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Cytology tologic diagnosis was multicentric cheap 200mg ketoconazole overnight delivery fungus horses, indicated a lipoma with xanthomatosis of anaplastic pancreatic carcinoma with car- the skin overlying the mass (note the yel- cinomatosis of the serosal surfaces of the lowish generic 200mg ketoconazole with visa fungus gnats infestation, thickened skin) purchase ketoconazole 200mg with mastercard fungus za kucha. The tumor and as- abdomen and the tunica muscularis of the sociated xanthoma were surgically excised intestines (courtesy of Cheryl Greenacre) generic ketoconazole 200mg with visa antifungal treatment for thrush. The bird did not non-healing wound that progressively en- respond to supportive care. Bi- and splenomegaly with raised white nod- opsy of the lesion revealed a squamous cell ules in the liver were noted at necropsy. Histopathology revealed an accumulation of lymphoid cells in the nodules, consistent Color 25. Histopathology of the mass con- A five-year-old male budgerigar was pre- firmed a squamous cell carcinoma (see Fig- sented for abdominal distention and left ure 25. The renal The mass was debulked and the histologic mass was histologically identified as a re- diagnosis was squamous cell carcinoma. The tumor margin was irradiated with a strontium-90 ophthalmic probe (courtesy of Color 25. A five-year-old budgerigar was presented with a rapidly growing firm mass on the Color 25. Cytology indi- A three-year-old cockatoo was presented cated a pleomorphic population of spindle with bilateral foot lesions characterized by cells suggestive of fibrosarcoma. If not associated with any The case was managed by amputating the specific dysfunction, lesions such as these affected wing (courtesy of Jane Turrel). A diffuse, firm, yellow A mature, male cockatiel was presented mass was noted in the carpal region on with a several-month history of poor gener- physical examination. The appearance of alized feather condition and feather loss the lesion was suggestive of xanthoma, and around the uropygial gland. A raised, firm, the demonstration of vacuolated macro- uropygial gland mass was evident. Cytol- phages, lipids and cholesterol crystals in a ogy of the mass revealed multiple mitotic fine-needle aspirate from the mass was figures. Radiographs indicated a history of a progressively enlarging ab- fracture of the mid-diaphyseal tibiotarsal dominal mass. This bird responded to a change in coma, and the client chose to have the bird diet and increased exercise over a three- euthanatized. Inset shows the dissected month period, followed by surgical excision bone, which had healed from the pathologic of the mass that was half its original size at fracture, with the pin in place. The bird was rhamphotheca, indicating inflammation of presented one year later with lethargy, the germinative layers of the beak. His- diographs indicated a large, soft tissue topathology was suggestive of a papilloma. Histologic lesions were consistent nal tubular adenocarcinoma with metasta- sis to the lung, liver and myocardium. A four-year-old budgerigar was presented with a rapidly growing, necrotic mass of the Color 25. The mass was interfering with the bird’s ability to eat, and the owners rot was presented for an acute onset of depression and apparent blindness. Histologic evaluation in- dicated the mass was a fibrosarcoma (cour- only abnormal physical examination find- ing was mild ataxia. A mild hetero- A ten-year-old Umbrella Cockatoo was pre- philia (19,000 cells/µl) was the only abnor- sented for dysphagia, weight loss and poor mal clinicopathologic finding. The tion, a large, pendulated, ulcerative sublin- bird would maintain weight and condition gual mass was identified. The bird had with supportive care but would deteriorate dystrophic feathers and was positive for when the supportive care was stopped. Cytology of a fine-needle aspirate of The ventral surface of the brain was nodu- the oral mass was suggestive of a giant cell lar in appearance. These neoplasms usually arise The microscopic appearance of these neoplasms is in the cerebral hemispheres. Microscopically, they quite striking, containing a mixture of tissue types are composed of small cells with round, hyperchro- derived from two or three germ cell layers. Evidence exists for budgerigar with blindness, exophthalmos and sei- both of these presentations of lymphoid neoplasia in zures. Rows of columnar cells were ar- coma is discussed in detail under the hemolymphatic ranged in irregular papillary projections, small ro- system. Meningioma: Meningiomas originate from neural crest cells or mesenchymal cells in contact with neu- Neuroblastoma and Ganglioneuroma: These neo- ral crest cells. Microscopically, meningiomas are plasms are derived from primitive neuroepithelial often characterized by whorls of