The Official Patient's Sourcebook on Avascular Necrosis

THE OFFICIAL PATIENT’S SOURCEBOOK on VASCULAR ECROSIS J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DIT...

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THE OFFICIAL PATIENT’S SOURCEBOOK

on

VASCULAR ECROSIS J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright Ó2002 by ICON Group International, Inc. Copyright Ó2002 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Tiffany LaRochelle Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consultation with your physician. All matters regarding your health require medical supervision. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation, in close consultation with a qualified physician. The reader is advised to always check product information (package inserts) for changes and new information regarding dose and contraindications before taking any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960The Official Patient’s Sourcebook on Avascular Necrosis: A Revised and Updated Directory for the Internet Age/James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary and index. ISBN: 0-597-83160-2 1. Avascular Necrosis-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem or as a substitute for consultation with licensed medical professionals. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors or authors. ICON Group International, Inc., the editors, or the authors are not responsible for the content of any Web pages nor publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this sourcebook for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications are copyrighted. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs or other materials, please contact us to request permission (e-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this sourcebook.

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Dedication To the healthcare professionals dedicating their time and efforts to the study of avascular necrosis.

Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this sourcebook which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which directly or indirectly are dedicated to avascular necrosis. All of the Official Patient’s Sourcebooks draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this sourcebook. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany LaRochelle for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for the Official Patient’s Sourcebook series published by ICON Health Publications.

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About ICON Health Publications In addition to avascular necrosis, Official Patient’s Sourcebooks are available for the following related topics: ·

The Official Patient's Sourcebook on Growth Plate Fractures

·

The Official Patient's Sourcebook on Muscular Dystrophy

·

The Official Patient's Sourcebook on Osteogenesis Imperfecta

·

The Official Patient's Sourcebook on Osteoporosis

·

The Official Patient's Sourcebook on Scoliosis

·

The Official Patient's Sourcebook on Sjogren's Syndrome

·

The Official Patient's Sourcebook on Spinal Stenosis

To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes & Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

Contents vii

Table of Contents INTRODUCTION...................................................................................... 1

Overview............................................................................................................... 1 Organization......................................................................................................... 3 Scope ..................................................................................................................... 3 Moving Forward................................................................................................... 4

PART I: THE ESSENTIALS ................................................. 7 CHAPTER 1. THE ESSENTIALS ON AVASCULAR NECROSIS: GUIDELINES ....................................................................................... 9

Overview............................................................................................................... 9 What Is Avascular Necrosis? ............................................................................. 10 What Causes Avascular Necrosis?..................................................................... 11 Who Is Likely to Develop Avascular Necrosis?.................................................. 12 What Are the Symptoms?................................................................................... 13 How Is Avascular Necrosis Diagnosed? ............................................................ 13 What Treatments Are Available?....................................................................... 15 What Research Is Being Done to Help People with Avascular Necrosis? ......... 17 Where Can I Find More Information about Avascular Necrosis? ..................... 17 More Guideline Sources ..................................................................................... 18 Vocabulary Builder............................................................................................. 22

CHAPTER 2. SEEKING GUIDANCE ....................................................... 25

Overview............................................................................................................. 25 Associations and Avascular Necrosis................................................................. 25 Finding Doctors.................................................................................................. 27 Finding a Rheumatologist .................................................................................. 29 Selecting Your Doctor ........................................................................................ 29 Working with Your Doctor ................................................................................ 30 Broader Health-Related Resources ..................................................................... 31

CHAPTER 3. CLINICAL TRIALS AND AVASCULAR NECROSIS ............. 33

Overview............................................................................................................. 33 Recent Trials on Avascular Necrosis ................................................................. 36 Benefits and Risks............................................................................................... 37 Keeping Current on Clinical Trials.................................................................... 40 General References.............................................................................................. 41 Vocabulary Builder............................................................................................. 42

PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL.................................................. 45 CHAPTER 4. STUDIES ON AVASCULAR NECROSIS .............................. 47

Overview............................................................................................................. 47

viii Contents

The Combined Health Information Database ..................................................... 47 Federally-Funded Research on Avascular Necrosis ........................................... 50 E-Journals: PubMed Central .............................................................................. 52 The National Library of Medicine: PubMed ...................................................... 52 Vocabulary Builder............................................................................................. 53

CHAPTER 5. BOOKS ON AVASCULAR NECROSIS ................................. 61

Overview............................................................................................................. 61 Book Summaries: Online Booksellers ................................................................. 61 The National Library of Medicine Book Index ................................................... 62 Chapters on Avascular Necrosis......................................................................... 66 General Home References ................................................................................... 67 Vocabulary Builder............................................................................................. 68

CHAPTER 6. MULTIMEDIA ON AVASCULAR NECROSIS ...................... 69

Overview............................................................................................................. 69 Bibliography: Multimedia on Avascular Necrosis ............................................. 69 Vocabulary Builder............................................................................................. 72

CHAPTER 7. PERIODICALS AND NEWS ON AVASCULAR NECROSIS ... 73

Overview............................................................................................................. 73 News Services & Press Releases ......................................................................... 73 Newsletter Articles ............................................................................................. 80 Academic Periodicals covering Avascular Necrosis........................................... 81 Vocabulary Builder............................................................................................. 83

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES ..................... 85

Overview............................................................................................................. 85 NIH Guidelines................................................................................................... 85 NIH Databases.................................................................................................... 86 Other Commercial Databases ............................................................................. 90 The Genome Project and Avascular Necrosis..................................................... 90 Specialized References......................................................................................... 95

PART III. APPENDICES .................................................... 97 APPENDIX A. RESEARCHING YOUR MEDICATIONS............................ 99

Overview............................................................................................................. 99 Your Medications: The Basics .......................................................................... 100 Learning More about Your Medications .......................................................... 102 Commercial Databases...................................................................................... 102 Contraindications and Interactions (Hidden Dangers) ................................... 104 A Final Warning .............................................................................................. 105 General References............................................................................................ 106

APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE ................... 107

Overview........................................................................................................... 107 What Is CAM? ................................................................................................. 107 What Are the Domains of Alternative Medicine?............................................ 108

Contents

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Can Alternatives Affect My Treatment? ......................................................... 111 Finding CAM References on Avascular Necrosis............................................ 112 Additional Web Resources................................................................................ 117 General References............................................................................................ 118

APPENDIX C. RESEARCHING NUTRITION ......................................... 121

Overview........................................................................................................... 121 Food and Nutrition: General Principles........................................................... 122 Finding Studies on Avascular Necrosis ........................................................... 126 Federal Resources on Nutrition........................................................................ 130 Additional Web Resources................................................................................ 131 Vocabulary Builder........................................................................................... 131

APPENDIX D. FINDING MEDICAL LIBRARIES.................................... 133

Overview........................................................................................................... 133 Preparation ....................................................................................................... 133 Finding a Local Medical Library ...................................................................... 134 Medical Libraries Open to the Public............................................................... 134

APPENDIX E. NIH CONSENSUS STATEMENT ON TOTAL HIP REPLACEMENT ................................................................................... 141

Abstract ............................................................................................................ 141 What Is Total Hip Replacement? ..................................................................... 143 What Are the Current Indications for Total Hip Replacement?...................... 144 What Are the Considerations Relating to a Prosthesis? .................................. 145 What Are the Responses of the Biological Environment? ................................ 149 What Are the Expected Outcomes?.................................................................. 151 What Are the Approaches for a Total Hip Replacement? ................................ 154 What Are the Most Productive Directions for Future Research?.................... 156 Vocabulary Builder........................................................................................... 158

ONLINE GLOSSARIES.................................................... 161 Online Dictionary Directories.......................................................................... 162

AVASCULAR NECROSIS GLOSSARY ....................... 163 General Dictionaries and Glossaries ................................................................ 179

INDEX................................................................................... 181

Introduction

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INTRODUCTION Overview Dr. C. Everett Koop, former U.S. Surgeon General, once said, “The best prescription is knowledge.”1 The Agency for Healthcare Research and Quality (AHRQ) of the National Institutes of Health (NIH) echoes this view and recommends that every patient incorporate education into the treatment process. According to the AHRQ: Finding out more about your condition is a good place to start. By contacting groups that support your condition, visiting your local library, and searching on the Internet, you can find good information to help guide your treatment decisions. Some information may be hard to find—especially if you don't know where to look.2 As the AHRQ mentions, finding the right information is not an obvious task. Though many physicians and public officials had thought that the emergence of the Internet would do much to assist patients in obtaining reliable information, in March 2001 the National Institutes of Health issued the following warning: The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading.3

Quotation from http://www.drkoop.com. The Agency for Healthcare Research and Quality (AHRQ): http://www.ahcpr.gov/consumer/diaginfo.htm. 3 From the NIH, National Cancer Institute (NCI): http://cancertrials.nci.nih.gov/beyond/evaluating.html. 1 2

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Avascular Necrosis

Since the late 1990s, physicians have seen a general increase in patient Internet usage rates. Patients frequently enter their doctor's offices with printed Web pages of home remedies in the guise of latest medical research. This scenario is so common that doctors often spend more time dispelling misleading information than guiding patients through sound therapies. The Official Patient’s Sourcebook on Avascular Necrosis has been created for patients who have decided to make education and research an integral part of the treatment process. The pages that follow will tell you where and how to look for information covering virtually all topics related to avascular necrosis, from the essentials to the most advanced areas of research. The title of this book includes the word “official.” This reflects the fact that the sourcebook draws from public, academic, government, and peerreviewed research. Selected readings from various agencies are reproduced to give you some of the latest official information available to date on avascular necrosis. Given patients’ increasing sophistication in using the Internet, abundant references to reliable Internet-based resources are provided throughout this sourcebook. Where possible, guidance is provided on how to obtain free-ofcharge, primary research results as well as more detailed information via the Internet. E-book and electronic versions of this sourcebook are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). Hard copy users of this sourcebook can type cited Web addresses directly into their browsers to obtain access to the corresponding sites. Since we are working with ICON Health Publications, hard copy Sourcebooks are frequently updated and printed on demand to ensure that the information provided is current. In addition to extensive references accessible via the Internet, every chapter presents a “Vocabulary Builder.” Many health guides offer glossaries of technical or uncommon terms in an appendix. In editing this sourcebook, we have decided to place a smaller glossary within each chapter that covers terms used in that chapter. Given the technical nature of some chapters, you may need to revisit many sections. Building one’s vocabulary of medical terms in such a gradual manner has been shown to improve the learning process. We must emphasize that no sourcebook on avascular necrosis should affirm that a specific diagnostic procedure or treatment discussed in a research study, patent, or doctoral dissertation is “correct” or your best option. This sourcebook is no exception. Each patient is unique. Deciding on appropriate

Introduction

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options is always up to the patient in consultation with their physician and healthcare providers.

Organization This sourcebook is organized into three parts. Part I explores basic techniques to researching avascular necrosis (e.g. finding guidelines on diagnosis, treatments, and prognosis), followed by a number of topics, including information on how to get in touch with organizations, associations, or other patient networks dedicated to avascular necrosis. It also gives you sources of information that can help you find a doctor in your local area specializing in treating avascular necrosis. Collectively, the material presented in Part I is a complete primer on basic research topics for patients with avascular necrosis. Part II moves on to advanced research dedicated to avascular necrosis. Part II is intended for those willing to invest many hours of hard work and study. It is here that we direct you to the latest scientific and applied research on avascular necrosis. When possible, contact names, links via the Internet, and summaries are provided. It is in Part II where the vocabulary process becomes important as authors publishing advanced research frequently use highly specialized language. In general, every attempt is made to recommend “free-to-use” options. Part III provides appendices of useful background reading for all patients with avascular necrosis or related disorders. The appendices are dedicated to more pragmatic issues faced by many patients with avascular necrosis. Accessing materials via medical libraries may be the only option for some readers, so a guide is provided for finding local medical libraries which are open to the public. Part III, therefore, focuses on advice that goes beyond the biological and scientific issues facing patients with avascular necrosis.

