Functional and mobility impairments associated with Paget's disease of bone

At the world's edge: Reconstructing diet and geographic origins in medieval Iceland using isotope and trace element analyses

Objectives

A multi‐isotope study was conducted on individuals buried at Skriðuklaustur monastery (AD 1493–1554) to investigate their geographic origins and dietary composition. Comparative material from individuals excavated from Skeljastaðir, an inland farm site was also analyzed.

Materials and methods

Bone collagen was extracted from 50 humans (Skriðuklaustur and Skeljastaðir) and 25 animals (Skriðuklaustur) and analyzed for δ¹³C, δ¹⁵N, and δ³⁴S. Dental enamel samples from 31 individuals (Skriðuklaustur) were also analyzed for ⁸⁷Sr/⁸⁶Sr, δ¹⁸O, δ¹³C, and trace elements (Pb, Sr, Zn, Ba).

Results

The mean value determined from individuals from Skriðuklaustur (n = 36) was δ¹³C = −18.7 ± 0.8‰, δ¹⁵N = 12.8 ± 1.1‰, and δ³⁴S = 9.0 ± 1.6‰, whereas at Skeljastaðir (n = 14), it was δ¹³C = −20.5 ± 0.8‰, δ¹⁵N = 7.8 ± 0.9‰, and δ³⁴S = 9.4 ± 1.6‰. At Skriðuklaustur, human dental enamel samples (n = 31) provided a ⁸⁷Sr/⁸⁶Sr range of 0.7060–0.7088, δ¹⁸O_phosphate from 13.9 to 16.1‰ and δ¹³C_carbonate from −16.6 to −12.9‰. Inferred drinking water (δ¹⁸O_dw) values range from −12.3 to −8.9‰. Sr concentrations range from 25.8 to 156.7 ppm, Ba from 0.11 to 0.81 ppm, Zn from 43.8 to 145.8 ppm, and Pb from 0.13 to 9.40 ppm.

Discussion

A combination of results indicates that the people from Skriðuklaustur were born in Iceland, but some lived inland during childhood while others lived closer to the coast. Since Skriðuklaustur was a hospital, these individuals may have sought medical treatment at the monastery. The δ¹³C and δ¹⁵N values determined from bone collagen indicate that the people residing at Skriðuklaustur consumed a diet high in marine protein, while those residing at Skeljastaðir exhibit values more consistent with terrestrial resources.

Combined Analysis of Two Multicenter, Randomized, Placebo-Controlled Studies of Pamidronate Disodium for the Palliation of Bone Pain in Men With Metastatic Prostate Cancer

Purpose: Bone metastases occur in approximately 80% of patients with advanced prostate cancer. Pain is common in these patients. The purpose of this study was to evaluate the effect of an intravenous bisphosphonate, pamidronate disodium, on pain control in metastatic prostate cancer patients.

Patients and Methods: Two multicenter, double-blind, randomized, placebo-controlled trials were conducted in patients with bone pain due to metastatic prostate cancer, with disease progression after first-line hormonal therapy. Intravenous pamidronate disodium (90 mg) or placebo was administered every 3 weeks for 27 weeks. Efficacy was measured via self-reported pain score (Brief Pain Inventory), analgesic use, the proportion of patients with a skeletal-related event (SRE; defined as pathologic fracture, radiation or surgery to bone, spinal cord compression, or hypercalcemia), and a pilot quantitative measurement of mobility. Laboratory evaluations included serum prostate-specific antigen, interleukin-6, bone alkaline phosphatase, and urinary bone resorption markers.

Results: Results of the two trials were pooled. There were no sustained significant differences between the pamidronate and placebo groups in self-reported pain measurements, analgesic use, proportion of patients with an SRE, or mobility at week 9 or 27. Urinary bone resorption markers were suppressed in the pamidronate group compared with placebo.

Conclusion: Pamidronate disodium failed to demonstrate a significant overall treatment benefit compared with placebo in palliation of bone pain or reduction of SREs. Evaluation of more potent bisphosphonates in patients with prostate cancer is warranted.

Economic and health-related quality of life considerations of new therapies in Parkinson's disease

The progressive disability of Parkinson's disease results in substantial burdens for patients, their families and society in terms of increased health resource use, poorer quality of life, caregiver burden, disrupted family relationships, decreases in social and leisure activities, deteriorating emotional well-being, and direct and indirect costs of illness. Health-related quality of life (HR-QOL) measures have been used successfully in cross-sectional studies to identify and characterise these burdens; however, there is not yet substantial evidence that these instruments will be responsive to changes in patients over time and that the results will provide patients and health professionals with clinically meaningful information useful in making decisions about treatment strategies. The few studies documenting direct and indirect costs indicate increased use of ancillary health and community services, significant adaptations in home and transportation, increased use of mobility and self-care aids, and lack of access to appropriate healthcare providers. Patients with Parkinson's disease incur higher hospital expenses, have increased number of prescriptions, and experience earnings loss; the latter also applies to family caregivers. The choice, intensity and timing of therapy are determined by a variety of factors: presenting symptoms, age, employment status, comorbidity, cognitive impairment and level of functional impairment. Choices must be individually tailored to a patient's physical and personal needs. To be useful for patients with Parkinson's disease in clinical practice, clinicians should be able to use HR-QOL measures to identify appropriate medical interventions or socio-behavioural modifications to modify the HR-QOL deficits. However, while the interplay of interventions and clinical outcomes are often well understood, the effects of interventions on HR-QOL outcomes have not been studied extensively. Little research has been done that explicitly links the signs and symptoms of Parkinson's disease to the HR-QOL outcomes. The only Parkinson's disease cost-effectiveness study as yet performed indicated higher costs for patients receiving pramipexole than for those not taking the drug, but additional quality life-years were gained. Longer term effectiveness of many treatment strategies, and the usefulness of HR-QOL instruments to assess these treatments for individual patients over time, are critical areas for future research.

Factors associated with self-rated health in patients with Paget's disease of bone

Multiple studies show that poor self-rated health (SRH) increases the risk of mortality up to 5-fold when compared to excellent SRH. This powerful association remains even with objective health status and risk factors controlled. However, few studies have examined the determinants of SRH, especially as they relate to specific chronic diseases. Here we identify personal characteristics and disease-related attributes that are strongly associated with SRH in a sample of patients with Paget's disease of bone to determine whether any factors can be modified. Two thousand people randomly selected from the Paget Foundation mailing list received a survey asking for information on demographics, general health and functioning, and the impact of Paget's disease. Nine hundred and fifty-eight PD patients returned the completed survey and answered the question, "How would you rate your overall health?" Answers ranged from excellent (1) to poor (5). Ordinary least squares regression was used, with SRH as the dependent variable, to identify those variables significantly associated with SRH. The overall regression model was significant (p = 0.0001; R2 = 0.44). Age (p = 0. 005), satisfaction with family help (p = 0.0001), number of comorbid conditions (p = 0.0001), functional limitations (p = 0.0003), disease impact (p = 0.0002), health compared to 5 years ago (p = 0. 0001), and depressive symptoms (p = 0.012) were significant predictors. Of these, satisfaction with family help, functional limitations, disease impact, and depressive symptoms are potentially modifiable with appropriate interventions. Future longitudinal studies should examine the effectiveness of such interventions in improving SRH.

Paget's disease of bone (osteitis deformans)

Paget's disease of bone is important in geriatric populations because it is the second most common bone disorder after osteoporosis. In older people, it may be responsible for chronic back pain and joint pain, skeletal deformities, hearing loss, and cranial nerve compression. Paget's disease can reduce both function and mobility in the older people. In addition to newer tests for assessing the activity of Paget's disease, effective therapy is available in the form of salmon calcitonin for nasal administration and new third generation bisphosphonates. Frequently, treatment can reverse the course of the disease. For these reasons, it is feasible for the physician to adopt an aggressive approach to diagnosis and treatment. The objective should be to relieve pain, improve mobility, and forestall debilitating complications. This review will focus on the manifestations and clinical management of Paget's disease. Two cases are presented that illustrate common management problems in older patients.