crescent-shaped cells that differentiate toward neuroblasts cells. Ganglioneuromas are usually benign, but excision based upon their location, size and proxim- may be malignant. Vascular Neoplasms: The most common vascular Schwannoma: These neoplasms previously have neoplasms observed in the central nervous system been reported as neurolemmomas or neurofibroma, are hemangiosarcoma and hamartoma. A hamartoma-like lesion the peripheral nerve sheaths in any location includ- has been reported in the brain of an 11-week-old ing unspecified peripheral nerves, cranial nerves, budgerigar. Microscopically, the lesion was composed sciatic plexus, gastrointestinal tract, testis, pineal of blood-filled spaces within the neuropil that com- gland, kidney, skin, muscle and spleen. Histologically, fusiform cells are ar- Teratoma: Grossly, these primordial germ cell neo- ranged in interwoven bundles, whorls or palisade plasms, which may be large and cystic, have been arrangements. These neo- plasms have greater cellularity, marked anaplasia, an increased mitotic rate and may metastasize. Ma- lignant schwannomas have been reported to occur in Canada Geese, but histologic studies have failed to demonstrate a neural origin. Lymphoid Neoplasia (Lymphosarcoma): M a r e k ’ s disease in chickens is often associated with leg pa- ralysis secondary to ischiatic nerve infiltration by neoplastic lymphocytes. Microscopically, the lymphoid infiltrates may vary from small lymphocytes and plasma cells to lymphoblasts. The mass was surgically removed in conjunction with enu- Ocular Neoplasms cleation. The mass reappeared two years later and the bird was The following discussion is concerned with primary euthanatized. Neo- plasms involving the eyelids, conjunctiva and orbit are discussed under appropriate organ systems and into the retrobulbar space. Intraocular neoplasms in birds may be associated Malignant Medulloepithelioma: Intraocular medul- with blindness, hyphema or aqueous flare. Some neo- loepitheliomas are primitive neoplasms that origi- plasms, such as malignant lymphoma, may be visu- nate from the optic cup epithelium88 and have been alized occasionally by ophthalmoscopy. These cells were curs with some frequency and usually indicates a arranged in nests, sheets and rosettes. Foci of ne- retrobulbar space-occupying lesion or extension of crosis also were observed. Neoplastic cells extended malignant ocular neoplasia into the retrobulbar into the retrobulbar spaces, infiltrating the optic area.

In the present work discount 200mg ketoconazole mastercard fungus zombie spider, two selected Myanmar medicinal plants generic 200mg ketoconazole visa fungus kills ants, namely Zanthoxylum alatum Roxb ketoconazole 200 mg mastercard fungal cell wall. Antibacterial screening by agar well diffusion method against Bacillus subtillis buy discount ketoconazole 200mg online fungus eyelid, Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus pumalis, Candida albicans and Mycobacterium species of different extracts of Mak-kat seeds and Taw-shauk roots indicated that polar extracts are good candidates for active compounds, especially ethyl acetate extract. Xanthoxylin (L-1) was isolated as major constituent from active ethyl acetate extract of Z alatum Roxb. The isolated compounds were characterized and identified by chemical methods, modern spectroscopic methods and reference to biosynthesis pathways. Finally, the antidiarrheal activity of the aqueous extract of Zanthoxylum alatum Roxb. There were significant reduction in faecal outputs and frequency of droppings when the plant extracts of 3. In addition, the aqueous extract (3g/kg dose) was found to possess significant antidiarrheal activity, with experimental in vivo antidiarrheal index of 71. Investigation of chemical constituents and bioactivities of some organic compounds from rhizomes of Boesenbergia pandurata (Roxb. Besenbergia pandurata (Roxb) (Seik-phoo) red and yellow rhizomes were chosen for the investigation of chemical analysis and biological action. Rhizomes and roots of this plants are used in cases of stomachic, cough, confinement, diarrhea, also for rheumatism and muscular pains and as tonic and skin liniment in traditional medicine. By silica gel column chromatographic separation technique, seven compounds namely, pinostrobin (A-1, 2%, m. Therefore, Seik-phoo (yellow rhizome) may possess higher antimicrobial potency than that of red rhizome. It was observed that both extracts were free from acute toxic or harmful effects in the concentration range from 3g/kg to the maximal permissible dose 12g/kg. Antidiarrhea activity of aqueous extract of Seik-phoo (yellow) rhizome was carried out using castor oil induced anti diarrhea model in mice. The response parameters assessed includes antidiarrhea, anti secretory and intestinal transit activaties. A significant reduction of fecal output and