Scope While this sourcebook covers avascular necrosis, your doctor, research publications, and specialists may refer to your condition using a variety of terms. Therefore, you should understand that avascular necrosis is often considered a synonym or a condition closely related to the following: ·

Aseptic Necrosis

·

Ischemic Bone Necrosis

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Avascular Necrosis

·

Osteonecrosis

In addition to synonyms and related conditions, physicians may refer to avascular necrosis using certain coding systems. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is the most commonly used system of classification for the world's illnesses. Your physician may use this coding system as an administrative or tracking tool. The following classification is commonly used for avascular necrosis:4 ·

733.4 aseptic necrosis of bone

·

733.40 aseptic necrosis of bone, site unspecified

·

733.41 head of humerus

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733.42 head and neck of femur

·

733.43 medial femoral condyle

·

733.44 talus

·

733.49 other

For the purposes of this sourcebook, we have attempted to be as inclusive as possible, looking for official information for all of the synonyms relevant to avascular necrosis. You may find it useful to refer to synonyms when accessing databases or interacting with healthcare professionals and medical librarians.

Moving Forward Since the 1980s, the world has seen a proliferation of healthcare guides covering most illnesses. Some are written by patients or their family members. These generally take a layperson's approach to understanding and coping with an illness or disorder. They can be uplifting, encouraging, and highly supportive. Other guides are authored by physicians or other healthcare providers who have a more clinical outlook. Each of these two styles of guide has its purpose and can be quite useful. As editors, we have chosen a third route. We have chosen to expose you to as many sources of official and peer-reviewed information as practical, for the purpose of educating you about basic and advanced knowledge as 4 This list is based on the official version of the World Health Organization's 9th Revision, International Classification of Diseases (ICD-9). According to the National Technical Information Service, “ICD-9CM extensions, interpretations, modifications, addenda, or errata other than those approved by the U.S. Public Health Service and the Health Care Financing Administration are not to be considered official and should not be utilized. Continuous maintenance of the ICD-9-CM is the responsibility of the federal government.”

Introduction

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recognized by medical science today. You can think of this sourcebook as your personal Internet age reference librarian. Why “Internet age”? All too often, patients diagnosed with avascular necrosis will log on to the Internet, type words into a search engine, and receive several Web site listings which are mostly irrelevant or redundant. These patients are left to wonder where the relevant information is, and how to obtain it. Since only the smallest fraction of information dealing with avascular necrosis is even indexed in search engines, a non-systematic approach often leads to frustration and disappointment. With this sourcebook, we hope to direct you to the information you need that you would not likely find using popular Web directories. Beyond Web listings, in many cases we will reproduce brief summaries or abstracts of available reference materials. These abstracts often contain distilled information on topics of discussion. Before beginning your search for information, it is important for you to realize that avascular necrosis is considered a relatively uncommon condition. Because of this, far less research is conducted on avascular necrosis compared to other health problems afflicting larger populations, like breast cancer or heart disease. Nevertheless, this sourcebook will prove useful for two reasons. First, if more information does become available on avascular necrosis, the sources given in this book will be the most likely to report or make such information available. Second, some will find it important to know about patient support, symptom management, or diagnostic procedures that may be relevant to both avascular necrosis and other conditions. By using the sources listed in the following chapters, selfdirected research can be conducted on broader topics that are related to avascular necrosis but not readily uncovered using general Internet search engines (e.g. www.google.com or www.yahoo.com). In this way, we have designed this sourcebook to complement these general search engines that can provide useful information and access to online patient support groups.5

For example, one can simply go to www.google.com, or other general search engines (e.g. www.yahoo.com, www.aol.com, www.msn.com) and type in “diseasex support group” to find any active online support groups dedicated to diseasex.

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Avascular Necrosis

While we focus on the more scientific aspects of avascular necrosis, there is, of course, the emotional side to consider. Later in the sourcebook, we provide a chapter dedicated to helping you find peer groups and associations that can provide additional support beyond research produced by medical science. We hope that the choices we have made give you the most options available in moving forward. In this way, we wish you the best in your efforts to incorporate this educational approach into your treatment plan. The Editors

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PART I: THE ESSENTIALS

ABOUT PART I Part I has been edited to give you access to what we feel are “the essentials” on avascular necrosis. The essentials of a disease typically include the definition or description of the disease, a discussion of who it affects, the signs or symptoms associated with the disease, tests or diagnostic procedures that might be specific to the disease, and treatments for the disease. Your doctor or healthcare provider may have already explained the essentials of avascular necrosis to you or even given you a pamphlet or brochure describing avascular necrosis. Now you are searching for more indepth information. As editors, we have decided, nevertheless, to include a discussion on where to find essential information that can complement what your doctor has already told you. In this section we recommend a process, not a particular Web site or reference book. The process ensures that, as you search the Web, you gain background information in such a way as to maximize your understanding.

Guidelines

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CHAPTER 1. THE ESSENTIALS ON AVASCULAR NECROSIS: GUIDELINES Overview Official agencies, as well as federally-funded institutions supported by national grants, frequently publish a variety of guidelines on avascular necrosis. These are typically called “Fact Sheets” or “Guidelines.” They can take the form of a brochure, information kit, pamphlet, or flyer. Often they are only a few pages in length. The great advantage of guidelines over other sources is that they are often written with the patient in mind. Since new guidelines on avascular necrosis can appear at any moment and be published by a number of sources, the best approach to finding guidelines is to systematically scan the Internet-based services that post them.

The National Institutes of Health (NIH)6 The National Institutes of Health (NIH) is the first place to search for relatively current patient guidelines and fact sheets on avascular necrosis. Originally founded in 1887, the NIH is one of the world's foremost medical research centers and the federal focal point for medical research in the United States. At any given time, the NIH supports some 35,000 research grants at universities, medical schools, and other research and training institutions, both nationally and internationally. The rosters of those who have conducted research or who have received NIH support over the years include the world's most illustrious scientists and physicians. Among them are 97 scientists who have won the Nobel Prize for achievement in medicine.

6

Adapted from the NIH: http://www.nih.gov/about/NIHoverview.html.

10 Avascular Necrosis

There is no guarantee that any one Institute will have a guideline on a specific disease, though the National Institutes of Health collectively publish over 600 guidelines for both common and rare diseases. The best way to access NIH guidelines is via the Internet. Although the NIH is organized into many different Institutes and Offices, the following is a list of key Web sites where you are most likely to find NIH clinical guidelines and publications dealing with avascular necrosis and associated conditions: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc. ) with guidelines available at http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS); fact sheets and guidelines at http://www.nih.gov/niams/healthinfo/

Among those listed above, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is especially noteworthy. The mission of NIAMS, a part of the National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. The National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. The NIAMS provides the following guideline concerning avascular necrosis.7

What Is Avascular Necrosis?8 Avascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surface. This disease also is known as osteonecrosis, aseptic necrosis, and ischemic bone necrosis.

7 This and other passages are adapted from the NIH and NIAMS (http://www.niams.nih.gov/hi/index.htm). “Adapted” signifies that the text is reproduced with attribution, with some or no editorial adjustments. 8 Adapted from The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): http://www.niams.nih.gov/hi/topics/avascular_necrosis/index.htm.

Guidelines 11

Although it can happen in any bone, avascular necrosis most commonly affects the ends (epiphysis) of long bones such as the femur, the bone extending from the knee joint to the hip joint. Other common sites include the upper arm bone, knees, shoulders, and ankles. The disease may affect just one bone, more than one bone at the same time, or more than one bone at different times. Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis each year. Orthopaedic doctors most often diagnose the disease. The amount of disability that results from avascular necrosis depends on what part of the bone is affected, how large an area is involved, and how effectively the bone rebuilds itself. The process of bone rebuilding takes place after an injury as well as during normal growth. Normally, bone continuously breaks down and rebuilds--old bone is reabsorbed and replaced with new bone. The process keeps the skeleton strong and helps it to maintain a balance of minerals. In the course of avascular necrosis, however, the healing process is usually ineffective and the bone tissues break down faster than the body can repair them. If left untreated, the disease progresses, the bone collapses, and the joint surface breaks down, leading to pain and arthritis.

What Causes Avascular Necrosis? Avascular necrosis has several causes. Loss of blood supply to the bone can be caused by an injury (trauma-related avascular necrosis or joint dislocation) or by certain risk factors (nontraumatic avascular necrosis), such as some medications (steroids), blood coagulation disorders, or excessive alcohol use. Increased pressure within the bone also is associated with avascular necrosis. The pressure within the bone causes the blood vessels to narrow, making it hard for the vessels to deliver enough blood to the bone cells.

Injury When a joint is injured, as in a fracture or dislocation, the blood vessels may be damaged. This can interfere with the blood circulation to the bone and lead to trauma-related avascular necrosis. Studies suggest that this type of avascular necrosis may develop in more than 20 percent of people who dislocate their hip joint.


Steroid Medications Corticosteroids such as prednisone are commonly used to treat diseases in which there is inflammation, such as systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, and vasculitis. Studies suggest that long-term, systemic (oral or intravenous) corticosteroid use is associated with 35 percent of all cases of nontraumatic avascular necrosis. However, there is no known risk of avascular necrosis associated with the limited use of steroids. Patients should discuss concerns about steroid use with their doctor. Doctors aren't sure exactly why the use of corticosteroids sometimes leads to avascular necrosis. They may interfere with the body's ability to break down fatty substances. These substances then build up in and clog the blood vessels, causing them to narrow. This reduces the amount of blood that gets to the bone. Some studies suggest that corticosteroid-related avascular necrosis is more severe and more likely to affect both hips (when occurring in the hip) than avascular necrosis resulting from other causes.

Alcohol Use Excessive alcohol use and corticosteroid use are two of the most common causes of nontraumatic avascular necrosis. In people who drink an excessive amount of alcohol, fatty substances may block blood vessels, causing a decreased blood supply to the bones that results in avascular necrosis.

Other Risk Factors Other risk factors or conditions associated with nontraumatic avascular necrosis include Gaucher's disease, pancreatitis, radiation treatments and chemotherapy, decompression disease, and blood disorders such as sickle cell disease.

Who Is Likely to Develop Avascular Necrosis? Avascular necrosis affects both men and women and affects people of all ages. It is most common among people in their thirties and forties. Depending on a person's risk factors and whether the underlying cause is trauma, it also can affect younger or older people.

Guidelines 13

What Are the Symptoms? In the early stages of avascular necrosis, patients may not have any symptoms. As the disease progresses, however, most patients experience joint pain--at first, only when putting weight on the affected joint, and then even when resting. Pain usually develops gradually and may be mild or severe. If avascular necrosis progresses and the bone and surrounding joint surface collapse, pain may develop or increase dramatically. Pain may be severe enough to limit the patient's range of motion in the affected joint. In some cases, particularly those involving the hip, disabling osteoarthritis may develop. The period of time between the first symptoms and loss of joint function is different for each patient, ranging from several months to more than a year.

How Is Avascular Necrosis Diagnosed? After performing a complete physical examination and asking about the patient's medical history (for example, what health problems the patient has had and for how long), the doctor may use one or more imaging techniques to diagnose avascular necrosis. As with many other diseases, early diagnosis increases the chances of treatment success. It is likely that the doctor first will recommend a radiograph, commonly called an x ray. X rays can help identify many causes of joint pain, such as a fracture or arthritis. If the x ray is normal, the patient may need to have more tests. Research studies have shown that magnetic resonance imaging, or MRI, is the most sensitive method for diagnosing avascular necrosis in the early stages. The tests described below may be used to determine the amount of bone affected and how far the disease has progressed.

