Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice.

UNLABELLED: The purpose of this study was to assess whether education and referral by a nurse practitioner could improve treatment adherence in patients with low bone mineral density in the orthopedic office. Our customized project did show some improvement but resistance to care continues in this unique population of patients. INTRODUCTION: Osteoporosis and osteopenia are significant clinical problems. Nearly 50% of adults over the age of 50 are osteopenic (Looker et al. in Osteoporos Int 22:541-549, 2011). Many patients with osteoporosis are not taking calcium or vitamin D, or any active treatment, even after dual energy X-ray absorptiometry (DXA) and demonstration of low bone mineral density (Dell et al. in J Bone Joint Surg Am 91(Suppl 6):79-86, 2009). One hypothesis to explain low adherence with osteoporosis treatment is lack of patient education. This study was designed to compare a control group with an education-intervention group (receiving patient education from a nurse practitioner) to determine any effect of education on treatment adherence. METHODS: A total of 242 females and 105 males were studied as a control: a total of 292 females and 155 male were studied in the education group. Patients in the education group received educational materials and were counseled by a single nurse practitioner. Patients had a DXA performed and patients with osteoporosis or osteopenia were followed to assess treatment. At 12 months, patients received follow-up phone calls to determine patient use of calcium, vitamin D, and/or an active treatment. Results between the groups were compared. RESULTS: Significantly more patients began calcium and vitamin D after education (p = 0.04); significantly more patients were taking or were recommended for an active treatment after education (p = 0.03). Thirty percent of patients either did not follow up or refused active treatment for osteoporosis. Approximately 50% of patients with osteoporosis were not taking an FDA-approved pharmacologic agent for osteoporosis treatment, despite education. CONCLUSION: After patient education and referral to endocrinology, significantly more patients began calcium and vitamin D supplementation. However, up to 50% of patients with osteoporosis would not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.

The Effect on Bone Outcomes of Adding Exercise to Supplements for Osteopenic Breast Cancer Survivors: A Pilot Randomized Controlled Trial.

BACKGROUND: Cancer treatment-induced bone loss is an important long-term effect in breast cancer survivors, but evidence regarding lifestyle interventions for preventing cancer treatment-induced bone loss is lacking. OBJECTIVE: The aim of this study was to investigate the feasibility, safety, and effects of a 6-month combined home-based exercise and calcium and vitamin D supplements (EX + SUPP) intervention compared with calcium and vitamin D supplements alone (SUPP) on bone health of osteopenic breast cancer survivors. METHODS: In this pilot randomized controlled trial, we enrolled 43 women with breast cancer who were diagnosed as osteopenic through bone mineral density screening. Women were randomly assigned to the EX + SUPP group (n = 23) or the SUPP group (n = 20). RESULTS: The rates of participant retention (90.7%) and of counseling calls delivered to the EX + SUPP group (90.3%) were high. The average exercise adherence rate was 69.5% for weight-bearing exercise and 48.5% for resistance exercise. The EX + SUPP group reported no injuries or adverse events. Despite positive findings of adherence and safety, no significant group differences were observed for bone mineral density, bone turnover marker, or physical performance. CONCLUSIONS: A home-based exercise program for bone health among osteopenic breast cancer survivors is feasible and safe. There was no significant additive effect of exercise on bone outcomes under the conditions studied, however, suggesting the need for a larger trial. IMPLICATIONS FOR PRACTICE: Effective exercise intervention may require more intensive components such as higher loading forces and longer duration for improving bone health among this population.

Metabolic bone disease in very-low-birth-weight infants: assessment, prevention, and treatment by neonatal nurse practitioners.

OBJECTIVE: To describe the current practice of neonatal nurse practitioners in assessing skeletal health and preventing and treating metabolic bone disease in very-low-birth-weight infants. DESIGN: Descriptive, retrospective survey. PARTICIPANTS: Neonatal nurse practitioners in the continental United States were systematically randomly selected. A 64% response rate was obtained (112). MAIN OUTCOME MEASURES: Responses to questions about assessing skeletal health and preventing and treating metabolic bone disease in very-low-birth-weight infants. RESULTS: Current practice of neonatal nurse practitioners includes assessing skeletal health of very-low-birth-weight infants on the 7th (47.3%) or 14th (19.6%) day of life, with subsequent assessments every 7 (63.3%) or 14 (18.8%) days. Neonatal nurse practitioners (85.1%) estimate the incidence of metabolic bone disease at less than 15%. Neonatal nurse practitioners initiate total parenteral nutrition (99%), provide parenteral calcium and phosphorous in ratios of 1.3-1.7:1 (9%), and add powdered fortifier (90.1%) and liquid fortifier (25.2%) to expressed breast milk. All respondents use formulas made for premature infants. Physical therapy is used by 46.8% of neonatal nurse practitioners. CONCLUSIONS: Neonatal nurse practitioners underestimate the incidence of metabolic bone disease. Parenteral calcium and phosphorous are given but in quantities that differ from the recommended ratio. Most neonatal nurse practitioners use formulas made for premature infants and add powdered fortifier to expressed breast milk. Although physical therapy is prescribed, more research on its effect on bone mineralization is warranted before this practice is recommended without reservation.