the frequency of droppings in the first hour of administration (53. Thus, the rhizomes of Seik-phoo (red and yellow) plant may be used as antimicrobial, antidiarrheal and antioxidant agents in traditional medicine formulations. Investigation of chemical constituents and mosquito repellency of Melaleuca leucadendron Linn. The repellent activity was tested on human volunteers by mean of arm in cage studies againts A. No lethality in mice was observed when fed with 95% ethanol extract of Ka-lan leaves up to 9g/kg body weight dose. Investigation of mosquito repellent activities of some compounds in Cymbopogon winterianus Jowitts. Asteracerce, Mel-di-dote in Myanmar), were selected for investigation of mosquito repellent activity. The result revealed that topical application of 25% (w/v) citronella oil in acetone-water provided at least 1½ h of complete protection. In addition, 100%, 25% 10%, 5% and 2% (w/v) citronella oil after 6h single application reduced the biting rate by 90. All isolated compounds showed better repellent activity than their mother extracts. Because of its high yield, it can be considered as an alternative in mosquito repellent formulation. All the plant extracts and isolated compounds did not cause dermal irritation when applied to human skin. Investigation of organic constitutents and bioactivity of the leaves of Vitex trifolia Linn. In the present work, investigation of some phyto organic constituents and some biological activities such as antimicrobial and antimalarial activities were carried out on the leaves of two selected medicinal plants: Vitex trifolia Linn. These plants are traditionally used as remedy for the treatment of sinusitis and malaria. The identifies of all of the isolated compounds were determined by measurement of their melting points, some physico-chemical properties and also by modern spectroscopic techniques. All of these extracts were tested on 6 strains of pathogenic microorganisms such as Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus subtilis, Bacillus pumalis, Candida albican and Mycobacterium tuberculosis by agar plate diffusion method. The antimicrobial activity of isolated compounds such as vitexilactone, p-hydroxy benzoic acid, a mixture of fatty acid ethyl esters (E) and n-hexadecanoic acid were also determined by agar plate diffusion method against S. Among them, vitexilactone and p-hydroxy benzoic acid and mixture of fatty acid esters (E) were found to exhibit the antimicrobial activity effectively against the S. Therefore, from these observations it can be inferred that vitexilactone and p-hydroxy benzoic acid, oil mixture (E) and n-hexadecanoic acid can be used in the treatment of diseases namely; sinusitis, skin infections, respiratory tract infections, urinary tract infections, external ear infections, septicemia, tuberculosis and leprosy etc. The morphological and microscopical characters of the leaves, stems and roots were also studied. In morphological study, the plant is annual herb; the stem is ascending or spreading, simple or much branched. Microscopical characters of leaves, stems and roots were also undertaken and examination of powdered drug were carried out for standardization of drugs. In microscopical study, the epidermal cell of lower and upper surface of lamina were wavy and covered with striated cuticle. Calcium oxalate crystals formed as bundles of raphide present in spongy layers of leaves, cortex layers of leaves, cortex layers of stems and peridem layer of roots. The collected plants were dried, powdered and stored in airtight bottle for further use. The preliminary phytochemical examination was carried out to examine the chemical constituents. This examination showed the presence of alkaloids, glycosides, amino acid, phenolic compounds, reducing sugar, saponins, steroid, tannins and terpenoids. Physicochemical characterization such as moisture content, total ash, acid insoluble ash, water soluble ash, polar to non-polar soluble matter content were carried out to determine the soluble matter content. Isolation of chemical constituents of the plant extract was carried out by silica gel column chromatography and selective solvent solubility method. Various solvent extracts of plant and isolated compounds (oleanolic acid and asperuloside) were tested against different microorganisms for their antimicrobial activity by using agar well diffusion method. It was found that isolated compounds showed more significant antimicrobial activity than different solvent extract. The acute toxicity test was carried out with 70% ethanolic extract of Su–la–na-pha by using albino mice. It was observed that the 70% ethanolic extract was free from acute toxicity or harmful effect during observation period of 2 weeks even with maximum permissible dose of 16g/kg. Using albino rats at 6g/kg dose tested diuretic activity of 70% ethanolic extract of O.

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Repeat blood work to assess renal in the state of acute anemia generic ketoconazole 200 mg with mastercard fungus from pedicure, adaptive changes compen- function and serum electrolytes cheap 200 mg ketoconazole mastercard antifungal walgreens, and progression of sate for decreased oxygen delivery order ketoconazole 200mg visa fungus gnats soil drench. It is unclear if this anemia will influence the decision to place central adaptive state could influence the overall outcome in venous access or a peritoneal dialysis catheter cheap ketoconazole 200mg with visa killing fungus gnats with sand. Even though it is at times difficult or a progressively positive fluid balance in the setting to distinguish between symptoms related to the under- of decreased urine output. Placement of invasive lines lying disease and a true reaction to transfusion, the should only be undertaken by experienced profes- incidence of transfusion-related reactions has been sionals as bleeding complications are not infrequently reported to be as high as 1. Another important factor to consider when mak- avoid difficulties due to marked volume overload and ing the decision to transfuse packed red cells is the edema and might decrease the risk of procedure-asso- strong potential of bone marrow suppression in a ciated complications. Presence of hypertension or res- patient who has an appropriate bone marrow response piratory involvement might require the insertion of an indicated by an elevated reticulocyte count. Posttransfusion hematocrit levels above 30% potential need for future transfusion. There is ongoing debate about the optimal diu- that prolonged thrombocytopenia is associated with an retic prescription. It appears that in hemodynamically increased risk for long-term renal abnormalities [7]. A trial of furosemide at a dose of 2–4 available data caution treating providers to withhold −1 −1 mg kg dose or as continuous drip should be consid- platelet transfusion given the potential to increase for- ered. The addition of a downstream thiazide diuretic mation of hyaline platelet-fibrin thrombi and worsen- can potentially further enhance urine output. In a ing of microthrombi by transfusing additional platelets recent meta-analysis of patients with acute renal fail- [24, 27]. An absolute indication for platelet transfusion ure (including critically ill patients), loop diuretics in the setting of documented thrombocytopenia is acute did not affect mortality or the need for renal replace- and clinically significant bleeding, which is rarely ment therapy but shortened the duration of dialysis seen in clinical practice; most centers also agree on and improved urine output [3]. However, since the platelet transfusion as a prophylactic measure before majority of the patients in these studies were not criti- performing an invasive procedure such as placement cally ill, conclusions for this particular population are of a central venous catheter. These has been established, focus is on conservative medical advances are due to a combination of several factors, management of acute renal failure. Renal failure can including availability of continuous forms of hemodi- present either in the oligoanuric form or nonoligoa- alysis in children, especially younger children, quality nuric form. Accurate fluid management is critical for of vascular access, and our improved understanding of both groups since renal failure can progress toward the pathophysiology of individual disease entities [35]. Several factors need to be taken into close documentation of the fluid balance by meas- consideration, most of all modes of dialysis and early uring intake and output including insensible losses provision of proper access by the pediatric intensiv- (350–400 cc m−2); this is important to avoid volume ist or pediatric surgeon. Having central venous access overload, one of the most common indications for available early will avoid difficulties with placement in initiation of renal replacement therapy. It is helpful to decide on a mode mal recommended daily allowance adjusted for age. Studies have also shown that patients Abnormalities in a baseline cholesterol and triglycer- with less volume overload and lower levels of uremia ide levels might warrant restriction of lipids, which is might have an overall better prognosis [23, 46]. It is important to remem- dinated with the placement of dialysis access to avoid ber that all modalities of dialysis have certain poten- additional procedural sedation. In the presence of hyperkalemia, diuretics, therapy under the direction of the Pediatric Nephrologist bicarbonate and potassium binding resins among and Intensivist. The choice of dialysis mode depends others (see chapter on hyperkalemia) should be used on the individual experience of the treating providers until proven noneffective and the decision to proceed and center. It is important to remember preferred mode unless abdominal complications, most that insulin with glucose and treatment with bicar- often serious colitis requiring surgical intervention, bonate only lead to a temporary decrease in extra- pose a contraindication to this form of renal replace- cellular potassium levels by intracellular shifting but ment therapy. Children with not require the presence and experience of specialized acute renal failure in the intensive care unit are fre- staff as in the other forms of renal replacement ther- quently malnourished, often due to a combination of apy. The peritoneal dialysis catheter can be placed at an exhausting primary disease and malabsorption of the bedside or in the operating room and is essentially nutrients [4]. In the past, fluid restriction to avoid a ready for use immediately after placement. Peritoneal positive fluid balance in a child with oligoanuric renal dialysis solutions are available from a number of man- failure was one of the mainstays of supportive care. It seems therefore intuitive that early Three variables allow adjustment of the ultrafiltration dialysis in oligoanuric children and avoidance of pro- volume and clearance: dextrose content of the solu- longed nutritional restriction might be a reasonable tion, fill volume, and frequency of exchanges. Continuous forms of renal replace- 5 Progressive and profound azotemia ment therapy are quite gentle and used in the coop- 6 Need for transfusion of blood products in the erative child but require the presence of experienced setting of oliguria personnel. Sedation and potentially intubation might 7 Removal of inflammatory mediators in the be required for a younger child to successfully perform critically ill child the procedure, interventions that are rarely necessary Chapter 16 Hemolytic Uremic Syndrome 227 with peritoneal dialysis. Care must be taken with respect to bleeding tiate complications from primary disease as opposed complications, clotting of the circuit, and infection. A system-based approach is helpful to Young age and cardiovascular instability of the child organize and manage these issues. A detailed discussion on the topic of hyperten- requires nursing staff with experience in hemodialysis sion can be found elsewhere is this book. Fluid removal and electrolyte shifting occur over the pathogenesis of hypertension: First, hyper expan- a much shorter time compared with the other forms of sion of the intravascular volume secondary to an imbal- dialysis, making this a suboptimal mode of therapy in ance of fluid needs and inability to excrete and second, the hemodynamically unstable patient. Depending on the severity of vigorously debated but no consensus approach has the child’s illness and degree of blood pressure eleva- emerged so far. Bernard surgical consultation, mostly due to bowel perforation decrease in mortality is primarily due to increased as shown by Brandt et al. Other potential complications include chole- replacement therapy and risk for chronic renal disease lithiasis and rectal prolapse. Patients who need dialysis for more than 1 week are at higher risk of chronic renal 16. Children with persistent proteinuria, Significant neurologic involvement as indicated by the microscopic hematuria, hypertension or those individ- presence of mental status changes, seizures, general- uals whose level of azotemia do not return to baseline ized or focal neurological deficits, or evidence of cere- are at highest risk for long-term kidney abnormalities. Any unexplained neurologic prognosis was associated with absence of overt pro- symptoms warrant timely and thorough investigation, teinuria, predicted creatinine clearance greater than preferably under the guidance of a pediatric neurolo- −1 −2 80 cc min per 1. Magnetic reso- modern practice, it appears that cortical necrosis and a nance imaging with attention to ischemia as well as greater than 50% disease involvement of glomeruli on electroencephalography to rule out subclinical status histopathology correlate with a poorer prognosis. Minimizing the use of those agents or a trial off men consistent with hyperfiltration and hyperperfusion might help to differentiate between disease-associated injury are closely correlated. Pancreatic involve- the form of proteinuria or hematuria or other pathology ment including pancreatitis and transient diabetes mel- years after complete recovery is difficult, and defining litus has been reported in 5–15% of individuals [15]. Since therapy to disease prevention is to minimize exposure risk and has over the years remained mainly supportive, this avoidance of bacterial spreading. Proper handling of Chapter 16 Hemolytic Uremic Syndrome 229 meat products and preparation of foods, especially 4. Bosch T, Wendler T (2001) Extracorporeal plasma treat- of children at risk theoretically could improve manage- ment in thrombotic thrombocytopenic purpura and hemo- ment and overall outcome. J Pediatr Promising basic science development includes 125:519–26 intranasal application of the B subunit of E. In a rodent model, rats given the intranasal appli- Shilkofski N (2005) The Harriet Lane Handbook.