X Ray An x ray is a common tool that the doctor may use to help diagnose the cause of joint pain. It is a simple way to produce pictures of bones. The x ray of a person with early avascular necrosis is likely to be normal because x rays are not sensitive enough to detect the bone changes in the early stages of the disease. X rays can show bone damage in the later stages, and once the diagnosis is made, they are often used to monitor the course of the condition. Magnetic Resonance Imaging (MRI)


MRI is quickly becoming a common method for diagnosing avascular necrosis. Unlike x rays, bone scans, and CT (computed/computerized tomography) scans, MRI detects chemical changes in the bone marrow and can show avascular necrosis in its earliest stages. MRI provides the doctor with a picture of the area affected and the bone rebuilding process. In addition, MRI may show diseased areas that are not yet causing any symptoms. Bone Scan Also known as bone scintigraphy, bone scans are used most commonly in patients who have normal x rays. A harmless radioactive dye is injected into the affected bone and a picture of the bone is taken with a special camera. The picture shows how the dye travels through the bone and where normal bone formation is occurring. A single bone scan finds all areas in the body that are affected, thus reducing the need to expose the patient to more radiation. Bone scans do not detect avascular necrosis at the earliest stages.

Computed/Computerized Tomography A CT scan is an imaging technique that provides the doctor with a threedimensional picture of the bone. It also shows “slices” of the bone, making the picture much clearer than x rays and bone scans. Some doctors disagree about the usefulness of this test to diagnose avascular necrosis. Although a diagnosis usually can be made without a CT scan, the technique may be useful in determining the extent of bone damage.

Biopsy A biopsy is a surgical procedure in which tissue from the affected bone is removed and studied. Although a biopsy is a conclusive way to diagnose avascular necrosis, it is rarely used because it requires surgery.

Functional Evaluation of Bone Tests to measure the pressure inside a bone may be used when the doctor strongly suspects that a patient has avascular necrosis, despite normal results of x rays, bone scans, and MRIs. These tests are very sensitive for detecting increased pressure within the bone, but they require surgery.

Guidelines 15

What Treatments Are Available? Appropriate treatment for avascular necrosis is necessary to keep joints from breaking down. If untreated, most patients will experience severe pain and limitation in movement within 2 years. Several treatments are available that can help prevent further bone and joint damage and reduce pain. To determine the most appropriate treatment, the doctor considers the following aspects of a patient's disease: ·

The age of the patient.

·

The stage of the disease--early or late.

·

The location and amount of bone affected--a small or large area.

·

The underlying cause of avascular necrosis--with an ongoing cause such as corticosteroid or alcohol use, treatment may not work unless use of the substance is stopped.

The goal in treating avascular necrosis is to improve the patient's use of the affected joint, stop further damage to the bone, and ensure bone and joint survival. To reach these goals, the doctor may use one or more of the following treatments.

Conservative Treatment Conservative treatments have been used experimentally alone or in combination. However, these treatments rarely provide lasting improvement. Therefore, most patients will eventually need surgery to repair the joint permanently. Some conservative treatments are: ·

Medicines--to reduce fatty substances (lipids) that increase with corticosteroid treatment or to reduce blood clotting in the presence of clotting disorders. Nonsteroidal anti-inflammatory drugs may also be prescribed to reduce pain.

·

Reduced weight bearing--If avascular necrosis is diagnosed early, the doctor may begin treatment by having the patient remove weight from the affected joint. The doctor may recommend limiting activities or using crutches. In some cases, reduced weight bearing can slow the damage caused by avascular necrosis and permit natural healing. When combined with medication to reduce pain, reduced weight bearing can be an effective way to avoid or delay surgery for some patients.


·

Range-of-motion exercises--may be prescribed to maintain or improve joint range of motion.

·

Electrical stimulation--to induce bone growth.

Surgical Treatment ·

Core decompression--This surgical procedure removes the inner layer of bone, which reduces pressure within the bone, increases blood flow to the bone, and allows more blood vessels to form. Core decompression works best in people who are in the earliest stages of avascular necrosis, often before the collapse of the joint. This procedure sometimes can reduce pain and slow the progression of bone and joint destruction in these patients.

·

Osteotomy--This surgical procedure reshapes the bone to reduce stress on the affected area. There is a lengthy recovery period, and the patient's activities are very limited for 3 to 12 months after an osteotomy. This procedure is most effective for patients with advanced avascular necrosis and those with a large area of affected bone.

·

Bone graft--A bone graft may be used to support a joint after core decompression. Bone grafting is surgery that transplants healthy bone from one part of the patient, such as the leg, to the diseased area. Commonly, grafts (called vascular grafts) that include an artery and veins are used to increase the blood supply to the affected area. There is a lengthy recovery period after a bone graft, usually from 6 to 12 months. This procedure is complex and its effectiveness is not yet proven. Clinical studies are under way to determine its effectiveness.

·

Arthroplasty/total joint replacement--Total joint replacement is the treatment of choice in late-stage avascular necrosis and when the joint is destroyed. In this surgery, the diseased joint is replaced with artificial parts. It may be recommended for people who are not good candidates for other treatments, such as patients who do not do well with repeated attempts to preserve the joint. Various types of replacements are available, and people should discuss specific needs with their doctor.

For most people with avascular necrosis, treatment is an ongoing process. Doctors may first recommend the least complex and invasive procedure, such as protecting the joint by limiting movement, and watch the effect on the patient's condition. Other treatments then may be used to prevent further bone destruction and reduce pain. It is important that patients carefully follow instructions about activity limitations and work closely with their doctor to ensure that appropriate treatments are used.

Guidelines 17

What Research Is Being Done to Help People with Avascular Necrosis? With proper treatment, most people with avascular necrosis can lead productive lives. But there is still a lot to learn about prevention, diagnosis, and treatment. For example, researchers are studying: ·

New ways to diagnose avascular necrosis in its earliest stages, when nonsurgical treatment is most likely to help.

·

The various causes of avascular necrosis so that, someday, it may be possible to prevent the disease.

·

New treatments and improvement of the treatments that are available. In the future, medication may be an effective treatment for avascular necrosis.

·

Improvements to the various types of hip replacements, to prevent younger patients from needing more than one hip replacement during their lives.

Where Can I Find More Information about Avascular Necrosis? For more information, contact: National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse National Institutes of Health 1 AMS Circle Bethesda, MD 20892-3675 Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge) TTY: 301-565-2966 Fax: 301-718-6366 www.niams.nih.gov/ The clearinghouse provides information about various forms of arthritis and rheumatic disease and bone, muscle, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can also be found on the NIAMS Web site.


American Academy of Orthopaedic Surgeons P.O. Box 2058 Des Plaines, IL 60017 Phone: 800-824-BONES (2663) (free of charge) www.aaos.org The academy publishes brochures on total joint replacement, arthritis, arthroscopy, and other subjects. Single copies of a brochure are available free of charge by sending a self-addressed, stamped (business-size) envelope to (name of brochure) at the address above. Arthritis Foundation 1330 West Peachtree Street Atlanta, GA 30309 Phone: 404-872-7100 or 800-283-7800 (free of charge) or call your local chapter (listed in the telephone directory) www.arthritis.org This is the main voluntary organization devoted to providing information and services to people affected by arthritis, rheumatic diseases, and related conditions. The Hip Society 951 Old Country Road, #182 Belmont, CA 94002 Phone: 650-596-6190 Fax: 650-508-2039 This society maintains a list of physicians who are specialists in problems of the hip and provides physician referrals by geographic area.

More Guideline Sources The guideline above on avascular necrosis is only one example of the kind of material that you can find online and free of charge. The remainder of this chapter will direct you to other sources which either publish or can help you find additional guidelines on topics related to avascular necrosis. Many of the guidelines listed below address topics that may be of particular relevance to your specific situation or of special interest to only some patients with avascular necrosis. Due to space limitations these sources are listed in a concise manner. Do not hesitate to consult the following sources by either using the Internet hyperlink provided, or, in cases where the contact information is provided, contacting the publisher or author directly.

Guidelines 19

Topic Pages: MEDLINEplus For patients wishing to go beyond guidelines published by specific Institutes of the NIH, the National Library of Medicine has created a vast and patientoriented healthcare information portal called MEDLINEplus. Within this Internet-based system are “health topic pages.” You can think of a health topic page as a guide to patient guides. To access this system, log on to http://www.nlm.nih.gov/medlineplus/healthtopics.html. From there you can either search using the alphabetical index or browse by broad topic areas.

If you do not find topics of interest when browsing health topic pages, then you can choose to use the advanced search utility of MEDLINEplus at http://www.nlm.nih.gov/medlineplus/advancedsearch.html. This utility is similar to the NIH Search Utility, with the exception that it only includes material linked within the MEDLINEplus system (mostly patient-oriented information). It also has the disadvantage of generating unstructured results. We recommend, therefore, that you use this method only if you have a very targeted search.

The Combined Health Information Database (CHID) CHID Online is a reference tool that maintains a database directory of thousands of journal articles and patient education guidelines on avascular necrosis and related conditions. One of the advantages of CHID over other sources is that it offers summaries that describe the guidelines available, including contact information and pricing. CHID’s general Web site is http://chid.nih.gov/. To search this database, go to http://chid.nih.gov/detail/detail.html. In particular, you can use the advanced search options to look up pamphlets, reports, brochures, and information kits. The following was recently posted in this archive: ·

Shoulder Replacement Surgery: Relieving Your Shoulder Pain Source: San Bruno, CA: StayWell Company. 2000. 16 p. Contact: Available from StayWell Company. 1100 Grundy Lane, San Bruno, CA 94066-3030. (800) 333-3032. Website: www.staywell.com. PRICE: Call or write for current pricing on single and bulk orders. Summary: This illustrated booklet provides people who have shoulder replacement surgery with information on undergoing and recovering from this surgical procedure. The booklet describes the anatomy of the


healthy shoulder and identifies problems that can cause pain and stiffness, such as osteoarthritis, rheumatoid arthritis, fracture, avascular necrosis, and rotator cuff tear. This is followed by a discussion of the orthopedic evaluation to assess the shoulder, focusing on the medical history, the physical examination, and diagnostic tests such as x rays, computed tomography, and magnetic resonance imaging. The booklet then outlines the steps involved in preparing for surgery, that is, having a general physical and dental examination, storing blood, informing the surgeon about any medications being taken, and planning ahead to make home recovery go more smoothly. In addition, the booklet discusses preparations in the days before surgery, describes the surgical technique for replacing part or all of the shoulder, and offers guidelines on recovering in the hospital and at home. The booklet includes a surgical checklist to help readers remember what to do before and after surgery. 11 figures. ·

Questions and Answers About Avascular Necrosis Source: Bethesda, MD: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse. 2001. 20 p. Contact: Available from National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse. 1 AMS Circle, Bethesda, MD 20892-3675. (877) 226-4267 or (301) 495-4484. Fax (301) 718-6366. TTY (301) 565-2966. E-mail: [email protected]. Website: www.niams.nih.gov. PRICE: 1 to 25 copies free. Order Number: AR-150QA (booklet), or AR-150L QA (large print). Summary: This fact sheet for people with avascular necrosis, or osteonecrosis, uses a question and answer format to provide information on the disease. Avascular necrosis, which most commonly affects the ends of long bones, is described as a disease resulting from the temporary or permanent loss of the blood supply to the bones. Causes can be injuries, certain risk factors, steroid medications, and alcohol use. The fact sheet explains how, in its early stages, people may not experience any symptoms, how the disease progresses, how it is diagnosed, and what are the available treatments. It also describes current research on the causes and treatment for the disease. Two voluntary health organizations are listed for additional information about avascular necrosis. A large print version of this fact sheet is also available.

Guidelines 21

The National Guideline Clearinghouse™ The National Guideline Clearinghouse™ offers hundreds of evidence-based clinical practice guidelines published in the United States and other countries. You can search their site located at http://www.guideline.gov by using the keyword “avascular necrosis” or synonyms. The following was recently posted: ·

ACR Appropriateness Criteria™ for diagnostic imaging of avascular necrosis of the hip. Source: American College of Radiology.; 1995 (revised 1999); 8 pages http://www.guideline.gov/FRAMESETS/guideline_fs.asp?guideline=00 1642&sSearch_string=avascular+necrosis The NIH Search Utility

After browsing the references listed at the beginning of this chapter, you may want to explore the NIH Search Utility. This allows you to search for documents on over 100 selected Web sites that comprise the NIH-WEBSPACE. Each of these servers is “crawled” and indexed on an ongoing basis. Your search will produce a list of various documents, all of which will relate in some way to avascular necrosis. The drawbacks of this approach are that the information is not organized by theme and that the references are often a mix of information for professionals and patients. Nevertheless, a large number of the listed Web sites provide useful background information. We can only recommend this route, therefore, for relatively rare or specific disorders, or when using highly targeted searches. To use the NIH search utility, visit the following Web page: http://search.nih.gov/index.html.

