Osteoporosis

 

It is a condition found primarily among middle aged and elderly postmenopausal women.

Osteoporosis is a disorder characterized by a decrease in total bone mass without a change in chemical composition. It occurs when the rate of bone re- absorption exceeds the rate of formation. Because of the reduction in number of cells, there is a decrease in thickness of the cortex, a thinning of the trabeculae and increased porosity of bone. As a result fractures occur with greater frequency. Common fractures sites include the vertebrae, femur and radius and often these occur in spite of little or no trauma. The rate of femoral fractures alone doubles for each decade after the age of 50.

The cause of osteoporosis may be age related changes such as decreased estrogen production associated with menopause. The decline in circulating 17-beta-estradiol is the predominant factor in the accelerated bone loss that begins after the menopause and continues for 6 to 8 years. Decreased intestinal absorption of calcium and production of Vitamin D, reduced physical activity and increased parathyroid hormone secretion may also cause osteoporosis. Some factors that increase risk include gastrectomy, hyperthyroidism, rheumatoid arthritis, immobilization and chronic inadequate calcium intake.

Vertebral fractures are also common in people with osteoporosis. The compact bone mass in the vertebrae is responsible for humped backs characteristics of many elderly people. Dissolution of the jawbone is another frequent symptom of osteoporosis. It is major contributing factor in periodontal disease, resulting in premature loss of teeth.

It is sensible to encourage all old people and especially those with radiological evidence of osteoporosis, to be as physically active as possible. The more they are on their feet, less is the risk of pathological fractures of the femur and spine.

An osteoporotic bone has lost both calcium and protein and so it is not unreasonable to think that a diet low in calcium and protein might accelerate the osteoporotic process, though there is no evidence to prove that increase in calcium intake reduces the incidence of osteoporosis in old people.

It is sensible for old people to take a diet with ample calcium that is to drink a glass of milk regularly. Some old people have a markedly reduced capacity to absorb calcium from the gut and in such patients therapeutic doses of calcium salt might be of benefit.

Since etiology is unknown, it is common sense to prescribe a diet adequate in calcium and protein.

The National Institute of Health consensus conference on osteoporosis recommended a daily calcium inta

ke of 1000 to 1500 mg for all postmenopausal women.

Every woman should be aware of the bone thinning disorders known as osteoporosis. This preventable condition affects one in four women over age 60, and is a major cause of fractures of the spine, hip, wrist, and other parts of the skeleton. Exactly what causes osteoporosis is not fully understood. Decreasing hormones levels, inadequate calcium in the diet, lack of exposure to sunlight (which helps the body manufacture the vitamin D necessary for calcium absorption), and inactivity may play a role.

Bones are self-maintained throughout life by a continual process known as remodeling, in which small amounts of old bone are removed and new bone is formed in its place. Beginning at about age 33, however, a little more bone is lost than is gained.

Certain dietary and exercise practices can help prevent or slow the loss of bone, and are also prescribed in treating osteoporosis:

·    The daily diet should include foods that are high in calcium. Dairy products such as milk, cheese, buttermilk, and yogurt are the best sources of this mineral. Other sources include dark green leafy vegetables (such as collards, turnip, greens, spinach, and broccoli), salmon, sardines, soybeans, and tofu.

·     Although the current recommended dietary allowance (RDA) for calcium is 800 mg per day, many researchers now believe that women over 40 need 1000 to 1500 mg daily. One cup of milk has about 300 mg of calcium. Other foods provide the mineral in smaller amounts. If the daily diet does not provide enough calcium, doctors may prescribe calcium supplements.

·      It is also important to get adequate amount of vitamin D; scientists recommend 400 IU daily. Vitamin fortified milk and cereals, egg yolk, saltwater fish, and liver are rich sources. Frequent, brief exposure to sunlight will help to meet the daily need for this vitamin.

·   Regular exercise is another important preventive measure because it stimulates formation of new bone. Activities that place moderate stress on the spine and the long bones of the body are best. Simple exercises to maintain strength in the shoulders, chest, back, and arms also are helpful.

·    Although protein is an important daily requirement, excessive intake can lead to loss of calcium. Women following diets which are high in protein should consider cutting back. Protein is found primarily in meats, poultry, fish, and dairy products. However, since dairy products are also important sources of calcium, this is not the food to cut back on. Forty-four grams of protein each day are sufficient for adult women; 56 gm are recommended for adult men. Once chicken breast has 26 gm of protein; a cup of milk has 8 gm.

• Cigarette smoking and drinking alcoholic beverage or beverages containing caffeine can increase body’s requirement for calcium.

Muscle Cramps

A muscle cramp is a sudden and involuntary contraction of one or more of the body muscles. Muscle cramps can cause excruciating pain. Excess exercise or physical labour, particularly in hot weather, may lead to muscle cramps.

Symptoms:

Most muscle cramps develop in the leg muscles, particularly the muscle of the calf. There is sudden and sharp pain in the muscle and the patient may be able to feel or see a hard lump of muscle tissue beneath the skin.

-          Sharp and sudden pain in the muscle involved.

-          May cause severe discomfort in the hands and feet.

-          Is associated with leg swelling, redness or skin changes.

-          Associated with muscle weakness.

Causes:

• Overuse of a muscle, dehydration, muscle strain or simply holing a position for a prolonged period of time may result in a muscle cramp.
•   Inadequate blood supply: Narrowing of the arteries that deliver blood to the legs, as in arteriosclerosis, can produce cramp like pain in the legs and feet while exercising.
•    Nerve compression: Compression of nerves in the spine can produce cramp like pain in the legs. The pain usually worsens the longer the patient walks.
•  Mineral Depletion: Deficiency of Potassium, sodium, calcium or magnesium in the diet can cause leg cramps.
•   Diuretics: Diuretics are water pills which are used in high blood pressure. They cause depletion of minerals like Sodium, Potassium, magnesium and calcium, causing cramps.

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-         Risk Factors:

Factors that may increase your risk of muscle cramps include.

-          Age: Older people lose muscle mass. The remaining muscle may get overstressed more easily. This may increase the risk of muscle cramps.

-          Dehydration: Dehydration causes frequent muscle cramps.

-          Pregnancy: Muscle cramps also are more common during pregnancy.

-          Medical Diseases: Certain medical diseases like diabetes, liver diseases and thyroid disease is associated with a higher risk of muscle cramps.

Treatment:

• Stretching exercises and drinking plenty of fluid, such as water, is helpful in treating simple muscle cramps.
•    Sufficient salt intake improves symptoms. Sodium loss causes cramps.
•  Vitamin E, calcium and vitamin D3, vitamin B complex, folic acid and iron helps in prevention and treatment of cramps.
•   Calcium channel blockers and Quinine tablets are effective in cases not controlled by conservative treatment.

Prevention:

-          Fruits, fruit juices and green leafy vegetables

-          Avoid dehydration. Drink plenty of fluids.

-          Stretch the muscles. Stretch before and after you use any muscle for an extended period. If you tend to have leg cramps at night, stretch before bedtime. Light exercise, such as riding a stationary bicycle for a few minutes before bedtime, also may help prevent cramps while you’re sleeping.

STRESS OBESITY

Stress and anger is a potent mix. Anger leads to weight gain and stress prevents weight loss. Many women struggling with weight loss actually don’t eat much, but are unable to slim down. There are various reasons for this kind of rigidity of weight, and most are part of our daily lives.

THE ROLE OF ANGER.

An average city dweller experiences more anger than other people. When we get angry, the body pumps a large quantity of the fighter hormone (cortisol), which rushes to all parts of the body to prepare itself for a “fight or defend” situation. This hormone stays in the body for a long time and changes a person’s metabolism from the ‘consumption pattern’ to the ‘storage pattern’ variety. So the same foods that could have been used up by the body are now stored, which increases a person’s bulk. This hormone is also responsible for weak muscles and pot-belly fat, which are typical indicators of stress-related obesity.

FOOD CRAVINGS

Anger and stress also cause hormones (neuro-peptides Y) to set off cravings for food that are high in fat, sugar and salt. People find dieting painful not because they eat less food, but because their minds and bodies cry out for junk food. A stress-obese body displays certain body traits. In men, the person develops weak or soft arms or leg muscles, fat around the belly, an emerging double chin and darkening or hyper pigmentation. In women, stress obesity shows us as excessive fat around the belly, skin changes such as acne or roughness, and as fat deposits on the back and waist. They may also develop excessive facial hair, and retain water, causing them to feel bloated all the time.

STOP WEIGHT GAIN

Stress obesity cannot simply be treated by going on a diet because there is a combination of several hormones resisting weight loss. It requires greater help in terms of professional treatment, which involves herbal medicines, stress management, specific exercises and regulation of diet patterns. However there are certain steps that can easily be taken at home to halt the march of stubborn weight gain.

WHAT YOU CAN DO

-          Drink two litres of water every day. Begin your day with two glasses of water on an empty stomach.

-          Have triphala in the night to increase alkaline levels in the gut.

-          Keep dinner as light as possible with minimum or no salt.

-          Take natural diuretics such as jasmine tea, barley water, nimbu paani etc.             

Fibromatosis

The term 'Fibromatosis' was intoduced for the first time by Arthur Purdy Stout.
Fibromatosis includes a broad group of related fibrous lesions . The term fibromatosis refers to a group of benign soft tissue tumors (fibromas), which have certain characteristics in common, including absence of cytologic and clinical malignant features, a histology consistent with proliferation of well-differentiated fibroblasts, an infiltrative growth pattern, and aggressive clinical behavior with frequent local recurrence.

Salient Features:

1. Macroscopically, cut surface is usually pale, whorled and fibrous with irregular margin.
2. Microscopically,  there is proliferation of palely eosinophilic fibroblasts and myofibroblasts.   
3. Infiltrative pattern
4. Presence of abundant collagen between the tumour cells.
5. Absence of cytological features of malignancy.
6. Cellularity and mitotic activity are extremely variable.
7. Other light microscopic features include:
    i.   thick-walled blood vessels sharply outlined from surrounding tissue.
    ii.  perivascular lymphocytic infiltrate at the advancing edge of the tumour.
    iii. rarely metaplastic ossification or cartilage formation.
8. Immunohistochemistry: Vimentin -Positive; Variably positivity for SMA, CD117 & desmin ; CD34 - Negative.  Staining correlates with the cellularity.
9. Aggressive clinical behaviour characterized  by repeated local recurrences. There is no evidence of metastasis.
10. Ultrastructural study confirms fibroblastic and myofibroblastic features. Presence of intracytoplasmic collagen formation has been described.

Fibromatosis is subdivided into two major groups: 

I  Superficial (fascial) fibromatoses: 

Features: 1. Slow growing tumour ; 2. Small size ;  3. Arise from fascia or aponeurosis ;   4. Less aggressive.

A. Palmar fibromatosis (Dupuytren's contracture)
B. Plantar fibromatosis (Ledderhose's disease)
C. Penile fibromatosis (Peyronie's diseasee)
D. Knucle pads

II  Deep (musculoaponeurotic) fibromatoses:

Features: 1. Rapidly growing tumour ;  2. Usually attain large size ;  3. Involve deeper structures (musculature of trunk and the extremities).

A. Extraabdominal fibromatosis (extraabdominal desmoid)
B. Abdominal fibromatosis (abdominal desmoid)
C. Intraabdominal fibromatosis (intraabdominal desmoid)
            1. Pelvic fibromatosis
            2. Mesenteric fibromatosis
            3. Gardner's syndrome (Familial adenomatous polyposis)

Desmoid tumor can be defined as a pseudoencapsulated infiltrative growth of well-differentiated collagenous fibroblasts and fibrocytes arising either in fascia or musculoaponeurotic structures.

The etiology of desmoid tumors is poorly defined. The most commonly implicated etiologic factors are trauma, hormonal disturbances, and genetic or hereditary factors.

Desmoid tumours of the anterior abdominal wall are much less common than extra-abdominal desmoids.

They may occur at any age but are most common in the third and fourth decades.

Although both sexes may be affected, abdominal desmoids predominate in females, particularly in females of childbearing age.

Extra-abdominal desmoids, which most commonly occur on the back, chest wall, head and neck, or lower extremity, have a male predominance.

Most patients complain of a painless mass of several months or years' duration.

The microscopic picture is variable and generally corresponds to the patient's age. The pattern usually found in the older child exhibits moderate cellular fibrous tissue with an intertwining fascicular pattern. Less cellular examples of the tumour are associated with larger amounts of collagen and are encountered in older subjects.

The primary consideration in surgical treatment of desmoid tumours should be the prevention of local recurrence.

In most instances, this can be achieved by wide local excision or muscle group resection.

Recurrence after surgery is well recognized and tumour recurrence as late as 5 and 10 years after initial surgery has been documented.

Desmoplastic fibroma of bone is considered the osseous counterpart of the soft tissue desmoid tumour.

Differential Diagnosis:

Gastrointestinal Stromal Tumour:

Gross features:

GIST: Soft and lobulated with hemorrhage, necrosis, or cystification.

Intra-abdominal fibromatosis: firm, tan and homogenous.

Micorscopic features:

GIST: Presence of spindle or epithelial cells with variable architecture, nuclear atypia and myxoid or hyalinized stroma. Necrosis and hemorrhage present in some cases.

Intra-abdominal fibromatosis: Composed of broad, sweeping fascicles of monotonous spindle cells. Bland nuclear features, and finely collagenous stroma. Necrosis, hemorrhage, and myxoid denegeration are not seen.

HIFU in Uterine Fibroids

Uterine fibroids or myomas are the most common tumours to affect women, and are present in up to 40% of women in the reproductive age group. Not all of these women are symptomatic, and they usually do not require any treatment for these fibroids. Occasionally, the fibroids can cause pain, heavy menstrual as well as inter-menstrual bleeding, and pressure effects such as frequency of urination due to the size of the fibroid. In a small number of cases, fibroids can be a cause of infertility.

Fibroids are traditionally known to grow very slowly throughout the reproductive life of a woman, and they exhibit a growth spurt during pregnancy. After menopause, a fibroid typically begins regressing in size, and at this stage, fibroids rarely need to be treated.

Attempts at symptomatic relief through medications have largely been unsuccessful, leaving the patient suffering from fibroids no option other than surgery.

The mainstay of treatment of symptomatic fibroids has been surgery, which could be either myomectomy (removal of the fibroid), or hysterectomy (removal of the uterus). Of these, only hysterectomy ensures that the patient will never suffer from fibroids again, but is a rather radical option for a benign tumour that only requires symptomatic relief. Also, a hysterectomy is followed by a lengthy recovery period before the patient returns to normal activities. Both hysterectomy as well as myomectomy can also be done laparoscopically (key-hole surgery), dramatically reducing the post- operative morbidity. However, even these are invasive techniques, and the risks and possible complications of surgery and anesthesia remain a constant threat.

The search for non-invasive techniques to provide the patient with relief from this otherwise non- threatening illness led to other minimally invasive options like Uterine Artery Embolisation, and Radio- Frequency Ablation which however had limited efficacy, and considerable adverse effects like excruciating post-treatment pain.

MRI guided HIFU or Magnetic Resonance Imaging- guided High Intensity Focused Ultrasound is an innovative mode for genuinely non-invasive treatment of fibroids. Under MRI guidance, sound waves are passed into the body and focused into the fibroid to heat and coagulate the tissues.

As fibroids are almost always benign, with a neglible percentage showing the presence of a sarcoma (malignancy),fibroids only require treatment for the alleviation of symptoms due to the fibroid.

This is a day-care surgery, where the patient reports to the clinic for the procedure, undergoes the procedure and is able to walk out and go home after the procedure. The patient is able to go back to her regular routine within the next 24 hours, and the symptomatic relief obtained with this procedure is comparable to that following a myomectomy in the long term

In this procedure, the MRI acquires high resolution 3-D images of the fibroid and surrounding structures. These images are used for accurate planning and mapping of the treatment. During treatment, the HIFU transducer focuses the ultrasound beam into the fibroid as per the planned areas (cells) and heats the tissue up to 65 degree Celsius, coagulating it. This is called sonication.

MRI guided HIFU ensures patient safety by having a number of safety mechanisms built into the system. All of these ensure that apart from the tissue being targeted, no other organ or tissue is affected by the treatment.

In a nutshell, MRI guided HIFU satisfies the need for a non-invasive procedure that is a safe, gentle, and convenient way to provide long-lasting relief from the symptoms caused by uterine fibroids