The most common risk factors are as follows: • Age (50–90 years) • Female • Thinness • Small stature • Prior fragility fracture • Parental history of hip fracture • Current tobacco smoker • Long-term use of glucocorticoids • Rheumatoid arthritis • Other causes of secondary osteoporosis (e buy ketoconazole 200 mg line fungus definition medical. Vitamin D Deficiency The importance of vitamin D sufficiency in bone health has been underappreciated in the past discount 200mg ketoconazole fungus gnats kill larvae. Emerging research is showing a direct correlation between both bone density and blood levels of vitamin D3 purchase ketoconazole 200 mg with amex antifungal spray. Higher blood levels of vitamin D are associated with a lower rate of fractures of virtually all types; lower blood levels of vitamin D are associated with a higher rate of fractures of all types ketoconazole 200mg fast delivery antifungal medications oral. Since vitamin D can be produced in our bodies by the action of sunlight on 7-dehydrocholesterol (a compound the body can manufacture from cholesterol) in the skin, many experts consider it more of a hormone than a vitamin. Strictly defined, a vitamin is an essential compound the human body cannot manufacture, while a hormone is a compound that the human body manufactures and that serves to control a particular function. This form of vitamin D is also the most popular supplement form, so taking it in supplement form bypasses the need to manufacture it in the skin. Disorders of the liver or kidneys result in impaired conversion of cholecalciferol to more potent vitamin D compounds. In some patients who have osteoporosis, there are high levels of calcidiol, while the level of calcitriol is quite low, signifying a problem with the kidneys. So, it may not be enough to supplement with vitamin D3, as many people with osteoporosis may not be converting it fully to calcitriol. Many theories have been proposed to account for this decreased conversion seen in some patients with osteoporosis, including lack of parathyroid hormone, lack of estrogen, magnesium deficiency, and deficiency of the trace mineral boron. Diet and Lifestyle As significant as genetic factors are in osteoporosis risk, there is no question that the major determinants of bone health are diet and lifestyle. Factors that influence bone health include physical activity; protein intake; acid-base homeostasis; smoking; alcohol consumption; and intake of calcium, vitamin K, and vitamin D. To achieve peak bone mass, a young woman requires adequate calories, protein, and calcium. Smoking Women smokers tend to lose bone more rapidly and have a lower bone mass than those who do not smoke. It may be that smoking interferes with estrogen metabolism, although the mechanism is not clearly known. Alcohol Consumption of seven alcoholic drinks or more per day, which is considered heavy, has been shown to increase the risk of falls and hip fractures. However, moderate alcohol consumption seems to lower the risk of hip fractures in older women. It is thought that moderate amounts of alcohol inhibit bone resorption by increasing estradiol concentrations. The evidence is overwhelming that highly active individuals have higher bone mass24 and those who are sedentary have a lower bone mass. Individuals who require bed rest25 or who are confined to a wheelchair experience a rapid and dramatic loss of bone. Exercise functions primarily to reduce osteoporosis risk by stimulating the activity of osteoblasts, the bone-building cells. Hormonal Factors A woman’s hormonal status clearly influences bone mass and the rate of bone resorption. After menopause, all women lose bone, and this loss is especially accelerated in the first five years. The drop in estrogen production that comes with menopause, no matter at what age, increases the rate of bone resorption. The earlier menopause occurs before the average age of onset (51 years), the sooner the bones lose the protective effect of endogenous estrogen. Women who have premature