Additional Web Sources A number of Web sites that often link to government sites are available to the public. These can also point you in the direction of essential information. The following is a representative sample: ·

AOL: http://search.aol.com/cat.adp?id=168&layer=&from=subcats

·

drkoop.comÒ: http://www.drkoop.com/conditions/ency/index.html

·

Family Village: http://www.familyvillage.wisc.edu/specific.htm

·

Google: http://directory.google.com/Top/Health/Conditions_and_Diseases/


·

Med Help International: http://www.medhelp.org/HealthTopics/A.html

·

Open Directory Project: http://dmoz.org/Health/Conditions_and_Diseases/

·

Yahoo.com: http://dir.yahoo.com/Health/Diseases_and_Conditions/

·

WebMDÒHealth: http://my.webmd.com/health_topics

Vocabulary Builder The material in this chapter may have contained a number of unfamiliar words. The following Vocabulary Builder introduces you to terms used in this chapter that have not been covered in the previous chapter: Arthroplasty: Surgical reconstruction of a joint to relieve pain or restore motion. [NIH] Arthroscopy: Endoscopic examination, therapy and surgery of the joint. [NIH] Biopsy: The removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis. [EU] Bursitis: Inflammation of a bursa, occasionally accompanied by a calcific deposit in the underlying supraspinatus tendon; the most common site is the subdeltoid bursa. [EU] Cataract: An opacity, partial or complete, of one or both eyes, on or in the lens or capsule, especially an opacity impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Dislocation: The displacement of any part, more especially of a bone. Called also luxation. [EU] Femur: The longest and largest bone of the skeleton, it is situated between the hip and the knee. [NIH] Inflammation: A pathological process characterized by injury or destruction

Guidelines 23

of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU] Lupus: A form of cutaneous tuberculosis. It is seen predominantly in women and typically involves the nasal, buccal, and conjunctival mucosa. [NIH]

Myositis: Inflammation of a voluntary muscle. [EU] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Orthopaedic: Pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopaedics. [EU] Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness, particularly after prolonged activity. [EU] Osteonecrosis: Death of a bone or part of a bone, either atraumatic or posttraumatic. [NIH] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Pancreatitis: Acute or chronic inflammation of the pancreas, which may be asymptomatic or symptomatic, and which is due to autodigestion of a pancreatic tissue by its own enzymes. It is caused most often by alcoholism or biliary tract disease; less commonly it may be associated with hyperlipaemia, hyperparathyroidism, abdominal trauma (accidental or operative injury), vasculitis, or uraemia. [EU] Prednisone: A synthetic anti-inflammatory glucocorticoid derived from cortisone. It is biologically inert and converted to prednisolone in the liver. [NIH]


Radiology: A specialty concerned with the use of x-ray and other forms of radiant energy in the diagnosis and treatment of disease. [NIH] Rheumatoid: Resembling rheumatism. [EU] Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Systemic: Pertaining to or affecting the body as a whole. [EU] Tendinitis: Inflammation of tendons and of tendon-muscle attachments. [EU] Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

Vasculitis: Inflammation of a vessel, angiitis. [EU] Veins: The vessels carrying blood toward the heart. [NIH]

Seeking Guidance 25

CHAPTER 2. SEEKING GUIDANCE Overview Some patients are comforted by the knowledge that a number of organizations dedicate their resources to helping people with avascular necrosis. These associations can become invaluable sources of information and advice. Many associations offer aftercare support, financial assistance, and other important services. Furthermore, healthcare research has shown that support groups often help people to better cope with their conditions.9 In addition to support groups, your physician can be a valuable source of guidance and support. Therefore, finding a physician that can work with your unique situation is a very important aspect of your care. In this chapter, we direct you to resources that can help you find patient organizations and medical specialists. We begin by describing how to find associations and peer groups that can help you better understand and cope with avascular necrosis. The chapter ends with a discussion on how to find a doctor that is right for you.

Associations and Avascular Necrosis As mentioned by the Agency for Healthcare Research and Quality, sometimes the emotional side of an illness can be as taxing as the physical side.10 You may have fears or feel overwhelmed by your situation. Everyone has different ways of dealing with disease or physical injury. Your attitude, your expectations, and how well you cope with your condition can all Churches, synagogues, and other houses of worship might also have groups that can offer you the social support you need. 10 This section has been adapted from http://www.ahcpr.gov/consumer/diaginf5.htm. 9


influence your well-being. This is true for both minor conditions and serious illnesses. For example, a study on female breast cancer survivors revealed that women who participated in support groups lived longer and experienced better quality of life when compared with women who did not participate. In the support group, women learned coping skills and had the opportunity to share their feelings with other women in the same situation. There are a number of directories that list additional medical associations that you may find useful. While not all of these directories will provide different information, by consulting all of them, you will have nearly exhausted all sources for patient associations.

The National Health Information Center (NHIC) The National Health Information Center (NHIC) offers a free referral service to help people find organizations that provide information about avascular necrosis. For more information, see the NHIC’s Web site at http://www.health.gov/NHIC/ or contact an information specialist by calling 1-800-336-4797.

DIRLINE A comprehensive source of information on associations is the DIRLINE database maintained by the National Library of Medicine. The database comprises some 10,000 records of organizations, research centers, and government institutes and associations which primarily focus on health and biomedicine. DIRLINE is available via the Internet at the following Web site: http://dirline.nlm.nih.gov/. Simply type in “avascular necrosis” (or a synonym) or the name of a topic, and the site will list information contained in the database on all relevant organizations. The Combined Health Information Database Another comprehensive source of information on healthcare associations is the Combined Health Information Database. Using the “Detailed Search” option, you will need to limit your search to “Organizations” and “avascular necrosis”. Type the following hyperlink into your Web browser: http://chid.nih.gov/detail/detail.html. To find associations, use the drop boxes at the bottom of the search page where “You may refine your search by.” For publication date, select “All Years.” Then, select your preferred language and the format option “Organization Resource Sheet.” By making

Seeking Guidance 27

these selections and typing in “avascular necrosis” (or synonyms) into the “For these words:” box, you will only receive results on organizations dealing with avascular necrosis. You should check back periodically with this database since it is updated every 3 months. The National Organization for Rare Disorders, Inc. The National Organization for Rare Disorders, Inc. has prepared a Web site that provides, at no charge, lists of associations organized by specific diseases. You can access this database at the following Web site: http://www.rarediseases.org/cgi-bin/nord/searchpage. Select the option called “Organizational Database (ODB)” and type “avascular necrosis” (or a synonym) in the search box.

Online Support Groups In addition to support groups, commercial Internet service providers offer forums and chat rooms for people with different illnesses and conditions. WebMDÒ, for example, offers such a service at their Web site: http://boards.webmd.com/roundtable. These online self-help communities can help you connect with a network of people whose concerns are similar to yours. Online support groups are places where people can talk informally. If you read about a novel approach, consult with your doctor or other healthcare providers, as the treatments or discoveries you hear about may not be scientifically proven to be safe and effective. The following Internet sites may be of particular interest: ·

Health Link USA www.healthlinkusa.com/38ent.htm

·

OrthoWorld www.orthoworld.com/support/support-groups.htm

·

Osteonecrosis/Avascular Necrosis Support Group International www.medhelp.org/HealthTopics/Osteoporosis.html

Finding Doctors One of the most important aspects of your treatment will be the relationship between you and your doctor or specialist. All patients with avascular necrosis must go through the process of selecting a physician. While this


process will vary from person to person, the Agency for Healthcare Research and Quality makes a number of suggestions, including the following:11 ·

If you are in a managed care plan, check the plan's list of doctors first.

·

Ask doctors or other health professionals who work with doctors, such as hospital nurses, for referrals.

·

Call a hospital’s doctor referral service, but keep in mind that these services usually refer you to doctors on staff at that particular hospital. The services do not have information on the quality of care that these doctors provide.

·

Some local medical societies offer lists of member doctors. Again, these lists do not have information on the quality of care that these doctors provide.

Additional steps you can take to locate doctors include the following: ·

Check with the associations listed earlier in this chapter.

·

Information on doctors in some states is available on the Internet at http://www.docboard.org. This Web site is run by “Administrators in Medicine,” a group of state medical board directors.

·

The American Board of Medical Specialties can tell you if your doctor is board certified. “Certified” means that the doctor has completed a training program in a specialty and has passed an exam, or “board,” to assess his or her knowledge, skills, and experience to provide quality patient care in that specialty. Primary care doctors may also be certified as specialists. The AMBS Web site is located at http://www.abms.org/newsearch.asp.12 You can also contact the ABMS by phone at 1-866-ASK-ABMS.

·

You can call the American Medical Association (AMA) at 800-665-2882 for information on training, specialties, and board certification for many licensed doctors in the United States. This information also can be found in “Physician Select” at the AMA's Web site: http://www.amaassn.org/aps/amahg.htm.

If the previous sources did not meet your needs, you may want to log on to the Web site of the National Organization for Rare Disorders (NORD) at http://www.rarediseases.org/. NORD maintains a database of doctors with This section has been adapted from the AHRQ: http://www.ahrq.gov/consumer/qntascii/qntdr.htm. 12 While board certification is a good measure of a doctor's knowledge, it is possible to receive quality care from doctors who are not board certified. 11

Seeking Guidance 29

expertise in various rare diseases. The Metabolic Information Network (MIN), 800-945-2188, also maintains a database of physicians with expertise in various metabolic diseases.

Finding a Rheumatologist The American College of Rheumatology (ACR) maintains a geographic directory of member physicians called “Find a Rheumatologist.” To access this database, log on to http://www.rheumatology.org/directory/geo.asp. You will be given the option to search for a rheumatologist by name, by U.S. State, or by country. To contact the ACR, you can use the following information: American College of Rheumatology 1800 Century Place, Suite 250 Atlanta, GA 30345 Phone: (404) 633-3777 Fax: (404) 633-1870 E-mail: [email protected]

Selecting Your Doctor13 When you have compiled a list of prospective doctors, call each of their offices. First, ask if the doctor accepts your health insurance plan and if he or she is taking new patients. If the doctor is not covered by your plan, ask yourself if you are prepared to pay the extra costs. The next step is to schedule a visit with your chosen physician. During the first visit you will have the opportunity to evaluate your doctor and to find out if you feel comfortable with him or her. Ask yourself, did the doctor: ·

Give me a chance to ask questions about avascular necrosis?

·

Really listen to my questions?

·

Answer in terms I understood?

·

Show respect for me?

·

Ask me questions?

·

Make me feel comfortable?

13 This

section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.


·

Address the health problem(s) I came with?

·

Ask me my preferences about different kinds of treatments for avascular necrosis?

· Spend enough time with me? Trust your instincts when deciding if the doctor is right for you. But remember, it might take time for the relationship to develop. It takes more than one visit for you and your doctor to get to know each other.

Working with Your Doctor14 Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care and have better results. Here are some tips to help you and your doctor become partners: ·

You know important things about your symptoms and your health history. Tell your doctor what you think he or she needs to know.

·

It is important to tell your doctor personal information, even if it makes you feel embarrassed or uncomfortable.

·

Bring a “health history” list with you (and keep it up to date).

·

Always bring any medications you are currently taking with you to the appointment, or you can bring a list of your medications including dosage and frequency information. Talk about any allergies or reactions you have had to your medications.

·

Tell your doctor about any natural or alternative medicines you are taking.

·

Bring other medical information, such as x-ray films, test results, and medical records.

·

Ask questions. If you don't, your doctor will assume that you understood everything that was said.

·

Write down your questions before your visit. List the most important ones first to make sure that they are addressed.

