Osteoporosis

Key points:

- Osteoporosis is under-recognised and under-treated, even in people who present with a minimal trauma fracture.

- A minimal trauma fracture is sufficient for a presumptive diagnosis of osteoporosis medicines can start prior to obtaining BMD results with dual energy x-ray absorptiometry (DXA).

- Guidelines recommend risk factor assessment and that modifiable risk factors be addressed in all postmenopausal women aged >45 years and men aged > 50 years.

- A full diagnostic investigation is indicated for:

• women> 50 YEARS and men> 60 years with other clinical risk factors 
• Patients > 45 years with a minimal trauma fracture or suspected vertebral fracture 
• patients who have causes of secondary osteoporosis (medical conditions or medicines such as long-term, high-dose corticosteroids)
• adults aged over 70 years 

- Clinical risk factors (CRFs), use the mneumonic of shattered 

Previous minimal trauma fracture, family history 

• S: steroid use (oral corticosteroid use > 5mg/day)
• H: hyperthyroidism, hyper parathyroidism and hypercalciuria 
• A: Alcohol and tobacco use 
• T: Thin (BMI < 22)
• T: Testosteron decrease (e.g. anti androgen ca, prostate Rx)
• E: Early menopause 
• R: renal or liver failure 
• E: Erosive/inflammatory bone disease (e.g. myeloma or rheumatoid arthritis)
• D: Dietary Calcium decrease/malabsorption , DM1 

- The strongest risk factor is age > 70. Peak bone mass is achieved by age 30. Bone loss occurs steadily from the age of about 40, with accelerated loss in perimenopausal period (4-6%) before slowing again after the age of 70 (1-2% per year).

- Basic investigations: DEXA, Ca, PO, ALP, FBE, UEC, LFT, myeloma screen if indicated

• Hip bone mineral density best predictor for hip fracture
• Lumbar spine bone mineral density best for monitoring treatment effect
• 
  

- Management:

• lifestyle measures
• quit smoking and reduce ETOH consumption 
• Weight bearing exercise may increase bone mineral density 
• Balance exercises such as tai chi reduce risk of falls 
• Calcium and vitamin D supplements 
• recommended dietary intake of calcium is between 1000 and 1300 mg per day, depending on age and sex
• Most Australians do not reach the recommended dietary intake so daily supplements of 500-600 mg of calcium are sometimes needed
• Safety of calcium is still a controversial topic as there is evidence that it may increase risks of MI
• Home based fall prevention program, with visual assessment and a home visit
• Medications 
• Bisphosphonates and Denosumab
• Criteria: minimal trauma fracture or age > 70 with T score <=-2.5
• Bisphosphonates: well tolerated, some significant side effects: oesophageal cancer? (not proven), osteonecrosis of the jaw (see dentist prior to commence treatment) and do not use with the other antiresorptive or anabolic agents
•  Denosumab: use with caution in patients with severely impaired kidney function as denosumab may exacerbate hypocalcaemia 
• Raloxifene 
• postmenopausal woman with a minimal trauma fracture and risk of vertebral fractures predominatly
• reduces vertebral fracture but not non vertebral fractures in postmenopausal women
• Reduces risk of breast cancer so suitable for women at high breast cancer risk
• Associated with increased risk of DVT or pulmonary embolism in meta-analyses
• Strontium ranelate
• Criteria: unable to tolerate other medications or contraindicated to other medications
• assess patient risk of developing CVD before treatment due to safety concerns in patients with history of CVD, embolism or stroke 
• Teriparatide 
• Reduces vertebral and non - vertebral fractures in postmenopausal women 
• limited evidence in men
• must be initiated by a consultant physician
• Vitamin D deficiency
• 600 IU per day for people under 70
• 800 IU per day of people over 70 
• 1000-2000 IU per day may be required for sun avoiders or those at high risk of deficiency
• Monitor treatment response and review therapy to encourage adherence
• BMD measurements 2 years after the commencement of therapy or 1-2 years after therapy changes significantly

Approach to ceasing medications in elderly patients

Key questions to ask:

1. Is there a valid reason for each medication ?

2. Is the drug part of a prescribing cascade to counteract side effects of other medication?

3. Is the drug more likely to do harm than good in medium to long term ?

4. Is the drug prescribed unnecessary or ineffective or amenable to non drug intervention?

5. Is the drug primarily preventive medicine, which is unlikely to confer any patient important benefit over the patient's remaining lifespan?

