Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis

The adjusted incidence rate of hip fracture in Thailand has increased more than 31% from 1997 to 2006. Mortality and morbidity after hip fracture are also high. One year mortality after a hip fracture has increased from 18% in 1999 to 21% in 2007. The Thai Osteoporosis Foundation (TOPF) developed the first Clinical Practice Guideline (CPG) in 2002 and keeps updating the CPG since then. This latest version of the CPG is our attempt to provide comprehensive positional statement on the diagnosis, prevention and treatment of osteoporosis in Thailand. The study group who revised this position statement contains experts from the TOPF, Four Royal Colleges of Thailand, includes the Orthopaedic Surgeons, Gynecologists and Obstetricians, Physiatrists, Radiologists and 2 Associations of Endocrinologists and Rheumatologists which have involved in the management of patients with osteoporosis.

A nomogram for predicting osteoporosis risk based on age, weight and quantitative ultrasound measurement

INTRODUCTION

Quantitative ultrasound measurement (QUS) or clinical risk index alone are not reliable tools for the identification of women with osteoporosis. This study examined the prognostic value of combined QUS and clinical risk index for predicting osteoporosis risk in Thai women.

METHODS

The study was designed as a cross-sectional investigation with 300 women of Thai background, aged between 38 and 85 years (mean age: 58). Femoral neck bone mineral density (BMD) was measured by DXA (Hologic QDR-4500; Bedford, MA, USA). A femoral neck BMD T-scores <or= -2.5 was defined as "osteoporosis"; otherwise, "non-osteoporosis". QUS was measured by Achilles+ (GE Lunar, Madison, WI, USA) and converted to T-score. Three models for predicting osteoporosis were considered: model I included age, weight and QUS, model II included age and weight, and model III included only QUS. The prognostic performance among the models was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

The prevalence of osteoporosis was 12.7% (n=38/300) by femoral neck BMD. Age, weight and QUS were each significantly associated with osteoporosis risk. The AUC+/-SE value for model I was 0.86 +/- 0.03, which was significantly higher (p=0.02) than that for model II (AUC = 0.80 +/- 0.04) or model III (AUC = 0.79 +/- 0.04). Based on the estimated parameters of model I, a nomogram was constructed for predicting osteoporosis.

CONCLUSION

These data suggest that the combination of QUS and age and weight could significantly improve the prognosis of osteoporosis in Asian women, and that the nomogram can assist primary care physicians in the identification of high-risk women.

Levodopa induced motor complications in Thai Parkinson's disease patients

BACKGROUND

Long-term levodopa usage in Parkinson's disease (PD) patients is known to cause several motor complications. It may be related to several factors such as levodopa dosage, duration of treatment and severity of disease.

OBJECTIVE

To study the prevalence of levodopa motor complications and associated factors in Thai Parkinson's disease patients.

MATERIAL AND METHOD

The authors prospectively collected baseline characteristics of PD patients, details of treatment and complications from 3 hospitals in various parts of Thailand. These patients were diagnosed by UK PD Brain Bank criteria.

RESULTS

A total of 154 patients aged 68.1 +/- 9.5 years were recruited. Age of onset was 61.2 +/- 9.8 years. Most patients were in Hoehn-Yahr stage 1-3. The common clinical features were bradykinesia, rigidity and resting tremor Treatments were levodopa (98.1 per cent), anticholinergic (29.9 per cent), dopamine agonists (26 per cent) and COMT inhibitor (9.1 per cent). Eighty-five per cent of the patients had excellent response to levodopa. However, 25 per cent of patients developed motor complications, which were wearing off (79 per cent), on-off fluctuation (45 per cent), freezing (42 per cent), morning dyskinesia (10.5 per cent) and permanent dyskinesia (23.7 per cent). Twelve patients developed severe levodopa induced chorea. Factors associated with levodopa side effects were earlier age of onset, long duration of disease, advanced stage, higher levodopa dosage and long duration of levodopa treatment. In the present study, age of onset was inversely correlated with H-Y stage, while dosage of levodopa was positively correlated with H-Y stage but inversely correlated with lower ADL score, which may be due to advanced disease state.

CONCLUSION

Levodopa motor complications are common in Thai PD patients. Wearing off on-off fluctuation and freezing are common forms of motor complications.

Seizure-related injuries in northeast Thailand

OBJECTIVE

The authors aimed to assess the frequency, characteristics, and risk of seizure-related injuries from traffic accidents, near-drowning, burns, fractures, head and soft tissue injuries.

MATERIAL AND METHOD

Attending physicians assisted 300 consecutive seizure patients to complete a questionnaire. The types and frequency of injuries were then expressed in terms of the type of seizure and related activity.