·

Consider bringing a friend with you to the appointment to help you ask questions. This person can also help you understand and/or remember the answers.

This section has been adapted from the AHRQ: www.ahrq.gov/consumer/qntascii/qntdr.htm.

14

Seeking Guidance 31

·

Ask your doctor to draw pictures if you think that this would help you understand.

·

Take notes. Some doctors do not mind if you bring a tape recorder to help you remember things, but always ask first.

·

Let your doctor know if you need more time. If there is not time that day, perhaps you can speak to a nurse or physician assistant on staff or schedule a telephone appointment.

·

Take information home. Ask for written instructions. Your doctor may also have brochures and audio and videotapes that can help you.

·

After leaving the doctor's office, take responsibility for your care. If you have questions, call. If your symptoms get worse or if you have problems with your medication, call. If you had tests and do not hear from your doctor, call for your test results. If your doctor recommended that you have certain tests, schedule an appointment to get them done. If your doctor said you should see an additional specialist, make an appointment.

By following these steps, you will enhance the relationship you will have with your physician.

Broader Health-Related Resources In addition to the references above, the NIH has set up guidance Web sites that can help patients find healthcare professionals. These include:15 ·

Caregivers: http://www.nlm.nih.gov/medlineplus/caregivers.html

·

Choosing a Doctor or Healthcare Service: http://www.nlm.nih.gov/medlineplus/choosingadoctororhealthcareserv ice.html

·

Hospitals and Health Facilities: http://www.nlm.nih.gov/medlineplus/healthfacilities.html

You can access this information at: http://www.nlm.nih.gov/medlineplus/healthsystem.html.

15


Clinical Trials 33

CHAPTER 3. CLINICAL TRIALS AND AVASCULAR NECROSIS Overview Very few medical conditions have a single treatment. The basic treatment guidelines that your physician has discussed with you, or those that you have found using the techniques discussed in Chapter 1, may provide you with all that you will require. For some patients, current treatments can be enhanced with new or innovative techniques currently under investigation. In this chapter, we will describe how clinical trials work and show you how to keep informed of trials concerning avascular necrosis.

What Is a Clinical Trial?16 Clinical trials involve the participation of people in medical research. Most medical research begins with studies in test tubes and on animals. Treatments that show promise in these early studies may then be tried with people. The only sure way to find out whether a new treatment is safe, effective, and better than other treatments for avascular necrosis is to try it on patients in a clinical trial.

The discussion in this chapter has been adapted from the NIH and the NEI: www.nei.nih.gov/netrials/ctivr.htm.

16


What Kinds of Clinical Trials Are There? Clinical trials are carried out in three phases: ·

Phase I. Researchers first conduct Phase I trials with small numbers of patients and healthy volunteers. If the new treatment is a medication, researchers also try to determine how much of it can be given safely.

·

Phase II. Researchers conduct Phase II trials in small numbers of patients to find out the effect of a new treatment on avascular necrosis.

·

Phase III. Finally, researchers conduct Phase III trials to find out how new treatments for avascular necrosis compare with standard treatments already being used. Phase III trials also help to determine if new treatments have any side effects. These trials--which may involve hundreds, perhaps thousands, of people--can also compare new treatments with no treatment. How Is a Clinical Trial Conducted?

Various organizations support clinical trials at medical centers, hospitals, universities, and doctors' offices across the United States. The “principal investigator” is the researcher in charge of the study at each facility participating in the clinical trial. Most clinical trial researchers are medical doctors, academic researchers, and specialists. The “clinic coordinator” knows all about how the study works and makes all the arrangements for your visits. All doctors and researchers who take part in the study on avascular necrosis carefully follow a detailed treatment plan called a protocol. This plan fully explains how the doctors will treat you in the study. The “protocol” ensures that all patients are treated in the same way, no matter where they receive care. Clinical trials are controlled. This means that researchers compare the effects of the new treatment with those of the standard treatment. In some cases, when no standard treatment exists, the new treatment is compared with no treatment. Patients who receive the new treatment are in the treatment group. Patients who receive a standard treatment or no treatment are in the “control” group. In some clinical trials, patients in the treatment group get a new medication while those in the control group get a placebo. A placebo is a harmless substance, a “dummy” pill, that has no effect on avascular necrosis. In other clinical trials, where a new surgery or device (not a medicine) is being tested, patients in the control group may receive a “sham

Clinical Trials 35

treatment.” This treatment, like a placebo, has no effect on avascular necrosis and does not harm patients. Researchers assign patients “randomly” to the treatment or control group. This is like flipping a coin to decide which patients are in each group. If you choose to participate in a clinical trial, you will not know which group you will be appointed to. The chance of any patient getting the new treatment is about 50 percent. You cannot request to receive the new treatment instead of the placebo or sham treatment. Often, you will not know until the study is over whether you have been in the treatment group or the control group. This is called a “masked” study. In some trials, neither doctors nor patients know who is getting which treatment. This is called a “double masked” study. These types of trials help to ensure that the perceptions of the patients or doctors will not affect the study results. Natural History Studies Unlike clinical trials in which patient volunteers may receive new treatments, natural history studies provide important information to researchers on how avascular necrosis develops over time. A natural history study follows patient volunteers to see how factors such as age, sex, race, or family history might make some people more or less at risk for avascular necrosis. A natural history study may also tell researchers if diet, lifestyle, or occupation affects how a disease or disorder develops and progresses. Results from these studies provide information that helps answer questions such as: How fast will a disease or disorder usually progress? How bad will the condition become? Will treatment be needed? What Is Expected of Patients in a Clinical Trial? Not everyone can take part in a clinical trial for a specific disease or disorder. Each study enrolls patients with certain features or eligibility criteria. These criteria may include the type and stage of disease or disorder, as well as, the age and previous treatment history of the patient. You or your doctor can contact the sponsoring organization to find out more about specific clinical trials and their eligibility criteria. If you are interested in joining a clinical trial, your doctor must contact one of the trial's investigators and provide details about your diagnosis and medical history. If you participate in a clinical trial, you may be required to have a number of medical tests. You may also need to take medications and/or undergo


surgery. Depending upon the treatment and the examination procedure, you may be required to receive inpatient hospital care. Or, you may have to return to the medical facility for follow-up examinations. These exams help find out how well the treatment is working. Follow-up studies can take months or years. However, the success of the clinical trial often depends on learning what happens to patients over a long period of time. Only patients who continue to return for follow-up examinations can provide this important long-term information.

Recent Trials on Avascular Necrosis The National Institutes of Health and other organizations sponsor trials on various diseases and disorders. Because funding for research goes to the medical areas that show promising research opportunities, it is not possible for the NIH or others to sponsor clinical trials for every disease and disorder at all times. The following lists recent trials dedicated to avascular necrosis.17 If the trial listed by the NIH is still recruiting, you may be eligible. If it is no longer recruiting or has been completed, then you can contact the sponsors to learn more about the study and, if published, the results. Further information on the trial is available at the Web site indicated. Please note that some trials may no longer be recruiting patients or are otherwise closed. Before contacting sponsors of a clinical trial, consult with your physician who can help you determine if you might benefit from participation. ·

Decompression Coring Versus Conservative Therapy in Patients With Avascular Necrosis of the Hip Related to Sickle Cell Disease Condition(s): Bone Avascular Necrosis; Sickle Cell Anemia Study Status: This study is no longer recruiting patients. Sponsor(s): National Center for Research Resources (NCRR); University of North Carolina Purpose - Excerpt: Objectives: I. Phase II trial to determine surgical morbidity of decompression coring, including any adverse events in the perioperative period and the rate of secondary medical or surgical interventions. II. Collect preliminary data to determine if decompression coring results in a substantial improvement in pain and mobility compared to conservative therapy in patients with avascular necrosis of the hip related to sickle cell disease. Study Type: Interventional

17

These are listed at www.ClinicalTrials.gov.

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Contact(s): California; Children's Hospital of Oakland, Oakland, California, 94609, United States; Elliott P. Vichinsky 510-428-3651; North Carolina; University of North Carolina School of Medicine, Chapel Hill, North Carolina, 27599-7070, United States; Eugene P Orringer 919-8439486. Study chairs or principal investigators: Elliott P. Vichinsky, Study Chair; University of North Carolina Web Site: http://clinicaltrials.gov/ct/gui/c/w2r/show/NCT00006130

Benefits and Risks18 What Are the Benefits of Participating in a Clinical Trial? If you are interested in a clinical trial, it is important to realize that your participation can bring many benefits to you and society at large: ·

A new treatment could be more effective than the current treatment for avascular necrosis. Although only half of the participants in a clinical trial receive the experimental treatment, if the new treatment is proved to be more effective and safer than the current treatment, then those patients who did not receive the new treatment during the clinical trial may be among the first to benefit from it when the study is over.

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If the treatment is effective, then it may improve health or prevent diseases or disorders.

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Clinical trial patients receive the highest quality of medical care. Experts watch them closely during the study and may continue to follow them after the study is over.

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People who take part in trials contribute to scientific discoveries that may help other people with avascular necrosis. In cases where certain diseases or disorders run in families, your participation may lead to better care or prevention for your family members. The Informed Consent

Once you agree to take part in a clinical trial, you will be asked to sign an “informed consent.” This document explains a clinical trial's risks and benefits, the researcher’s expectations of you, and your rights as a patient. This section has been adapted from ClinicalTrials.gov, a service of the National Institutes of Health: http://www.clinicaltrials.gov/ct/gui/c/a1r/info/whatis?JServSessionIdzone_ct=9jmun6f2 91. 18


What Are the Risks? Clinical trials may involve risks as well as benefits. Whether or not a new treatment will work cannot be known ahead of time. There is always a chance that a new treatment may not work better than a standard treatment. There is also the possibility that it may be harmful. The treatment you receive may cause side effects that are serious enough to require medical attention.

How Is Patient Safety Protected? Clinical trials can raise fears of the unknown. Understanding the safeguards that protect patients can ease some of these fears. Before a clinical trial begins, researchers must get approval from their hospital's Institutional Review Board (IRB), an advisory group that makes sure a clinical trial is designed to protect patient safety. During a clinical trial, doctors will closely watch you to see if the treatment is working and if you are experiencing any side effects. All the results are carefully recorded and reviewed. In many cases, experts from the Data and Safety Monitoring Committee carefully monitor each clinical trial and can recommend that a study be stopped at any time. You will only be asked to take part in a clinical trial as a volunteer giving informed consent.

What Are a Patient's Rights in a Clinical Trial? If you are eligible for a clinical trial, you will be given information to help you decide whether or not you want to participate. As a patient, you have the right to: ·

Information on all known risks and benefits of the treatments in the study.

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Know how the researchers plan to carry out the study, for how long, and where.

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Know what is expected of you.

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Know any costs involved for you or your insurance provider.

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Know before any of your medical or personal information is shared with other researchers involved in the clinical trial.

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Talk openly with doctors and ask any questions.

Clinical Trials 39

After you join a clinical trial, you have the right to: ·

Leave the study at any time. Participation is strictly voluntary. However, you should not enroll if you do not plan to complete the study.

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Receive any new information about the new treatment.

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Continue to ask questions and get answers.

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Maintain your privacy. Your name will not appear in any reports based on the study.

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Know whether you participated in the treatment group or the control group (once the study has been completed). What about Costs?

In some clinical trials, the research facility pays for treatment costs and other associated expenses. You or your insurance provider may have to pay for costs that are considered standard care. These things may include inpatient hospital care, laboratory and other tests, and medical procedures. You also may need to pay for travel between your home and the clinic. You should find out about costs before committing to participation in the trial. If you have health insurance, find out exactly what it will cover. If you don't have health insurance, or if your insurance company will not cover your costs, talk to the clinic staff about other options for covering the cost of your care. What Should You Ask before Deciding to Join a Clinical Trial? Questions you should ask when thinking about joining a clinical trial include the following: ·

What is the purpose of the clinical trial?

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What are the standard treatments for avascular necrosis? Why do researchers think the new treatment may be better? What is likely to happen to me with or without the new treatment?

