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Calcium Supplementation in Osteoporosis - Question 1

Two conditions that can occur to Mary-Lou include Alzheimer's and Brain tumour. The two symptoms that have been noted after going through the case include memory loss and disorientation. The Alzheimer's is the state in which two pathological hallmark work which includes extracellular beta-amyloid deposits and intracellular neurofibrillary tangles. There are four stages of the Alzheimer’s which are effect on memory, early stage, middle stage and late stage. There are different hypothesis that is related to the prognosis of Alzheimer’s and one of the most popular hypothesis is the amyloid cascade hypothesis. The pathophysiology starts with the alteration of the APP processing followed by an overproduction of Beta AP production. The next step is the plague formation which leads to the neurodegeneration which leads to symptoms of the disorder in the patient. The neurodegeneration is followed by neuronal loss and ultimately leading to Alzheimer’s (Kocahan & Doğan, 2017).

Pathophysiology of the brain tumour is related to the three types of the risk factor which includes precipitating factor that is a family history of immunosuppression. The second type of factor includes unknown factor and the third factor is the predisposing factor that includes exposure to radiation that leads to the mutation leading to a brain tumour. The issue starts with the increased growth of the tumour that leads to elevated intracranial pressure in the brain which increases complication for the patient. The condition leads to the reduction in the amount of CSF and blood which lead to initial compensatory mechanism followed by secondary mechanism (Lapointe et al., 2018).

Calcium Supplementation in Osteoporosis - Question 2

One of the medicines prescribed to the patient is Fluoxetine which is a second-generation antidepressant drug and it acts via selective serotonin reuptake inhibition. The medicine works by blocking the transporters that are involved in the serotonin reuptake present in the presynaptic terminal. The results of the blocking lead to the elevated amount of 5-hydroxytryptamine in the brain which directly improves the serotonin amount. The increased level of the serotonin in the brain leads to the upliftment of the mood and reduce the depressive episode of the patient which improve the patient condition. One of the suggestions that need to be followed during this medication is no use of alcohol while taking this medication (Drug Bank, 2020a). Another drug that was prescribed to the diazepine that helps to reduce the anxiety or insomnia in the patient. The medication is considered to be important as it produces different effects to improve the patient condition which includes amnestic, anticonvulsant, muscle-relaxant, anxiolytic and sedative. These effects lead to the facilitation of the gamma-aminobutyric acid which is an inhibitory neurotransmitter present in the central nervous system. The drug bind to the different receptors present in the different region of the brain or spinal cord and this binding has increased in the inhibitory effect of the gamma-aminobutyric acid. It is involved in the sleep induction that occurs due to the action of CNS involvement. The important aspect of medication is it should be administered before the meal on empty stomach and alcohol is also restricted in it (Drug Bank, 2020b).

Calcium Supplementation in Osteoporosis - Question 3

Based on the case study information, it can be deduced that Mary Lou is suffering from alcohol addiction. The addiction is indicative through the regular increase in wine consumption by Mary for a sound sleep that is now dependent on alcohol intake. The medication to manage withdrawal has also been prescribed to Mary by the practitioner under a similar consideration.

The pathogenesis of alcohol addiction is associated with the neuroadaptation and reward system of the body. The consumption of alcohol releases dopamine that makes the act of alcohol consumption “pleasurable” for an individual. The regular use triggers the reward system creates a physical dependency in the consumer (Bedse et al., 2019). The alcohol dependence is also associated with the psychological stressors that impact the increased consumption of an individual. Alcohol consumption is associated to be developed as a coping mechanism for stress, anxiety, and depression in the individuals that results in the development of dependency and addiction. Addiction in the individual due to physical or psychological reasons can result in poor coordination, memory impairment and behavioural changes (Bach et al., 2019). Both physical and psychological dependencies are associated with dopamine release in the individual that promoted a reward-motivated behaviour in the individuals through triggering of the nucleus accumbent region of the brain. The biological factors that are related to alcohol addiction in a patient include GABA, corticosteroid releasing factors, glutamate, 5HT, and endogenous opioid systems (Bedse et al., 2019).