6. Is the drug imposing unacceptable treatment burden?

References:
RACGP check program

Approach to neck pain

Key points:

- The commonest cause of neck pain is idiopathic dysfunction of the facet joints without a history of injury.

- Again with most of conditions, history is the key.

- Try to determine whether it is non specific neck pain, discogenic or neck pain caused by serious pathology.

- Most of the neck pain will resolve by itself. Beware of the red flag pointers.

- Red flag pointers for neck pain

• History of major trauma 
• Age > 50 years
• Constant pain (day and night)
• Fever > 38 
• Anterior neck (throat) pain 
• History of cancer
• Unexplained weight loss 
• Neurological deficit 
• Radicular pain in arm 
• Rheumatoid arthritis
• Down syndrome: hypoplastic odontoid process 

- When to refer 

• Persisting radicular pain in an arm despite conservative treatment
• Evidence of involvement of more than one nerve root lesion in the arm 
• Evidence of myelopathy, such as weakness, numbness, or clumsiness of the upper limbs
• Evidence, clinical or radiological, of cervical instability in post-accident victims, or people with Down syndrome or rheumatoid arthritis 

References:

John Murtagh 5th edition 

Approach to Dyspareunia

Key points:

- Painful intercourse is a source of considerable distress both physically and psychologically for the sufferer and also for her partner.

- Some authors claim that most cases (80%) of dyspareunia have a physical cause and careful physical examination is mandatory


- History is the key

- Causes of dyspareunia

• Pain worse on insertion 
• physiological inadequate lubrication
• Vaginitis in chronic candidiasis
• Vulvar dermatoses 
• Postnatal perineal scarring 
• Incompletely ruptured hymen 
• Vulvar vestibular sydrome (vestibulitis): well defined entry pain, painful inflammation of vulvar vestibular area, dull ache, burning or pruritus. Tenderness on touch of cotton tipped applicator
• Vulvovaginal atrophy 
• Vaginismus: well defined entry, involuntary spasm of muscles, difficulty of insertion of penis, tampons or digit. Palpable spasm and difficult inserting speculum. 
• Pain worse on deep penetration 
• Endometriosis: Deep pain; cyclic pain with menses, complained of something being bumped into. Enlarged adnexa and tender to touch. 
• PID
• Pelvic adhesions
• Ovarian and uterine tumours
• Postnatal

- Questions to ask

• Where is the located?
• When is the onset of the pain ? (before, entry, vaginal, deep or after)
• Is it pruritic, burning or aching in quality?
• What is the chronologic history? If multiple pain sites, which came first?
• Is it situational or positional ?
• Has it been lifelong or acquired?
• Are there other sexual dysfunctions such as arousal, lubrication or orgasmic difficulties ?
• What treatments have been attempted?
• Explore potential gynecologic causes
• Are there vaginal symptoms including discharge, burning or itching?
• Does patient have a history of STDs, especially HSV or HPV?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an obstetric delivery history of lacerations, episiotomies or other trauma?
• Is there an abdominal of genitourinary surgical or radiation history?
• Has the patient had prior pgynecologic diagnoses, including endometriosis, fibroids or chronic pelvic pain?
• What is the patient's current contraception method and its here any history of intrauterine device use?

References:

aafp : http://www.aafp.org/afp/2001/0415/p1535.html

John murtagh 8th edition

Polycystic ovarian syndrome

Key points :

- It is the most common endocrinological disorder (12-18 % women in reproductive age)

- Presentations: Menstrual irregularity (>35 or < 21 day cycles), overweight, hirsutism, fertility issues, pre diabetes, gestational diabetes or early onset type 2 diabetes, not high risk ethnic groups (Asian, indigenous, Nth African)

- Rotterdam Diagnostic criteria:

• Requires 2 of 
• Oligo- or anovulation 
• Clinical and/or biochemical hyperandrogegism
• Polycystic ovaries; and exclusion of other aetiologies

- Differential diagnosis investigations: TSH, Prolactin and FSH (if premature menopause suspected), free testosterone, DHEAS, SHBG, 17 hydroxy progesterone, FSH, LH

- Total testosterone is often normal in PCOS. cFT is often elevated. 

- PCOS management areas include:

• Emotional health: depresion and anxiety is more common. Assess mental health is the key. 
• Lifestyle : aim for 5-10 % weight loss 
• Cardiometaboic health: Smoking cessation, check BP annually, lipid profile and OGTT every 2 years
• Weight management:5-10% weight loss 
• Fertility: weight loss if BMI > 25 is the first line treatment, metformin (500 mg daily, increase by 500 mg per fortnight up to 1500 mg - 2000 mg average dose) and clomiphene 
• Menstrual cycle regulation: lifestyle and metformin, OCP 
• Clinical hyperandrogenism (eg hirsutism): OCP, if OCP alone doesn't work after 6 months, then try anti androgen (spironolactone) 
• Sleep apnoea 

References:
https://jeanhailes.org.au/contents/documents/Resources/Tools/PCOS_GP_tool.pdf

Achilles tendonosis

Key features:

- Often gradual and insidious onset.

- Diagnosis is mainly made via history and examination. Imaging is not indicated in most cases, however, if there are atypical features such as sudden onset and significant swelling. U/S may be appropriate

- U/S features of tendonosis: neb-vascularity and fusiform thickening

- X-ray is indicated when: insertional tenderness or posterior impingement

- Pathophysiology of tendonosis is not fully understood. May be related to overtraining.

- Management:

• Rest (may need to be off sports for 4 - 6 weeks)
• Gradual return to activities
• Eccentric exercise program (12 weeks, 3 sets, 15 reps of slow heel drop)
• NSAIDs
• Autologous blood injection and platelet rich plasma injection 
• GTN patch + eccentric exercise 

Ankylosing spondylitis

Key features:

- Ankylosing spondylitis encompasses a group of rheumatic disorders that share clinical, genetic and radiographic features and includes psoriatic arthritis, reactive arthritis or inflammatory bowel disease.

- Affects 1 in 200 individuals and is usually diagnosed many years after onset of symptoms . Chronic back pain is common and recognition of early disease requires clinical experience and a high index of suspicion. Further, inflammatory markers are not invariably elevated and radiographic changes are often late findings.

  - The presence of inflammatory back pain (IBP), the archetypal feature of AS, increases the likelihood of SpA to approximately 14%.

- Two very specific features of IBP are alternating buttock pain and awakening only in the second half of the night with spinal pain or stiffness. Table listed the difference between inflammatory and mechanical back pain

- Examination findings:

• Reduced spinal mobility: modified schober's test, lumbar side flexion and occiput to wall distance.
• Extra axial features: 50% asymmetric oligoarthrits (< 4joints), often targeting the lower limb joins, enthesitis and dactylitis.
• Extra-articular features: uniocular anterior uveitis in 40% of patients (presents with acute painful red eye, blurred vision and photophobia)

- Investigation findings: 

• Lab test: CRP, ESR (Only 50-70% of AS patients), HLA-B27
• Imaging: x-rays

References:

- http://www.racgp.org.au/download/Documents/AFP/2013/November/201311golder.pdf