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What tests and treatments will I need? Will I need surgery? Medication? Hospitalization?

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How long will the treatment last? How often will I have to come back for follow-up exams?

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What are the treatment's possible benefits to my condition? What are the short- and long-term risks? What are the possible side effects?


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Will the treatment be uncomfortable? Will it make me feel sick? If so, for how long?

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How will my health be monitored?

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Where will I need to go for the clinical trial? How will I get there?

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How much will it cost to be in the study? What costs are covered by the study? How much will my health insurance cover?

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Will I be able to see my own doctor? Who will be in charge of my care?

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Will taking part in the study affect my daily life? Do I have time to participate?

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How do I feel about taking part in a clinical trial? Are there family members or friends who may benefit from my contributions to new medical knowledge?

Keeping Current on Clinical Trials Various government agencies maintain databases on trials. The U.S. National Institutes of Health, through the National Library of Medicine, has developed ClinicalTrials.gov to provide patients, family members, and physicians with current information about clinical research across the broadest number of diseases and conditions. The site was launched in February 2000 and currently contains approximately 5,700 clinical studies in over 59,000 locations worldwide, with most studies being conducted in the United States. ClinicalTrials.gov receives about 2 million hits per month and hosts approximately 5,400 visitors daily. To access this database, simply go to their Web site (www.clinicaltrials.gov) and search by “avascular necrosis” (or synonyms). While ClinicalTrials.gov is the most comprehensive listing of NIH-supported clinical trials available, not all trials are in the database. The database is updated regularly, so clinical trials are continually being added. The following is a list of specialty databases affiliated with the National Institutes of Health that offer additional information on trials: ·

For clinical studies at the Warren Grant Magnuson Clinical Center located in Bethesda, Maryland, visit their Web site: http://clinicalstudies.info.nih.gov/

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·

For clinical studies conducted at the Bayview Campus in Baltimore, Maryland, visit their Web site: http://www.jhbmc.jhu.edu/studies/index.html

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For trials on arthritis, musculoskeletal and skin diseases, visit newly revised site of the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health: http://www.niams.nih.gov/hi/studies/index.htm

General References The following references describe clinical trials and experimental medical research. They have been selected to ensure that they are likely to be available from your local or online bookseller or university medical library. These references are usually written for healthcare professionals, so you may consider consulting with a librarian or bookseller who might recommend a particular reference. The following includes some of the most readily available references (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

A Guide to Patient Recruitment : Today's Best Practices & Proven Strategies by Diana L. Anderson; Paperback - 350 pages (2001), CenterWatch, Inc.; ISBN: 1930624115; http://www.amazon.com/exec/obidos/ASIN/1930624115/icongroupinterna

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A Step-By-Step Guide to Clinical Trials by Marilyn Mulay, R.N., M.S., OCN; Spiral-bound - 143 pages Spiral edition (2001), Jones & Bartlett Pub; ISBN: 0763715697; http://www.amazon.com/exec/obidos/ASIN/0763715697/icongroupinterna

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The CenterWatch Directory of Drugs in Clinical Trials by CenterWatch; Paperback - 656 pages (2000), CenterWatch, Inc.; ISBN: 0967302935; http://www.amazon.com/exec/obidos/ASIN/0967302935/icongroupinterna

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The Complete Guide to Informed Consent in Clinical Trials by Terry Hartnett (Editor); Paperback - 164 pages (2000), PharmSource Information Services, Inc.; ISBN: 0970153309; http://www.amazon.com/exec/obidos/ASIN/0970153309/icongroupinterna

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Dictionary for Clinical Trials by Simon Day; Paperback - 228 pages (1999), John Wiley & Sons; ISBN: 0471985961; http://www.amazon.com/exec/obidos/ASIN/0471985961/icongroupinterna

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Extending Medicare Reimbursement in Clinical Trials by Institute of Medicine Staff (Editor), et al; Paperback 1st edition (2000), National


Academy Press; ISBN: 0309068886; http://www.amazon.com/exec/obidos/ASIN/0309068886/icongroupinterna ·

Handbook of Clinical Trials by Marcus Flather (Editor); Paperback (2001), Remedica Pub Ltd; ISBN: 1901346293; http://www.amazon.com/exec/obidos/ASIN/1901346293/icongroupinterna

Vocabulary Builder The following vocabulary builder gives definitions of words used in this chapter that have not been defined in previous chapters: Abdomen: That portion of the body that lies between the thorax and the pelvis. [NIH] Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] Chronic: Persisting over a long period of time. [EU] Contraception: The prevention of conception or impregnation. [EU] Hepatic: Pertaining to the liver. [EU] Hydroxyurea: An antineoplastic agent that inhibits DNA synthesis through the inhibition of ribonucleoside diphosphate reductase. [NIH] Infertility: The diminished or absent ability to conceive or produce an offspring while sterility is the complete inability to conceive or produce an offspring. [NIH] Laparoscopy: Examination, therapy or surgery of the abdomen's interior by means of a laparoscope. [NIH] Mobility: Capability of movement, of being moved, or of flowing freely. [EU] Oophoritis: Inflammation of an ovary. [NIH] Ovulation: The discharge of a secondary oocyte from a vesicular follicle of the ovary. [EU] Perioperative: Pertaining to the period extending from the time of hospitalization for surgery to the time of discharge. [EU] Progesterone: Pregn-4-ene-3,20-dione. The principal progestational hormone of the body, secreted by the corpus luteum, adrenal cortex, and placenta. Its chief function is to prepare the uterus for the reception and development of the fertilized ovum. It acts as an antiovulatory agent when administered on days 5-25 of the menstrual cycle. [NIH] Remission: A diminution or abatement of the symptoms of a disease; also the period during which such diminution occurs. [EU]

Clinical Trials 43

Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Thalassemia: A group of hereditary hemolytic anemias in which there is decreased synthesis of one or more hemoglobin polypeptide chains. There are several genetic types with clinical pictures ranging from barely detectable hematologic abnormality to severe and fatal anemia. [NIH] Transaminase: Aminotransferase (= a subclass of enzymes of the transferase class that catalyse the transfer of an amino group from a donor (generally an amino acid) to an acceptor (generally 2-keto acid). Most of these enzymes are pyridoxal-phosphate-proteins. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU]

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PART II: ADDITIONAL RESOURCES AND ADVANCED MATERIAL

ABOUT PART II In Part II, we introduce you to additional resources and advanced research on avascular necrosis. All too often, patients who conduct their own research are overwhelmed by the difficulty in finding and organizing information. The purpose of the following chapters is to provide you an organized and structured format to help you find additional information resources on avascular necrosis. In Part II, as in Part I, our objective is not to interpret the latest advances on avascular necrosis or render an opinion. Rather, our goal is to give you access to original research and to increase your awareness of sources you may not have already considered. In this way, you will come across the advanced materials often referred to in pamphlets, books, or other general works. Once again, some of this material is technical in nature, so consultation with a professional familiar with avascular necrosis is suggested.

Studies 47

CHAPTER 4. STUDIES ON AVASCULAR NECROSIS Overview Every year, academic studies are published on avascular necrosis or related conditions. Broadly speaking, there are two types of studies. The first are peer reviewed. Generally, the content of these studies has been reviewed by scientists or physicians. Peer-reviewed studies are typically published in scientific journals and are usually available at medical libraries. The second type of studies is non-peer reviewed. These works include summary articles that do not use or report scientific results. These often appear in the popular press, newsletters, or similar periodicals. In this chapter, we will show you how to locate peer-reviewed references and studies on avascular necrosis. We will begin by discussing research that has been summarized and is free to view by the public via the Internet. We then show you how to generate a bibliography on avascular necrosis and teach you how to keep current on new studies as they are published or undertaken by the scientific community.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and avascular necrosis, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the


format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type in “avascular necrosis” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is a sample of what you can expect from this type of search: ·

Avascular Necrosis: Diagnosis, Staging, and Management Source: Journal of Musculoskeletal Medicine. 14(11):13-15,17, 21-24; November 1997. Summary: This journal article for health professionals discusses the early diagnosis, evaluation, and staging of nontraumatic avascular necrosis (AVN) of the hip joint. AVN is a poorly understood condition in which a decrease in the blood supply to bone results in its death. The hip is more frequently involved than other joints, and the consequences there are more serious. Without treatment, most cases will progress to bone collapse and eventually require reconstructive surgery. Understanding the causes and pathogenesis aids early diagnosis, which leads to more effective management. In the earlier stages, the goal is to institute treatment designed to retard disease progression and prevent femoral head collapse, including core decompression, bone grafting, osteotomy, and electrical stimulation. In the later stages, after significant collapse has occurred, management is conservative until reconstructive surgery, usually total hip replacement arthroplasty, is indicated. 15 references, 4 figures, and 5 tables. (AA-M).

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Avascular Necrosis Following Renal Transplantation Source: Transplantation Proceedings. 30(7): 3034-3035. November 1998. Contact: Available from Appleton and Lange. P.O. Box 86, Congers, NY 10920-0086. (203) 406-4623. Summary: Current improved graft survival following organ transplantation depends upon the combined use of various immunosuppressive drugs. Regardless of many favorable effects of each drug, they have some side effects. Avascular necrosis (AVN) following organ transplant is one of the complications that sometimes results from treatments to preserve the organ allograft. This article reports on a study that retrospectively analyzed patients with renal allografts in order to determine the cause or precipitating conditions for AVN, to evaluate the clinicopathologic features associated with AVN, and to establish a

Studies 49

treatment strategy. Thirteen cases (2.8 percent) of AVN of femoral head were developed among 462 patients studied. Among these, 11 cases of 365 (3.0 percent) were from living donors and 2 cases out of 97 (2.2 percent) were from cadaveric donors. The main clinical manifestations were hip joint pain and limitation of weight bearing and motion. The mean onset of first bone symptoms of AVN was 5.5 months. The type of donor, pretransplant type, and duration of dialysis showed no relation with the occurrence of AVN. The pretransplant level of blood urea nitrogen (BUN) was higher in the AVN group, but its significance is questionable due to a fluctuating level of the time of blood sampling. In this study, the cholesterol level did not show any significant relation with the AVN. Posttransplant weight gain can be suspected to be a favorable condition for AVN; however, in this population, posttransplant weight gain was not significant. The authors contend that AVN in bone may be induced by individual reactions to the steroid treatment. In the early stage of AVN, core decompression alone can be a successful treatment. In this study, 7 of 13 patients underwent core decompression. The authors conclude that they could not illustrate the definite precipitating factors for AVN in renal transplant recipients using steroids. 8 references. ·

Prevalence Rates and an Evaluation of Reported Risk Factors for Osteonecrosis (Avascular Necrosis) in Crohn's Disease Source: Canadian Journal of Gastroenterology. 14(2): 138-143. February 2000. Contact: Available from Pulsus Group, Inc. 2902 South Sheridan Way, Oakville, Ontario, Canada L6J 7L6. Fax (905) 829-4799. E-mail: [email protected]. Summary: Avascular necrosis (osteonecrosis, or bone death) occurs in Crohn's disease, but the rate of this particular complication is not known. This article reports on a study undertaken to elucidate the prevalence rates and reported risk factors for osteonecrosis in patients with Crohn's disease. Over 20 years, 875 patients with Crohn's disease, 492 women (56.1 percent) and 383 men (43.9 percent) were evaluated, with patient followup data available for a mean of 7.8 years. In this group, four men were seen with osteonecrosis. No woman was affected. All 4 patients had typical radiological, magnetic resonance imaging (MRI), or pathological changes of osteonecrosis involving the femoral heads, while two patients also had superimposed avascular necrosis involving the humeral heads. Patients ages ranged from 19 to 36 years at the time of diagnosis of their Crohn's disease, and all were white. In one patient, disease was confined to the colon, while three patients had disease involving the terminal ileum and colon. Disease behavior in two of the patients was classified as


penetrating because of concomitant ischiorectal abscesses, while one patient developed a metastatic colon carcinoma (cancer). Ankylosing spondylitis (a chronic inflammatory condition affecting the spine) was present in two patients, but no other extraintestinal manifestations developed. Two patients received corticosteroids as well as parenteral nutrition during the course of their disease; two received neither treatment. The overall rate of avascular necrosis in Crohn's disease was less than 0.5 percent, but for men with Crohn's disease, the risk was about 1 percent. In this series, risk of osteonecrosis could not be attributed to corticosteroid use, parenteral nutrition, or both forms of therapy administered together. 1 figure. 2 tables. 20 references.