menopause (before age 40), who began menstruating late in adolescence (e. Women who missed up to half of their expected menstrual periods because of low estrogen had 12% less vertebral bone mass than did those with normal menstrual cycles; those who missed more than half had 31% less bone mass than healthy controls. If levels start to decrease, there is an increase in the secretion of parathyroid hormone by the parathyroid glands and a decrease in the secretion of calcitonin by the thyroid and parathyroids. If calcium levels in the blood start to increase, there is a decrease in the secretion of parathyroid hormone and an increase in the secretion of calcitonin. Parathyroid hormone increases serum calcium levels primarily by increasing the activity of the osteoclasts, although it also decreases the excretion of calcium by the kidneys and increases the absorption of calcium in the intestines. In the kidneys, parathyroid hormone increases the conversion of calcidiol to calcitriol. Assessing Risk The more risk factors are present, the greater the potential for lower bone mass and the higher the risk of fracture. Risk factors alone cannot adequately determine whether an individual has low bone mass; rather, they are important guides in determining osteoporosis and fracture risks, and an understanding of these risks contributes to optimal prevention strategies. In addition, various medical conditions and medications can interrupt normal bone physiology and lead to osteoporosis. Secondary Causes of Bone Loss • Genetic disorders Hemochromatosis Hypophosphatasia Osteogenesis imperfecta Thalassemia • Hormonal disorders Cortisol excess Cushing’s syndrome Gonadal insufficiency Hyperthyroidism Primary hyperparathyroidism Type 1 diabetes Hypothalamic amenorrhea Premature ovarian failure • Gastrointestinal diseases Primary biliary cirrhosis Celiac disease Crohn’s disease Total astrectomy Gastric bypass • Other conditions Ankylosing spondylitis Chronic renal disease Lymphoma and leukemia Multiple myeloma Anorexia nervosa Bulimia Rheumatoid arthritis • Medications Aromatase inhibitors Cytotoxic agents Excessive thyroid dosing Gonadotropin-releasing hormone agonists or analogs Some long-term anticonvulsants (e. The World Health Organization’s criteria for the diagnosis of osteoporosis uses T-scores. Keep in mind that using the T-score instead of a Z-score increases the likelihood that you will be classified as having osteopenia, even though it is normal to lose some bone mass with aging. However, you can reduce your score significantly by taking steps to reduce or eliminate risk factors as described in this chapter. For women who are at risk of osteoporosis or who have already experienced significant bone loss, the benefits of natural hormone therapy (described below) outweigh the risks. The exception is women at high risk for breast cancer or women with a disease aggravated by estrogen, such as active liver diseases or certain cardiovascular diseases. Laboratory Tests of Bone Metabolism Tests for biochemical markers of bone turnover include a urine test that measures the breakdown products of bone, such as cross-linked N-telopeptide of type I collagen or deoxypyridium. These tests can be correlated with the rate of bone loss, but they are not intended to be used for the diagnosis of osteoporosis or monitoring of bone loss. The reduction of urinary levels of these markers of bone breakdown over a 2-year period has been correlated with increases in bone density measurements. A comprehensive plan that addresses all of these factors offers the greatest protection. Fortunately, osteoporosis in most cases is entirely preventable through diet, lifestyle, and proper supplementation. However, since drug therapy is such a major focus in the conventional prevention and treatment of osteoporosis, it is important for us to discuss it. Drug treatment focuses on the use of estrogen and progesterone, bisphosphonates, Evista (a selective estrogen receptor modulator), parathyroid hormone, and calcitonin.