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By Y. Dimitar. California State University, Los Angeles.

The inci- dent vertebral fractures is important in both clinical and dence of osteoporotic fractures increases with age purchase zenegra 100mg. Fewer population purchase 100 mg zenegra with visa, the financial and human costs associated with than 1% of back pain episodes are related to vertebral osteoporotic fractures will multiply exponentially buy 100 mg zenegra. Therefore vertebral fractures are often not cording to the International Osteoporosis Foundation 100mg zenegra with amex, more suspected in patients reporting back pain 100mg zenegra otc, unless associ- than 40% of middle-aged women in Europe will suffer ated with trauma. Trauma-related fractures, however, are one or more osteoporotic fracture during their remaining not considered as classical osteoporotic fractures. Some Vertebral fractures are the hallmark of osteoporosis height loss is expected with aging due to compression of and occur with a higher incidence earlier in life than any the intervertebral discs and postural changes. However, other type of osteoporotic fractures, including hip frac- height loss could also be due to multiple fractures, which tures. The importance of fragility fractures, of which represent significant and irreparable damage. Therefore it vertebral fractures are the most common, was acknowl- has been concluded that height loss is an unreliable indi- edged by the World Health Organization classification cri- cator of fracture status until it exceeds 4 cm. The criterion of the vertebral fractures are often not being considered in clini- World Health Organization defines severe osteoporosis cal patient evaluation, and it is relatively uncommon for as low bone mass (T score below –2. Improvements in detecting and report- The definition of osteoporosis is centered on the level ing vertebral fractures in patients with osteoporosis would of bone mass, which is measured as bone mineral density increase the potential of therapeutic intervention to pre- (BMD). In Radiographic assessment of vertebral fractures addition, many other risk factors have been identified, some of which are known to add to the risk independently of Radiographic diagnosis is considered to be the best way to BMD measurements. The combination of BMD with such identify and confirm the presence of osteoporotic verte- risk factors increases the gradient of risk/standard devia- bral fractures in clinical practice. Several clinical tional lateral radiographs of the thoracolumbar spine have trials have demonstrated that a substantial improvement in been visually evaluated by radiologists or clinicians to the assessment of the risk for future fractures can be ac- identify vertebral fractures. However, there is still no in- complished by the assessment of prevalent vertebral frac- ternationally agreed definition for vertebral fracture. One tures in combination with BMD measurements [2, 5, 15, global prospective study (the IMPACT study) compared 27, 31, 36, 39, 41]. Nonetheless, it remains a common the results of local radiographic reports from five conti- clinical practice to consider low BMD to be a risk fac- nents with that of subsequent central readings in more tor irrespective of the presence of vertebral fractures. This study demonstrated that vertebral fractures were frequently underdiagnosed radiologically worldwide, with false-neg- Clinical identification of vertebral fractures ative rates as high as 30% despite a strict radiographic protocol that provided an unambiguous vertebral fracture It has been shown that both symptomatic and asympto- definition and minimized the influence of inadequate film matic vertebral fractures are associated with increased quality. It was concluded that the failure was a global morbidity and mortality [8, 22, 35]. Morbidity associ- problem attributable to either lack of radiographic detec- ated with these fractures includes decreased physical func- tion or use of ambiguous terminology in reports. Large-scale prospec- the diagnosis of osteoporosis and to assess the severity or tive studies demonstrate that only about one of four verte- progression of the disease as well as to rule out nonfrac- bral fractures becomes clinically recognized. They introduced a classification of ver- and there would have to be changes in vertebral shape in tebral deformities as diagnosed from lateral thoracolum- order to account for incident vertebral fractures on follow- bar radiographs for the purpose of diagnosing the severity up radiographs. This method grades only the most se- fractures consist of a combination of wedge and endplate verely deformed vertebra on the radiograph. From a radiological prospective, there are vertebral bodies T3 (or T7) to L4 are evaluated. This grading reflected at its best in the semiquantitative fracture assess- scheme is based on the reduction in the anterior, middle, ment method proposed by Genant et al. In addition to height reductions, ical change, and vertebral fractures are differentiated from careful attention is given to alterations in the shape and other, nonfracture deformities. These features add severity grade based upon the visually apparent degree of a strong qualitative aspect to the interpretation. Unlike the other approaches the type ple, vertebral deformities due to degenerative changes of the deformity (wedge, biconcavity, or compression) is should be ruled out, whereas an endplate vertebral frac- no longer linked to the grading of a fracture in this ap- ture can be identified without a 20% reduction in the ver- proach. Nevertheless, in experienced, highly trained Thoracic and lumbar vertebrae from T4 to L4 are graded hands, it makes the approach both sensitive and specific. It considers the continuous character of vertebral fractures and makes a meaningful interpretation of follow-up radiographs possi- ble. Furthermore, inevitably arbitrary decisions regarding wedge, endplate, or crush deformities, as assessed in some grading schemes, are not necessary since most fractures Fig. The repro- ducibility of the method for the diagnosis of prevalent and incident vertebral fractures was found to be high, with in- traobserver agreement of 93–99% and interobserver agree- ment of 90–99%. This indicates that close agreement among readers can be reached using this standardized visual semi- quantitative grading method, and that subjectivity in the readings can be reduced.

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ALLHAT also included a lipid- heart disease and in those at high risk generic zenegra 100mg fast delivery, but with- lowering agent in over 10 000 of the enrolled out evidence of heart disease buy 100 mg zenegra visa, leads to impressive participants in a factorial design discount zenegra 100 mg line. The primary CARDIOVASCULAR 179 outcome for the lipid component was all-cause Rates of death in people who have had a mortality; this part of ALLHAT was an open order zenegra 100mg visa, or myocardial infarction used to be quite high generic zenegra 100 mg with mastercard. One of the antihypertensive agents, an alpha- Thus, trials using mortality alone as an end- adrenergic blocker, was stopped early because point may no longer be feasible even in sur- although there was little difference in the primary vivors of a heart attack, unless a very high outcome, there was a significant increase in risk group is studied. This has led to increased heart failure in the alpha-adrenergic blocker arm, use of combination endpoints, such as car- compared with the diuretic arm. The other two diovascular mortality plus non-fatal myocardial antihypertensive treatments, a calcium channel infarction. The Heart Outcomes Prevention Eval- blocker and an angiotensin-converting enzyme uation (HOPE) study compared the angiotensin- inhibitor, continued to the scheduled end of the converting enzyme inhibitor ramipril against trial. There were no differences between either placebo in 9297 people with either known vas- of these arms and the active control thiazide cular disease or diabetes plus another risk factor. There were The primary outcome was myocardial infarction, some differences in secondary outcomes, with the stroke or death from cardiovascular causes. Thus, diuretic being superior to the other agents for even though this was a high-risk sample, and heart failure, for example. The blood pressure the sample size was considerable, it was neces- component of ALLHAT showed that in an active sary to have a combination endpoint to achieve control trial, a very large sample size needed to be adequate power. There was a highly significant used to achieve adequate power, even when the and clinically impressive reduction in the primary primary outcome was a combination of events. One explanation may be that there was only The reason for the ejection fraction criterion a modest difference in low-density lipoprotein is that angiotensin-converting enzyme inhibitors cholesterol between the two groups. Almost 30% have been shown to be beneficial in those of the control group participants were receiving with heart failure or low ejection fraction. This non-study lipid-lowering therapy by the end eligibility criterion, however, also means that of the trial. The non-blinded design probably the event rate is lower than if those with helped foster that. So in at getting people to reduce their cholesterol levels order to have adequate power, even in this undoubtedly played a role. Also, people who relatively large study, a combination of events were thought to require lipid-lowering therapy is necessary as the primary outcome. Originally, and those already on such therapy were not the sample size was set at 14 000, and the eligible to be enrolled. Because only those primary outcome was cardiovascular death and already entered in ALLHAT for the hypertension non-fatal myocardial infarction. Early in the trial, component were candidates for the lipid-lowering primarily for feasibility reasons, the sample size component, the originally expected number of was reduced to 8100 and the primary outcome about 20 000 enrollees turned out to be 10 355, expanded to include the need for coronary further limiting the study power. Procedures such as 180 TEXTBOOK OF CLINICAL TRIALS need for revascularisation are often included as use of second, third and even fourth choice part of the endpoint. For example, is subject to considerable bias if the trial is not in the Systolic Hypertension in the Elderly blinded, which PEACE is. The clinical goal systolic blood pressure differed for each outcomes, however, are so important that many participant depending upon initial systolic blood trials have successfully tested their effects on pressure. If the blood pressure remained above death, myocardial infarction and stroke. If the participants for years, it was thought that drugs that reduced were still above the goal at two consecutive vis- cardiac arrhythmias should be approved on its, 25 mg of atenolol daily or matching placebo the basis of their antiarrhythmic effect, on was added. In participants who still did not the assumption that they would be clinically reach the goal systolic blood pressure, the dose beneficial. However, when the trials were done was increased to 50 mg of atenolol or matching that looked at clinical outcomes, it was seen that placebo. Blood pressure above apri- The Cardiac Arrhythmia Suppression Trial ori established escape levels, despite maximal (CAST) tested whether suppression of ventric- stepped-care therapy or corresponding placebo, ular arrhythmias by any of three antiarrhythmic was an indication for prescribing open-label drugs would reduce the incidence of sudden car- active drug therapy. In the first part of this trial, over Some trials of pharmaceutical agents compare 1700 patients whose ventricular arrhythmias were strategies, rather than drugs.

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