Federally-Funded Research on Avascular Necrosis The U.S. Government supports a variety of research studies relating to avascular necrosis and associated conditions. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.19 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally-funded biomedical research projects conducted at universities, hospitals, and other institutions. Visit the CRISP Web site at http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket. You can perform targeted searches by various criteria including geography, date, as well as topics related to avascular necrosis and related conditions. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally-funded studies use animals or simulated models to explore avascular necrosis and related conditions. In some cases, therefore, it may be difficult to understand how some basic or fundamental research could eventually translate into medical practice. The following sample is typical of the type of information found when searching the CRISP database for avascular necrosis: ·

Project Title: Early Diagnosis of Growth Disorders Using MRI Imaging Principal Investigator & Institution: Jaramillo, Diego; ; Massachusetts General Hospital 55 Fruit St Boston, Ma 02114

19 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

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Timing: Fiscal Year 2001; Project Start 5-JUL-1994; Project End 0-JUN2005 Summary: (provided by applicant): The goal of this research is the detection of epiphyseal ischemia and prediction of its growth sequelae using novel non-invasive magnetic resonance (MR) approaches. In animal models, we propose to determine the earliest changes in ischemia, to differentiate early from late ischemia leading to avascular necrosis; and to predict the deverlopment of growth arrest. In addition to conventional MR measures (proton density and T2 relaxation), we will investigate perfusion-related changes by early gadolinum (Gd) enhanced imaging; and diffusion related changes by line diffusion scanning and diffusion tensor imaging. We will also evaluate disturbances of the cartilaginous matrix including glycosaminoglycan depletion revealed by delayed GD enhanced imaging, and collagen content by magnetization transfer imaging. The major hypotheses are that MR parameters can 1) detect early ischemia, 2) differentiate early from late ischemia leading to sequelae, and 3) predict growth deformity through MR parameters that reflect tissue structure and vascularization of the immature epiphysis. Epiphyseal ischemia is a pathogenic pathway shared by many common pediatric disorders. Ischemia leading to avascular necrosis of the femoral head frequently causes hip deformity and disability in childhood. A hip that grows abnormally also predisposes to degenerative joint disease in adult; more than half of all adults with osteoarthritis of the hip suffered hip diseases as children. Imaging of cartilaginous disorders serves to guide early therapy, prevent or minimize deformity, and detect children predisposed to premature cartilage degeneration in adulthood. The specific aims are to: 1) determine the MR tissue characteristics of normal epiphyseal cartilage. Specifically, we wish to test whether the greater cellularity and vascularization of immature epiphyseal cartilage result in different MR tissue characteristics; 2) in early ischemia, determine temporal and spatial differences between diffusion imaging, T2 maps and Gd-enhanced imaging; 3) in prolonged ischemia, determine which MR parameters best predict irreversible damage; and 4) in a model of avascular necrosis, determine which MR parameters predict abnormal growth. Website: http://commons.cit.nih.gov/crisp3/CRISP.Generate_Ticket


E-Journals: PubMed Central20 PubMed Central (PMC) is a digital archive of life sciences journal literature developed and managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).21 Access to this growing archive of e-journals is free and unrestricted.22 To search, go to http://www.pubmedcentral.nih.gov/index.html#search, and type “avascular necrosis” (or synonyms) into the search box. This search gives you access to full-text articles. The following is a sample of items found for avascular necrosis in the PubMed Central database: ·

Corticosteroids and avascular necrosis of the femoral head by Allan Knight; 2001 August 21 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=81358&ren dertype=external

The National Library of Medicine: PubMed One of the quickest and most comprehensive ways to find academic studies in both English and other languages is to use PubMed, maintained by the National Library of Medicine. The advantage of PubMed over previously mentioned sources is that it covers a greater number of domestic and foreign references. It is also free to the public.23 If the publisher has a Web site that offers full text of its journals, PubMed will provide links to that site, as well as to sites offering other related data. User registration, a subscription fee, or some other type of fee may be required to access the full text of articles in some journals.

Adapted from the National Library of Medicine: http://www.pubmedcentral.nih.gov/about/intro.html. 21 With PubMed Central, NCBI is taking the lead in preservation and maintenance of open access to electronic literature, just as NLM has done for decades with printed biomedical literature. PubMed Central aims to become a world-class library of the digital age. 22 The value of PubMed Central, in addition to its role as an archive, lies the availability of data from diverse sources stored in a common format in a single repository. Many journals already have online publishing operations, and there is a growing tendency to publish material online only, to the exclusion of print. 23 PubMed was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM) at the National Institutes of Health (NIH). The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at Web sites of participating publishers. Publishers that participate in PubMed supply NLM with their citations electronically prior to or at the time of publication. 20

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To generate your own bibliography of studies dealing with avascular necrosis, simply go to the PubMed Web site at www.ncbi.nlm.nih.gov/pubmed. Type “avascular necrosis” (or synonyms) into the search box, and click “Go.” The following is the type of output you can expect from PubMed for “avascular necrosis” (hyperlinks lead to article summaries): ·

Treatment of experimental avascular necrosis of the femoral head with hyperbaric oxygen in rats: histological evaluation of the femoral heads during the early phase of the reparative process. Author(s): Levin D, Norman D, Zinman C, Rubinstein L, Sabo E, Misselevich I, Reis D, Boss JH. Source: Experimental and Molecular Pathology. 1999 October; 67(2): 99108. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10527761&dopt=Abstract

·

Bilateral aseptic necrosis of the humeral head following combined therapy for Hodgkin's lymphoma. Author(s): Virgolini L, De Maglio A. Source: Ital J Orthop Traumatol. 1992; 18(4): 543-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1345650&dopt=Abstract

Vocabulary Builder Adrenergic: Activated by, characteristic of, or secreting epinephrine or substances with similar activity; the term is applied to those nerve fibres that liberate norepinephrine at a synapse when a nerve impulse passes, i.e., the sympathetic fibres. [EU] Anoxia: A total lack of oxygen; often used interchangeably with hypoxia to mean a reduced supply of oxygen to the tissues. [EU] Antioxidant: One of many widely used synthetic or natural substances added to a product to prevent or delay its deterioration by action of oxygen in the air. Rubber, paints, vegetable oils, and prepared foods commonly contain antioxidants. [EU] Asparaginase: A hydrolase enzyme that converts L-asparagine and water to L-aspartate and NH3. EC 3.5.1.1. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Autoantigens:

Endogenous tissue constituents that have the ability to


interact with autoantibodies and cause an immune response. [NIH] Autoimmunity: Process whereby the immune system reacts against the body's own tissues. Autoimmunity may produce or be caused by autoimmune diseases. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Bile: An emulsifying agent produced in the LIVER and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Biopolymers: Polymers, such as proteins, DNA, RNA, or polysaccharides formed by any living organism. [NIH] Biosynthesis: The building up of a chemical compound in the physiologic processes of a living organism. [EU] Bradykinin: A nonapeptide messenger that is enzymatically produced from kallidin in the blood where it is a potent but short-lived agent of arteriolar dilation and increased capillary permeability. Bradykinin is also released from mast cells during asthma attacks, from gut walls as a gastrointestinal vasodilator, from damaged tissues as a pain signal, and may be a neurotransmitter. [NIH] Calibration: Determination, by measurement or comparison with a standard, of the correct value of each scale reading on a meter or other measuring instrument; or determination of the settings of a control device that correspond to particular values of voltage, current, frequency or other output. [NIH] Calpain: Cysteine proteinase found in many tissues. Hydrolyzes a variety of endogenous proteins including neuropeptides, cytoskeletal proteins, proteins from smooth muscle, cardiac muscle, liver, platelets and erythrocytes. Two subclasses having high and low calcium sensitivity are known. Removes Z-discs and M-lines from myofibrils. Activates phosphorylase kinase and cyclic nucleotide-independent protein kinase. [NIH] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Cardiomyopathy: A general diagnostic term designating primary myocardial disease, often of obscure or unknown etiology. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Caspases: A family of intracellular cysteine endopeptidases. They play a key

Studies 55

role in inflammation and mammalian APOPTOSIS. They are specific for aspartic acid at the P1 position. They are divided into two classes based on the lengths of their N-terminal prodomains. Caspases-1,-2,-4,-5,-8, and -10 have long prodomains and -3,-6,-7,-9 have short prodomains. EC 3.4.22.-. [NIH]

Cholestasis: Impairment of biliary flow at any level from the hepatocyte to Vater's ampulla. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Concomitant: Accompanying; accessory; joined with another. [EU] Cortical: Pertaining to or of the nature of a cortex or bark. [EU] Cysteine: A thiol-containing non-essential amino acid that is oxidized to form cystine. [NIH] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Cytoplasm: The protoplasm of a cell exclusive of that of the nucleus; it consists of a continuous aqueous solution (cytosol) and the organelles and inclusions suspended in it (phaneroplasm), and is the site of most of the chemical activities of the cell. [EU] Cytoskeleton: The network of filaments, tubules, and interconnecting filamentous bridges which give shape, structure, and organization to the cytoplasm. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Dementia: An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness. [NIH] Diffusion: The process of becoming diffused, or widely spread; the spontaneous movement of molecules or other particles in solution, owing to


their random thermal motion, to reach a uniform concentration throughout the solvent, a process requiring no addition of energy to the system. [EU] Electromyography: Recording of the changes in electric potential of muscle by means of surface or needle electrodes. [NIH] Electroporation: A technique in which electric pulses of intensity in kilovolts per centimeter and of microsecond-to-millisecond duration cause a temporary loss of the semipermeability of cell membranes, thus leading to ion leakage, escape of metabolites, and increased uptake by cells of drugs, molecular probes, and DNA. Some applications of electroporation include introduction of plasmids or foreign DNA into living cells for transfection, fusion of cells to prepare hybridomas, and insertion of proteins into cell membranes. [NIH] Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Enterocolitis: Inflammation involving both the small intestine and the colon; see also enteritis. [EU] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Eosinophils: Granular leukocytes with a nucleus that usually has two lobes connected by a slender thread of chromatin, and cytoplasm containing coarse, round granules that are uniform in size and stainable by eosin. [NIH] Epiphyseal: Pertaining to or of the nature of an epiphysis. [EU] Epitopes: Sites on an antigen that interact with specific antibodies. [NIH] Femoral: Pertaining to the femur, or to the thigh. [EU] Fibroblasts: Connective tissue cells which secrete an extracellular matrix rich in collagen and other macromolecules. [NIH] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Hematology:

A subspecialty of internal medicine concerned with

Studies 57

morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hepatocellular: Pertaining to or affecting liver cells. [EU] Hepatocytes: The main structural component of the liver. They are specialized epithelial cells that are organized into interconnected plates called lobules. [NIH] Humeral: 1. of, relating to, or situated in the region of the humerus : brachial. 2. of or belonging to the shoulder. 3. of, relating to, or being any of several body parts that are analogous in structure, function, or location to the humerus or shoulder. [EU] Hyperbaric: Characterized by greater than normal pressure or weight; applied to gases under greater than atmospheric pressure, as hyperbaric oxygen, or to a solution of greater specific gravity than another taken as a standard of reference. [EU] Hypoxia: Reduction of oxygen supply to tissue below physiological levels despite adequate perfusion of the tissue by blood. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU] Inotropic: Affecting the force or energy of muscular contractions. [EU] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Lymphocytic: Pertaining to, characterized by, or of the nature of lymphocytes. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU] Malignant: Tending to become progressively worse and to result in death. Having the properties of anaplasia, invasion, and metastasis; said of tumours. [EU] Mediator: An object or substance by which something is mediated, such as (1) a structure of the nervous system that transmits impulses eliciting a


specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Metabolite: process. [EU]