Calcium Supplementation in Osteoporosis - Question 4

Dosage adjustment is crucial in the elderly due to increased sensitivity and changes in absorption of drugs in the elderly (Poggesi, 2020). The changes in the drugs are of special consideration for drugs that affect the central nervous system. Dose reduction is suggested in the case of Mary Lou for MedX to limit the impact of the drug on the liver due to its protein binding and metabolic properties. The four age related changes associated with the medication in specific consideration to protein binding are reduced levels of albumin in elderly, reduced renal and hepatic clearance in elderly, limited vascular flow, and reduced tissue and muscle mass affecting drug absorption (Santos & Lindner, 2017). The drug absorption is reduced in the elderly in comparison to the younger individuals due to limited secretions and blood flow (Santos & Lindner, 2017). This affects the overall availability of protein in the blood for binding with the drug in the elderly and thus limits its absorption. The concentration of protein in the plasma concentration alters the drug intake in the elderly in two ways. First, by changing the effective concentration and by affecting the longevity of the drug in the stream. Since in case of MedX 98% of the molecules are found in albumin, the reduced levels of albumin in elderly age need to be considered for the dosage consideration to minimize the pressure exerted by the unused medications on the renal system of the patient (Santos & Lindner, 2017). Ion 5

Calcium Supplementation in Osteoporosis - Question 5

Osteoporosis is a very commonly occurring bone disease which is known as a skeletal disorder which compromises the strength of the bone of an individual, thus it creates greater danger of getting fractures. Hence, if a person has osteoporosis then it can be said, the bone quality and bone density are low in that individual. Generally, it can occur in any age but most often it happens in women as compared to their male counterparts. This disease is multifactorial and happens due to various factors like genetic, exogenous, intrinsic and lifestyle patterns. The major determinants of postmenopausal osteoporosis are deficiency of estrogen and secondary hyperparathyroidism in elders. This causes estrogen deficiency, decreased dietary intake and deficiency of Vitamin D (Föger-Samwald et al., 2020). In addition to that, usage of glucocorticoids frequently, also contribute towards very low bone mineral density and osteoporotic fractures. Osteoporosis also happens because of continuous cone remodelling (Curtis et al., 2016). The first sign of osteoporosis is chronic pain in the back of the patients. The pain could occur due to structure deformity that could happen because of weak bones of the spine. Joint imbalances could also occur and thus patient could feel excruciating pains. Pain which occurs due to osteoporosis could cause discomfort to the diseased individual and hence can raise awareness towards the progression of the disease (Paolucci et al., 2016). The second symptom of osteoporosis is the loss of height in people. Height loss is linked with a vertebral fracture in the patients of osteoporosis (Xu et al., 2011).

Calcium Supplementation in Osteoporosis - Question 6

One of the causes of osteoporosis is the deficiency of calcium and vitamin D in the body of the patient. A normal percentage of calcium with vitamin D is important for maintaining the metabolism of bone and thus it helps in the treatment and prevention of osteoporosis. Without calcium in the body, the process of bone remodelling would not happen properly. Calcium is taken up by other organs too while it is present in the blood and thus, the concentration of it depletes for the usage of bone making. Also, vitamin D helps in absorbing calcium but if it is not present in adequate amount then hindrance will occur in calcium absorption (Chiodini & Bolland, 2018). With that, hormonal disbalances also cause osteoporosis in people. Hormones like sex hormones, parathyroid hormones, thyroid hormone, gonadotropins, adrenocorticotropin hormone and others play an important role in maintaining calcium concentration in the body. For example, in women after menopause, there is a sudden drop of estrogen which increases the risk of fractures as the bone of the females loses mass then it eventually gains. Hence, it is evident that hormones can be the reason for osteoporosis (Cannarella et al., 2019). 

Calcium Supplementation in Osteoporosis - Question 7

The 3 physiological factors that responsible for fracture healing are growth factors and hormones, bone vascular system, and reduced vitamin D production in the skin. It is found that with age the production of growth factors and hormones decreases with age. The interaction of insulin-like growth factor (IGF)-I and –II and growth hormone (GH)-mediated somatic factors (somatomedins) are responsible for controlling skeletal growth, the proliferation of chondrocytes, function of osteoclast, osteocyte, and osteoblast. With age, the decreased serum levels of these factors and hormones result in increased risk or poor healing of the fracture (Yakar et al., 2019). With age, the rates of age-related dysfunction to the blood vascular system increase and there is a great decrease in its ability to regenerate to heal. It is also observed that vascular perfusion of the skeleton is poor in old age because the rate of angiogenesis is low in old age. This results in poor blood flow to the fracture site that causes slow healing and this is also associated with decreased bone strength in old age (Clark et al., 2017). With aging the vitamin D production in the skin also decreases and fracture dealing is delayed. Due to the reduction of the concentration of 7-dehydrocholesterol in the skin of the old individuals they produce low levels of vitamin D. In the older patient, the reduced vitamin D results in poor calcium absorption and bone mineral density decreases resulting in poor or delayed fracture healing (Gorter et al., 2017).

