients with COPD with mean age 70 years; 51.0% were male. Overall prevalence was 33.3 per 1,000 persons (95% confidence interval [CI]: 33.1-33.6); 66.4% were classified as GOLD A/B and 33.6% as C/D. The standardized prevalence of GOLD A/B was 21.9 per 1,000 persons (95% CI: 21.7-22.1) and of C/D was 11.1 (95% CI: 10.9-11.2). A total of 27,224 newly diagnosed COPD patients were identified with mean age 67 years at diagnosis; 53.0% were male. Incidence was 2.2 per 1,000 person-years (95% CI: 2.2-2.3); 68.7% were classified in categories A/B and 31.3% in C/D, of which 17.2% did not receive COPD maintenance medication. CONCLUSION: A third of COPD patients in the UK are considered high risk (GOLD 2013 categories C/D), and a third of patients are diagnosed for the first time at these severe stages. Given the progressive nature of the disease, results suggest that closer attention to respiratory symptoms for early detection, diagnosis, and appropriate treatment of COPD in the UK is warranted.

Yo pongo, tu pones, todos ponen para ayudar a las familias de nuestra comunidad / I contribute, you contribute, we all contribute to help families of our community / Trago, você traz todos contribuem para ajudar as famílias da nossa comunidade

Objetivo: gestionar la creación y puesta en marcha de una red de apoyo intersectorial, cuyo fin es brindar soporte y contribuir a la solución de la problemática de las familias. Materiales y Métodos: estudio descriptivo, llevado a cabo en 42 familias, 15 líderes comunitarios y representantes de 8 instituciones y 11 trabajadores del centro de salud de un barrio de estratos 1 y 2 de la ciudad de Bucaramanga. Se aplicó un formato de valoración por dominios de la Asociación Norteamericana de Diagnósticos de Enfermería (NANDA) para identificar la problemática de las familias. El procesamiento de los datos, se realizó en Excel mediante la obtención de frecuencias y promedios para su posterior análisis. Resultados: se logró la creación y puesta en marcha de la red de apoyo, conformada por ocho instituciones del sector,con la cual se abordaron problemáticas como: inasistencia a programas de promoción y prevención, drogadicción, violencia intrafamiliar, embarazos en adolescentes. Conclusiones: la articulación interinstitucional y la conformación de redes de apoyo logran mejores efectos a nivel económico, social, espiritual, físico y psicológico, contribuyendo a la salud familiar. Asimismo, contribuye al desarrollo personal, profesional, liderazgo y construcción del conocimiento, propios de enfermería familiar como eje de abordaje en la salud pública.

Goal: To manage the creation and implementation of a network of cross sector support, which aims to provide support and contribute to the solution of the problems of families. Materials and Methods: A descriptive study was conducted in 42 families, 15 community leaders and representatives of eight institutions and 11 health center workers in a district of 1 and 2 statuses in the city of Bucaramanga. It was used the Format for valuation domains of the American Association of Nursing Diagnoses (NANDA) to identify the problems of families. The data processing was performed in Excel by obtaining frequencies and averages for further analysis. Results: Absence from promotion and prevention programs, drug addiction, domestic violence, teen pregnancy: the creation and implementation of the support network, consisting of eight institutions in the sector, which addressed issues as was achieved. Conclusions: interagency coordination and the creation of support networks achieve better effects in economic, social, spiritual, physical and psychological level, contributing to family health. It also contributes to personal, professional, leadership and knowledge. building, typical of family nursing as axis approach to public health.

Objetivo: Gerenciar a criação e implementação de uma rede de apoio intersetorial, que visa dar apoio e contribuir para a solução dos problemas das famílias. Materiais e Métodos: Estudo descritivo, realizado em 42 famílias, 15 líderes comunitários e representantes de oito instituições e 11 trabalhadores de centros de saúde no distrito de níveis 1 e 2, na cidade de Bucaramanga. Formato foi utilizada para domínios de avaliação da Associação Americana de Diagnósticos de Enfermagem (NANDA) para identificar os problemas das famílias. O processamento dos dados foi realizada no Excel através da obtenção de freqüências e médias para análise posterior. Resultados: Ausência de programas de promoção e prevenção, toxicodependência, violência doméstica, gravidez na adolescência: a criação e implementação da rede de apoio, constituída por oito instituições do setor, que abordou temas como foi conseguido. Conclusões: a coordenação interinstitucional ea criação de redes de apoio alcançar melhores efeitos em nível econômico, social, espiritual, física e psicológica, contribuindo para a saúde da família. Também contribui para a pessoal, profissional, liderança e construção do conhecimento, típico de enfermagem de família como eixo abordagem à saúde pública.