Re: Bone Issues

[Guest guest]

I forgot to attach the Slater study -- hopefully you can get the PDF open. There are other good endocrine studies too that I can forward. I have a entire file and could share at ASBS.

JB

-------------- Original message from jbship@...: --------------

,

The issues surronding bone demineralization probably won't get the attention that they deserve in the LABS project, mostly because funding is always tight and also because the studies are intense and require a GCRC or other research facility that can house the patients and conduct the studies. Low priority for the surgical group.

Our institution collects some basic labs, but we don't formally study bone health. In the past, we have probably not done that good of a job of even talking to patients about the increased risk -- though we have for the past few years. Our current surgeon only performs lap cases and only on BMI's <55...it is a really clean group from a surgical standpoint with very few complications -- I am surprised that any of them actually are past a Class I anethesia risk, but most are classified as II's on paper. My point here is that with this healthy obese group, there is not the push to extend the limb length, so most of our cases are about 100 cm.

The veteran surgeon with whom I work routinely does 150's for higher BMI's -- but doesn't follow up on bone health other than the Vitamin D, ionized Ca, PTH etc. I think we expect the PMD's to be screening patients at annual visits, but I don't think they know what to do -- at least within our system. I worked with one of our endocrinologist a couple of years ago to come up with some clinical practice guidelines. He recommended looking at the usual labs and a couple of others --- TSH, Free T4, Alb, ionized Ca, PTH, D, Mg, Phos. He said that the problem with having the surgeons get DEXA's is that they may or may not be able to interpret the results appropriately, nor are they well versed in the use of pharmacological agents and when they are indicated. We were able to define a group that was at increased risk for osteoporosis or osteomalacia -- long-term glucocorticoids use (lots of obese asthmatics) > 1 week per year (nearly all asthmatics that medicate!), smoking, excessive thyroid replacement treatment, PTH disorders, long-term use of anit-seizure meds, those with a history of low-energy falls. For those that have increased risk factors, he proposed closer monitoring to include yearly DEXA's. We don't know if hypogonadal men are at increased risk -- no one is looking at LH or total testosterone routinely.

I don't think we have really looked at endocrine response (other than gut hormones and metabolic obesity markers) to surgery, especially in women's health -- the changes in estrogen/testosterone are relevent to bone health as well. In the end, the risk of osteoporosis or perhaps osteomalcia seems to be an accepted risk given the benefits of the surgery even in the SOS and other long-term JI studies we don't hear about a epidemic of fractures in this group. Is that because we aren't asking or because it isn't clinically significant? We definetly are giving more nutrition information and encouraging specific supplementation than we were 20 years ago. I have a couple of 20 year patients -- most don't come in now so it is hard to know what really has happed.

We have had difficulty getting the nutrition bone study funded using absorption studies...I am considering proposing the urinary end markers that Goode and Brolin used. I would like to be able to talk with you about this at some point, you would probably have some good recommendations for the workgroup. You can e-mail me at jeanne.blankenship@... with a number to contact you if that would work for you. I will check around about the MeritScan. I have access to some bone guys that will be able to answer some of the questions you posed. I guess Alaska could be an issue, but Buffington's series found over 60% of obese patients to have hypovitamin D levels. The relationship of Vitamin D to metabolic syndrome and pancreatic function is also fascinating!

I am sorry that I am rambling on...I don't have your original e-mail here at work and am trying to remember the conversation. I do know that Flanagan is retiring by the way...I am from Oregon originally and they have posted for two surgeons...I hope they expand their nutrition piece as well...maybe I will eventually make it back to the Northwest yet!

Jeanne