The 2 complications of hip fracture that are prevalent in the elderly are infection in the urinary tract and development of blood clots in the legs. 

Calcium Supplementation in Osteoporosis - Question 8

A T-score of -3.0 indicates that the patient is suffering from severe osteoporosis (Bone and joint initiative, 2020). According to Khosla (2010), the pathogenesis of osteoporosis states that with age the parathyroid gland releases low levels of parathyroid hormones as a result there is high calcium release from the bones. Low parathyroid hormone is unable to acts on the kidney to stimulate the decreased release of calcium; as a result, there is more loss of calcium from the kidney, decrease in bone mass, and excessive bone resorption resulting in brittle and fragile bones; this condition is later known as osteoporosis. In women after menopause, there is a sharp decrease in estrogen that is responsible for protecting bones and this contributes to osteoporosis. However, this condition can be controlled with the help administration of bisphosphonates. According to Lewiecki et al. (2010), it is found that the administration of bisphosphonates results in preserving the bone structure, prevent bone loss, and strengthen bones by binding to the surface of bones and limiting the action of the bone-eroding cells. After the entry of bisphosphonates into the serum, they cause a decrease in survival and function of osteoclasts, impairment of acidification, and inhibition of release of lysosomal enzymes. Due to the antiresorptive properties of the bisphosphonates and its action, there is a high contribution to the increase in bone mass and strength.

Calcium Supplementation in Osteoporosis - Question 9

Medical terminology can be difficult to understand by someone who is not aware of medicine and it is really important for the healthcare professionals to make the patient understand his condition such that he can make an informed decision regarding the treatment (Pentz et al., 2019). This is also required in case the patient wants to make a decision for the trajectory of the disease and any end of life care. Malignant or malignancy is basically the spread of cancerous cells to other parts of the body which can be due to the blood or nearby areas by the cells (Peitzsch, Tyutyunnykova, Pantel & Dubrovska, 2017). The cells which are involved increase in number rapidly and this becomes a mass. On contrary, a benign tumor does not spread to other parts of the body and does not increase in size rapidly. Cancer cells are anaplastic in nature which does not resemble normal cells in terms of size, and features. For example, the normal cells usually die after the cells get matured and they are supposed to die but in malignancy the cells do not stop growing and they do not die so they pile on each other. When this mass of cells is at any place it is called malignant tumor. In contrary to this benign tumor remains relatively stagnant and resemble normal cell more. In terms of prognosis, Bruce does not have good prognosis as due to the condition being metastatic in nature the cancer has spread to other parts of the body.

Calcium Supplementation in Osteoporosis - Question 10

Cancer cells have specific characteristics which make them invasive and metastatic so that cancer cells spread to either distant parts of the body or spread to adjacent areas and this depends on the nature of the cancer (Martin, Ye, Sanders, Lane & Jiang, 2018). The metastasis can be mainly due to three different processes that is invasion, intravasation and extravasation. The cells which are cancerous in nature have lost their ability to be adhered to the adjacent cells. This happens due to the fact that cancerous cells secrete substances which degrade the basement membrane and the extracellular matrix. The proteins which are responsible for the motility and migration which either is expressed or suppressed in case of mutation which occurs as a part of cancerous growth. This loss of adhesion enables the cancerous cell to invade into the surrounding stroma and this is the process of invasion (Martin, Ye, Sanders, Lane & Jiang, 2018). One of the other characteristics of the cancerous growth is that the cells or the mass of cells have the tendency for angiogenesis that is formation of new blood vessels which is attached to major blood source. This is done because nutrition is required for the growth of the cells. This blood vessel becomes a source by which the cancer cells which gets detached from the primary source and travel to other parts which can be far or nearby. When the cells invade into nearby areas there is biochemical interaction which takes place between the cells and adhesion takes place and penetration happens to the endothelium and basement membrane (Martin, Ye, Sanders, Lane & Jiang, 2018).

Calcium Supplementation in Osteoporosis - Question 11

In case of Bruce, it is mentioned that he has neutropenia which is a risk of infection for him before the cancer treatment. Neutropenia is the decrease in the level of circulating neutrophils in the blood which is the primary defense system of the body (Zecha et al., 2019). The normal range of the neutrophils is 2,500 to 6,000 cu. Mm and in case of neutropenia it is reduced. The defense system or the immunity of the body is reduced which makes the patient more prone to infection. Neutrophils are the main warriors in case of immunity which by chemotactic activity activates other cells to induce inflammatory response and by phagocytic activity the pathogen is eliminated by the body (Zecha et al., 2019). In case of neutropenia, since the cells are less in number pathogens overpower the system such and there is cause of infection. The cancer treatment regimen which is decided for the patient is surgical removal of the polyps, bowel and affected part of the liver along with chemotherapy. During the surgery the patient loses blood which further reduces the count of white blood cells and makes the patient more prone to infections. Also surgery exposes the body to the pathogens furthermore and increases the chances of infections. It is also discussed that Bruce will undergo chemotherapy which would decrease the immunity of the patient and it would increase the infection (Zecha et al., 2019).

Calcium Supplementation in Osteoporosis - Question 12

Bruce due to his condition and the treatment modalities is at a higher risk to the infection even in hospital setting. In this current state of pandemic the patients who are affected by the novel virus COVID-19. In this case of Bruce, the transmission of infection can be minimized by keeping the patient in isolation and reduce the personnel visiting the patient so that the infections taken to the patient can be reduced. This is one of the chain of transmission can be broken as a part of reduction of infection (Kenyi, 2020). The other way in which the infection can be minimized is by taking robust measure of hygiene so that the pathogen present in the environment as well as transmission by unclean contact between the family visiting and even the healthcare professional. Also the healthcare professionals visiting the patient for follow-up and treatment should make the use of personal professional kits so that the risk of infection is reduced. Aseptic measures should be followed such that the viral load in the environment can be reduced. The chain of transmission that is reduced is the reduction of the viral load in the environment and inanimate surfaces. The entry of virus to the body is reduced by maintaining the hygiene of the people visiting the patient as well as the patient himself (Kenyi, 2020).

References for Effects of Leptin and Ghrelin

Bach, P., Bumb, J. M., Schuster, R., Vollstädt-Klein, S., Reinhard, I., Rietschel, M., ... & Koopmann, A. (2019). Effects of leptin and ghrelin on neural cue-reactivity in alcohol addiction: Two streams merge to one river?. Psychoneuroendocrinology, 100, 1-9. https://www.sciencedirect.com/science/article/pii/S0306453018307406

Bedse, G., Centanni, S. W., Winder, D. G., & Patel, S. (2019). Endocannabinoid signaling in the central amygdala and bed nucleus of the stria terminalis: Implications for the pathophysiology and treatment of alcohol use disorder. Alcoholism: Clinical and Experimental Research, 43(10), 2014-2027. https://onlinelibrary.wiley.com/doi/abs/10.1111/acer.14159

Bone and joint initiative. (2020). Getting your T-score. Retrieved from: https://www.usbji.org/programs/public-education-programs/fit-to-t/t-score#:~:text=The%20T%2Dscore%20is%20a,defined%20as%20%2D2.5%20or%20lower.

Cannarella, R., Barbagallo, F., Condorelli, R. A., Aversa, A., La Vignera, S., & Calogero, A. E. (2019). Osteoporosis from an endocrine perspective: The role of hormonal changes in the elderly. Journal of Clinical Medicine8(10), 1564. https://doi.org/10.3390/jcm8101564

Chiodini, I., & Bolland, M. J. (2018). Calcium supplementation in osteoporosis: Useful or harmful?. European Journal of Endocrinology178(4), D13–D25. https://doi.org/10.1530/EJE-18-0113

Clark, D., Nakamura, M., Miclau, T., & Marcucio, R. (2017). Effects of aging on fracture healing. Current Osteoporosis Reports, 15(6), 601–608. https://doi.org/10.1007/s11914-017-0413-9

Curtis, E. M., Moon, R. J., Dennison, E. M., Harvey, N. C., & Cooper, C. (2016). Recent advances in the pathogenesis and treatment of osteoporosis. Clinical Medicine (London, England)16(4), 360–364. https://doi.org/10.7861/clinmedicine.16-4-360

Föger-Samwald, U., Dovjak, P., Azizi-Semrad, U., Kerschan-Schindl, K., & Pietschmann, P. (2020). Osteoporosis: Pathophysiology and therapeutic options. EXCLI Journal19, 1017–1037. https://doi.org/10.17179/excli2020-2591

Gorter, E. A., Krijnen, P., & Schipper, I. B. (2017). Vitamin D status and adult fracture healing. Journal of Clinical Orthopaedics and Trauma8(1), 34–37. https://doi.org/10.1016/j.jcot.2016.09.003

Kenyi, E. E. (2020). COVID-19 and infection prevention and control in health facilities. Sudan Medical Journal13(2), 52-56. http://www.southsudanmedicaljournal.com/assets/files/Journals/vol_13_iss_2_may_20/IPC_Final.pdf.

Khosla S. (2010). Pathogenesis of osteoporosis. Translational Endocrinology & Metabolism1(1), 55–86. https://doi.org/10.1210/TEAM.9781879225718.ch2

Lewiecki E. M. (2010). Bisphosphonates for the treatment of osteoporosis: Insights for clinicians. Therapeutic Advances in Chronic Disease1(3), 115–128. https://doi.org/10.1177/2040622310374783

Martin, T. A., Ye, L., Sanders, A. J., Lane, J., & Jiang, W. G. (2018). Cancer invasion and metastasis: molecular and cellular perspective. Metastatic cancer: clinical and biological perspectives, Madame Curie Bioscience Database edited by Rahul Jandial.© 2013 Landes Bioscience. Jandial R: Landes Bioscience, 135-168.

Paolucci, T., Saraceni, V. M., & Piccinini, G. (2016). Management of chronic pain in osteoporosis: challenges and solutions. Journal of Pain Research9, 177–186. https://doi.org/10.2147/JPR.S83574

Peitzsch, C., Tyutyunnykova, A., Pantel, K., & Dubrovska, A. (2017). Cancer stem cells: the root of tumor recurrence and metastases. In Seminars in cancer biology (Vol. 44, pp. 10-24). Academic Press. https://doi.org/10.1016/j.semcancer.2017.02.011

Pentz, R. D., Lohani, M., Hayban, M., Switchenko, J. M., Dixon, M. D., DeFeo Jr, R. J., ... & Master, V. A. (2019). Videos improve patient understanding of misunderstood chemotherapy terminology. Cancer125(22), 4011-4018. https://doi.org/10.1002/cncr.32421

Poggesi, I. (2020). Special populations: Protein binding aspects. Drug Discovery and Evaluation: Methods in Clinical Pharmacology, 765-772. https://link.springer.com/content/pdf/10.1007/978-3-319-68864-0_10.pdf

Santos, A. L., & Lindner, A. B. (2017). Protein posttranslational modifications: roles in aging and age-related disease. Oxidative Medicine and Cellular Longevity, 2017. https://www.hindawi.com/journals/omcl/2017/5716409/abs/

Xu, W., Perera, S., Medich, D., Fiorito, G., Wagner, J., Berger, L. K., & Greenspan, S. L. (2011). Height loss, vertebral fractures, and the misclassification of osteoporosis. Bone48(2), 307–311. https://doi.org/10.1016/j.bone.2010.09.027

Yakar, S., Werner, H., & Rosen, C. J. (2018). Insulin-like growth factors: Actions on the skeleton. Journal of Molecular Endocrinology61(1), T115–T137. https://doi.org/10.1530/JME-17-0298

Zecha, J. A., Raber-Durlacher, J. E., Laheij, A. M., Westermann, A. M., Epstein, J. B., de Lange, J., & Smeele, L. E. (2019). The impact of the oral cavity in febrile neutropenia and infectious complications in patients treated with myelosuppressive chemotherapy. Supportive Care in Cancer, 1-13. https://doi.org/10.1007/s00520-019-04925-8

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