PBL 1

Question 1

whats the pathology of osteoporosis?

Answer 1

bone resorption > bone formation so we get decreased bone density

Question 2

what are the 3 possible mechanisms for osteoporosis?

Answer 2

inadequate peak in bone mass
excessive bone resorption e.g. lack of oestrogen or excessive PTH
inadequate formation of new bone during remodelling e.g. calcium and vit d deficiency

Question 3

what are the risk factors for osteoporosis?

Answer 3

postmenopause
alcohol 
smoking
immobility
malnutrition e.g. low BMI or ED
malabsorption e.g. crohns disease or coealic
white or asian race 
Fhx
hypogonadal states 
endocrine disorders 
rheumatologic disorders 
meds such as corticosteroids, antiepileptics, anticoagulants, L-thyroxine

Question 4

what are common fractures in those with osteoporosis?

Answer 4

vertebral column, ribs, hips and wrists

Question 5

what are some signs of compression fractures of the vertebral column?

Answer 5

loss of height
hunched posture
kyphosis
sudden back pain
radicular pain
spinal cord compression
cauda equina syndrome

Question 6

how do we diagnose osteoporosis?

Answer 6

DEXA scan to show decreased bone mineral density
blood test
check for Ca2+, PO3-, creatinine, vit D, TSH levels

Question 7

what are treatment options for osteoporosis?

Answer 7

Ca2+ and vit D supplementation
oral bisphosphonates e.g. alendronate or risedronate 
denosumab
teriparatide
SERM e.g. raloxifene 
Parathyroid hormone
fracture management
lifestyle changes

Question 8

what is alendronate used to treat??

Answer 8

corticosteroid induced osteoporosis
pagets disease
preventing osteoporosis in postmenopausal women

Question 9

how do nitrogen containing bisphosphonates work?

Answer 9

they inhibit farnesyl pyrophosphate synthase in osteoclasts what reduces their activity, reducing bone resorption.

Question 10

outline the function of RANK-L?

Answer 10

it binds to RANK receptors on monocytes which causes them to fuse together to form and activate osteoclasts

Question 11

how do osteoclasts cause bone resorption?

Answer 11

they secrete lysosomal enzymes, mainly collagenase, and HCL to digest collagen and dissolve the hydroxyappetite crystals into Ca2+ and Phosphta eions

Question 12

what are side effects of oral and IV bisphosphonates?

Answer 12

oral - upper GI effects

IV - osteonecrosis of the jaw

Question 13

how does denosumab work?

Answer 13

it inhibits RANK-L which prevents maturation and activation of osteoclasts

Question 14

what is the pathology of avascular necrosis?

Answer 14

when blood flow to a bone is interrupted or reduced, causing bone death

Question 15

what areas does avascular necrosis usually affect?

Answer 15

hips and shoulders

Question 16

what could cause avascular necrosis?

Answer 16

injury
fracture
damage to blood vessels
long term med use
excessive alcoholism

Question 17

in a nof fracture, what arteries are damaged to cause avascular necrosis?

Answer 17

retinacular arteries (or foveal in pediatric cases)

Question 18

what are the economic consequences of hip fractures?

Answer 18

Annual cost of fragility fractures in the UK is 4.4 billion and hip fractures account for around 2 billion of this.

Question 19

how can falls be prevented?

Answer 19

staying physically active
testing eyes and ears 
knowing side effects of medication
getting enough sleep
limiting alcohol
standing uo slowly
using an assistive device
proper foot care
wearing good shoes
immediately removing hazards
slowly coming off antipsychotics
well lit rooms
occupation therapists assessing the home
being on <4 meds

Question 20

why are anti-psychotics linked to falls?

Answer 20

they have been associated with hypotension, sedation and gait abnormalities

Question 21

what is the mental capacity act?

Answer 21

a framework to empower and protect people who may lack capcity to maje some decisions for themselves

Question 22

whats the criteria for having capacity?

Answer 22

being able to understand, retain, weigh up informatuon and communicate a decision

Question 23

what are the 5 statutory principles of mental capacity?

Answer 23

presumption of capacity
right to be supported to make their own decisions
rught to make eccentric or unwise decisions
health care providers should make decisions for others based on their best interests
health care providers making a decision for someone should choose the least restrictive option

Question 24

what is an advanced statement of wishes?

Answer 24

written statement that sets down your preferences, wishes, beliefs and values regarding your future care. - not legally binding!

Question 25

are advanced decisions to refuse treatment legally binding?

Answer 25

yes

Question 26

what can patients not refuse in advanced decisions to refuse treatment?

Answer 26

basic comfort and care

Question 27

what makes an advanced decision valid?

Answer 27

> 18 years old when you made this and you had the capacity to make, undrstand and communicate the decision
you specify clearly which treatments yiu wish to refuse
you explain the circumstances in which you wish to refuse them
its signed by you - and a witness if you want to refuse life-sustaining treatment
you made the advanced decision on your own accord without any coersion
you have not said or done anything that could contradict the advance decision since

Question 28

what are arguments against advanced care planning?

Answer 28

at the time of making it, the patient may not be in the position to sufficiently imagine what they will be like in this future time when the ADRT would apply

Question 29

outline the ethical issues around dementia and capacity?

Answer 29

patients must be supported and assumed to have capacity. The capaicyt must be assed in relation to a particular decision the individual needs to make at the time the decision needs to be made