RESULTS

The male (154) and female (146) patients were between 13 and 91 years of age (mean, 36.27 +/- 14.55). The seizure types comprised of Generalized Tonic-Clonic (GTC) (26%), secondary GTCs (21%) and complex partials (19%). Secondary causes accounted for 34% of seizures, and post-stroke was the most common (25.5%). The total number of seizure events per year was 8,525 and of these 7,306 included a fall with soft tissue injury (70%), head injury (22%), near-drowning (3%), burns (3%) and fracture or dislocation (1%). The ranking of significant risk factors for injuries was: 1) GTC seizure; 2) seizure with a fall; and, 3) number of seizures.

CONCLUSION

Seizure-related injuries are common among Thai epileptic patients; thus, consistent treatment and education about the risk of injury would protect patients.

Effects of physical activity and dietary calcium intake on bone mineral density and osteoporosis risk in a rural Thai population

The objective of the study was to determine the effects of modifiable risk factors on bone mineral density in postmenopausal Thai women. Dietary calcium intake (g/day), energy expenditure (kcal/day), and sunlight exposure (h/day) were assessed in 129 rural Thai women aged 63 years (range 50 to 84 years). Bone mineral density (BMD) at the femoral neck, lumbar spine, and distal radius were measured by dual-energy X-ray absorptiometry (DXA). The average dietary calcium intake was 236 +/- 188 g/day (mean +/- SD), while the energy expenditure was 2,118 +/- 656 kcal/day with 1.1 +/- 1.7 h of sunlight exposure. In multiple linear regression analysis, dietary calcium intake, energy expenditure, and years since menopause were significant and independent predictors of BMD at various sites. The three factors together accounted for between 35% and 45% of the variance of BMD. The prevalence of osteoporosis (defined as BMD T-scores < or =-2.5) was 33% at the femoral neck, 42% at the lumbar spine, and 35% at the distal radius. The risk of osteoporosis was higher in women with lower dietary calcium intake (< or =138 mg/day; prevalence rate ratio [PRR], 1.4; 95% confidence interval [CI], 1.0 to 1.9), lower energy expenditure (< or =1,682 kcal; PRR, 1.7; 95% CI, 1.2 to 2.3), and greater years since menopause (> or =6 years; PRR, 2.6; 95% CI, 1.2 to 5.8). The population attributable risk fraction of osteoporosis risk due to the three factors was 70%. These results suggest that in the Thai population, low dietary calcium intake and low physical activity together with advancing years since menopause were independent risk factors for low BMD.

Prevalence of hypovitaminosis D in elderly women living in urban area of Khon Kaen province, Thailand

This study included 106 volunteer elderly women who were living in an urban area of Khon Kaen province. The mean (+/-SD) of age and of serum 25(OH)D concentration of these elderly women was 69.42 (+/-6.77) years and 33.32 (+/-7.14) ng/ml respectively. There was a significant inverse relationship between serum 25(OH)D and PTH concentration. Serum PTH concentration started to increase steeply when serum 25(OH)D concentration declined < or = 35 ng/ml and increased significantly when serum 25(OH)D concentration declined < or = 30 ng/ml. Furthermore mean (+/-SD) of serum 25(OH)D concentration in the group of osteopenia and osteoporosis of femoral neck was 35.25 (+/-6.77) and 30.92 (+/-6.49) ng/ml respectively. As a result, the prevalence of hypovitaminosis D in these selected elderly women would be at least 34.9 per cent, or as high as 65.1 per cent.

Different mechanism of bone loss in ageing women and men in Khon Kaen Province

The changes of vitamin D status and biochemical markers of bone turnover have been reported with aging. In this study we determined age-related levels of vitamin D and biochemical markers of bone turnover in the general adult population between the ages of 20 and 84 years who were living in Khon Kaen province in northeastern Thailand. Serum 25 hydroxyvitamin D was determined as an indicator of vitamin D status. Serum total alkaline phosphatase and N-terminal mid fragment osteocalcin were measured as biochemical markers of bone formation and serum C-terminal fragment of type I collagen was measured as a marker of bone resorption. The levels of serum 25 hydroxyvitamin D were high in the Khon Kaen population. Men had higher levels of 25 hydroxyvitamin D than did women. However, there were no changes with age in either sex. In women, all biochemical markers of bone turnover increased with age after the fourth decade. The sharp increase was observed in the sixth decade which was around the menopausal age. In contrast, in men all biochemical markers of bone turnover except serum total alkaline phosphatase had a tendency to decrease with age.

CONCLUSION

There was no evidence of vitamin D deficiency in a Khon Kaen population. In addition, serum vitamin D levels did not decline with ageing. Women and men showed different changes of biochemical markers of bone turnover with ageing indicating gender difference in the pathogenesis of osteoporosis.