Any substance produced by metabolism or by a metabolic

Methotrexate: An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of dihydrofolate reductase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. [NIH] Microscopy: The application of microscope magnification to the study of materials that cannot be properly seen by the unaided eye. [NIH] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Myocardium: The muscle tissue of the HEART composed of striated, involuntary muscle known as cardiac muscle. [NIH] Neonatal: Pertaining to the first four weeks after birth. [EU] Neurites: In tissue culture, hairlike projections of neurons stimulated by growth factors and other molecules. These projections may go on to form a branched tree of dendrites or a single axon or they may be reabsorbed at a later stage of development. "Neurite" may refer to any filamentous or pointed outgrowth of an embryonal or tissue-culture neural cell. [NIH] Neurologic: Pertaining to neurology or to the nervous system. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neurons: The basic cellular units of nervous tissue. Each neuron consists of a body, an axon, and dendrites. Their purpose is to receive, conduct, and transmit impulses in the nervous system. [NIH] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH]

Studies 59

Perfusion: 1. the act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ. 2. a liquid poured over or through an organ or tissue. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]

Polyarthritis: An inflammation of several joints together. [EU] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Proteolytic: 1. pertaining to, characterized by, or promoting proteolysis. 2. an enzyme that promotes proteolysis (= the splitting of proteins by hydrolysis of the peptide bonds with formation of smaller polypeptides). [EU] Reagent: A substance employed to produce a chemical reaction so as to detect, measure, produce, etc., other substances. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Reflective: Capable of throwing back light, images, sound waves : reflecting. [EU] Reperfusion: Restoration of blood supply to tissue which is ischemic due to decrease in normal blood supply. The decrease may result from any source including atherosclerotic obstruction, narrowing of the artery, or surgical


clamping. It is primarily a procedure for treating infarction or other ischemia, by enabling viable ischemic tissue to recover, thus limiting further necrosis. However, it is thought that reperfusion can itself further damage the ischemic tissue, causing reperfusion injury. [NIH] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spondylitis: Inflammation of the vertebrae. [EU] Substrate: A substance upon which an enzyme acts. [EU] Synaptic: Pertaining to or affecting a synapse (= site of functional apposition between neurons, at which an impulse is transmitted from one neuron to another by electrical or chemical means); pertaining to synapsis (= pairing off in point-for-point association of homologous chromosomes from the male and female pronuclei during the early prophase of meiosis). [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Tumour: 1. swelling, one of the cardinal signs of inflammations; morbid enlargement. 2. a new growth of tissue in which the multiplication of cells is uncontrolled and progressive; called also neoplasm. [EU] Tyrosine: A non-essential amino acid. In animals it is synthesized from phenylalanine. It is also the precursor of epinephrine, thyroid hormones, and melanin. [NIH] Ventricular: Pertaining to a ventricle. [EU] Venules: The minute vessels that collect blood from the capillary plexuses and join together to form veins. [NIH]

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CHAPTER 5. BOOKS ON AVASCULAR NECROSIS Overview This chapter provides bibliographic book references relating to avascular necrosis. You have many options to locate books on avascular necrosis. The simplest method is to go to your local bookseller and inquire about titles that they have in stock or can special order for you. Some patients, however, feel uncomfortable approaching their local booksellers and prefer online sources (e.g. www.amazon.com and www.bn.com). In addition to online booksellers, excellent sources for book titles on avascular necrosis include the Combined Health Information Database and the National Library of Medicine. Once you have found a title that interests you, visit your local public or medical library to see if it is available for loan.

Book Summaries: Online Booksellers Commercial Internet-based booksellers, such as Amazon.com and Barnes & Noble.com, offer summaries which have been supplied by each title’s publisher. Some summaries also include customer reviews. Your local bookseller may have access to in-house and commercial databases that index all published books (e.g. Books in PrintÒ). The following have been recently listed with online booksellers as relating to avascular necrosis (sorted alphabetically by title; follow the hyperlink to view more details at Amazon.com): ·

Congenital hip dislocation--avascular necrosis : necrosis of the femoral head as a complication of different conservative and operative methods of reduction in congenital dislocation of the hip : collective statistics ; ISBN: 3136230019;


http://www.amazon.com/exec/obidos/ASIN/3136230019/icongroupin terna ·

Masters in Arthroscopy : Disk Three-Slap Lesions, Adhesive Capsulitis, and Avascular Necrosis (Masters in Arthroscopy, an Interactive Cd Series, 3) by Gary G. Poehling (Editor); ISBN: 0815136145; http://www.amazon.com/exec/obidos/ASIN/0815136145/icongroupin terna

The National Library of Medicine Book Index The National Library of Medicine at the National Institutes of Health has a massive database of books published on healthcare and biomedicine. Go to the following Internet site, http://locatorplus.gov/, and then select “Search LOCATORplus.” Once you are in the search area, simply type “avascular necrosis” (or synonyms) into the search box, and select “books only.” From there, results can be sorted by publication date, author, or relevance. The following was recently catalogued by the National Library of Medicine:24 ·

Apoptosis techniques and protocols. Author: edited by Judes Poirier; Year: 1997; Totowa, N.J.: Humana Press, c1997; ISBN: 0896034151 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0896034151/icongroupin terna

·

Congenital hip dislocation: avascular necrosis: necrosis of the femoral head as a complication of different conservative and operative methods of reduction in congenital dislocation of the hip: collective statistics. Author: prepared by the Commission for the; Year: 1982; New York: Thieme-Stratton, 1982; ISBN: 0865770425 http://www.amazon.com/exec/obidos/ASIN/0865770425/icongroupin terna

·

Cytokine handbook. Author: edited by Angus W. Thomson; Year: 1998; San Diego: Academic Press, c1998; ISBN: 0126896623 (alk. paper)

In addition to LOCATORPlus, in collaboration with authors and publishers, the National Center for Biotechnology Information (NCBI) is adapting biomedical books for the Web. The books may be accessed in two ways: (1) by searching directly using any search term or phrase (in the same way as the bibliographic database PubMed), or (2) by following the links to PubMed abstracts. Each PubMed abstract has a “Books” button that displays a facsimile of the abstract in which some phrases are hypertext links. These phrases are also found in the books available at NCBI. Click on hyperlinked results in the list of books in which the phrase is found. Currently, the majority of the links are between the books and PubMed. In the future, more links will be created between the books and other types of information, such as gene and protein sequences and macromolecular structures. See http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books.

24

Books 63

http://www.amazon.com/exec/obidos/ASIN/0126896623/icongroupin terna ·

Cytokines and lipocortins in inflammation and differentiation: proceedings of the International Conference on Molecular and Cellular Biology of IL-1, TNF, and Lipocortins in Inflammation and Differentiation, held in Siena, Italy, October 22-25, 1989. ; Year: 1990; New York: Wiley-Liss, c1990; ISBN: 0471568120 http://www.amazon.com/exec/obidos/ASIN/0471568120/icongroupin terna

·

Cytokines in cancer therapy. Author: volume editors, L. Bergmann, P.S. Mitrou; Year: 1994; Basel; New York: Karger, 1994; ISBN: 3805558090 http://www.amazon.com/exec/obidos/ASIN/3805558090/icongroupin terna

·

Effect of vascularity and necrosis on echo structure: an in vivo study. Author: Martti Pamilo; Year: 1983; Oulu: University of Oulu, 1983; ISBN: 9514215907 (pbk.)

·

Genetics of ocular disease; Acute retinal necrosis syndrome; Phthisis bulbi. Author: volume editor, W. Straub; Year: 1985; Basel; New York: Karger, 1985; ISBN: 3805539339 http://www.amazon.com/exec/obidos/ASIN/3805539339/icongroupin terna

·

Growth inhibitory and cytotoxic polypeptides: proceedings of a Genentech-Smith, Kline & French-Triton Biosciences-UCLA Symposium held in Keystone, Colorado, January 24-30, 1988. Author: editors, Harold L. Moses, Peter Lengyel, Charles D. Stiles; Year: 1989; New York: A.R. Liss, c1989; ISBN: 0845147021 http://www.amazon.com/exec/obidos/ASIN/0845147021/icongroupin terna

·

Handbook of mediators in septic shock. Author: edited by Edmund A. Neugebauer, John W. Holaday; Year: 1993; Boca Raton: CRC Press, c1993; ISBN: 0849335485 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0849335485/icongroupin terna

·

Hip: clinical studies and basic research: proceedings of the 1st Western Pacific Area Conference on the Hip, Tokyo, Japan, October 15-17, 1983. Author: editors, Ryozo Ueno ... [et al.]; Year: 1984; Amsterdam; New York: Excerpta Medica; New York, NY, USA: Sole distributors for the USA and Canada, Elsevier Science, 1984; ISBN: 0444806016 (Elsevier) http://www.amazon.com/exec/obidos/ASIN/0444806016/icongroupin terna


·

Idiopathic avascular necrosis of the femoral head. Author: Patterson, Richard Joseph, 1931-; Year: 1962; [Minneapolis] 1962

·

Idiopathic osteonecrosis of the femoral head: LXVII Congress of the Italian Society of Orthopaedics and Traumatology, Turin, 20-23 October 1982. Author: Società italiana di ortopedia e traumatologia. Congress (67th: 1982: Turin, Italy); Year: 1982; Bologna: Gaggi, [1982]

·

Intertrochanteric osteotomy. Author: edited by J. Schatzker; contributors, J. Aronson ... [et al.]; Year: 1984; Berlin; New York: SpringerVerlag, 1984; ISBN: 0387107193 (U.S.) http://www.amazon.com/exec/obidos/ASIN/0387107193/icongroupin terna

·

Kinetics and patterns of necrosis. Author: volume editor, G. Jasmin; Year: 1988; Basel; New York: Karger, 1988; ISBN: 3805546688 http://www.amazon.com/exec/obidos/ASIN/3805546688/icongroupin terna

·

Legg-Calve-Perthes disease. Author: by Jacob F. Katz; Year: 1984; New York: Praeger, 1984; ISBN: 0030637414 (alk. paper)

·

Legg-Calve-Perthes' disease. Author: Anthony Catterall; Year: 1982; Edinburgh; New York: Churchill Livingstone, 1982; ISBN: 0443019428

·

Mechanisms of cell death: the second annual conference of the Cell Death Society. Author: edited by Zahra Zakeri, Richard A. Lockshin, and Luis Benítez-Bribiesca; Year: 1999; New York: New York Academy of Sciences, 1999; ISBN: 1573312401 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/1573312401/icongroupin terna

·

Pigbel: necrotising enteritis in Papua New Guinea: proceedings of a workshop held in Goroka, Papua New Guinea, September 2-5, 1980. Author: edited by Michael W. Davis; Year: 1984; Goroka, Papua New Guinea: Papua New Guinea Institute of Medical Research, [1984]; ISBN: 9980710055 (pbk.) http://www.amazon.com/exec/obidos/ASIN/9980710055/icongroupin terna

·

Positron imaging for differentiation of recurrent brain tumor from radionecrosis. Author: ECRI; Year: 2001; Plymouth Meeting, PA: ECRI, c2001

·

Post-partum hypopituitarism. Author: by H.L. Sheehan and J.C. Davis; Year: 1982; Springfield, Ill.: Thomas, c1982; ISBN: 0398045232

·

Renal papillary necrosis. Author: Sandra Sabatini and Garabed Eknoyan, guest editors; Year: 1984; New York, N.Y.: Grune & Stratton, [c1984]

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·

Responses of the living organism to dead and fixed dead, enclosed tissue. Author: Peter Christiaan Makkes; Year: 1977; Amsterdam: Joko Offset, [1977?]

·

Segmental idiopathic necrosis of the femoral head. Author: edited by U.H. Weil; contributors, G. Buchhorn ... [et al.]; Year: 1981; Berlin; New York: Springer-Verlag, 1981; ISBN: 3540107185 (Berlin)

·

Tumor necrosis factor: molecular and cellular biology and clinical relevance. Author: editors, Walter Fiers, