Aug 19, 2016

Sticks and stones

The story

Other services will bend backwards to have you admit non-operative hip fractures in the wee hours of the morning. You'll want to treat osteoporosis well before that 2 am page.

The background

Guidelines recommend screening all women with bone mineral density testing at age 65. Those with a T-score of <-2.5 or an existing hip or spine fracture should begin drug therapy. Standard-of-care bisphosphonates prevent bone resorption and are time tested, but for patients who need to add bone mass – think those with very high fracture risk or those who have failed bisphosphonate therapy – teriparatide (Forteo), an injectable parathyroid hormone analog, is the only approved medication.

Another option

Abaloparatide, a selective parathyroid hormone receptor activator, has emerged as a second bone-builder. A phase 3 RCT found that postmenopausal women who received 18 months of daily abaloparatide injections had significantly fewer vertebral fractures and improved bone mineral density compared to placebo. Abaloparatide fracture rates were similar to teriparatide, but the study size was too small for direct comparison of the two agents. A transdermal patch version of abaloparatide remains in clinical trials.

The takeaway

Low adherence is a big problem for the 10 million Americans with osteoporosis. More drugs and delivery options can help, though the cost of abaloparatide, unknown as of writing, could be a barrier.

Say it on rounds

When the first time you can sit down to think about your list is after sunset

You're not the only one getting busy after dark. ICU trouble, in the form of elderly patient delirium, tends to begin after nightfall. An RCT of 700 patients in China found that infusion of low dose dexmedetomidine, a selective α2 adrenoceptor agonist, decreased postoperative delirium relative to placebo (9% vs 23%) among elderly patients in the ICU in the first 7 days after non-cardiac surgery. The medication was well tolerated, as patients had fewer episodes of hypertension and tachycardia than those on placebo.

When less is more

Good words to live by, and maybe better words for antibiotics. A multicenter, non-inferiority RCT from Spain found that shorter courses of antibiotics (median 5 days) were as effective as longer courses (median 10 days) in hospitalized patients with community acquired pneumonia. More than 75% of patients received quinolone-based regimens, and ICU patients were excluded. 
JAMA Intern Med

When you follow the money, and it doesn't go to you

An analysis of the costs of the Teaching Health Center GME Program – a $230 million federal initiative to fund primary care residency training programs – found the net costs to train new residents in ambulatory/clinic settings to be roughly $150,000 per resident per year. But a breakdown of the budget found that only 26% of expenses went toward resident compensation, while 30% were dedicated to supervising faculty and the rest to basic clinic operations.

Brush up


If you're wondering what gluten really means, it is the term for the storage proteins of wheat, rye, barley, and grain. The proteins are often incompletely digested by gastric and pancreatic enzymes, leaving large peptides as byproducts. And if you're wondering how to identify the 1% of the world's population with Celiac disease, look beyond diarrhea. Most Celiac patients don't have the disease's classic symptom. Instead, many adults present with anemia, osteoporosis, and other conditions like dermatitis herpetiformis and abdominal pain.

What's the evidence

For going gluten-free in Celiac disease? The only known treatment (investigations for new therapies are underway) improved diarrhea symptoms and abdominal pain within 4 weeks in a 215 person survey in patients with confirmed disease. For those with biopsy-proven damage to intestinal architecture, a gluten-free diet helped return intestinal mucosa to normal height within a median time of four years.

Poolside in Rio

A video of Olympic swimmer Fu Yuanhui discussing her period after a race set off a firestorm on the Chinese social network Weibo. Many are crediting Fu with shattering a taboo (especially strong in China) forbidding female athletes from speaking openly about their menstrual cycle.

Spread the word

Tell your friends about The Scope


Not a subscriber? Sign up at
Copyright © 2016 Medicine Scope. All rights reserved.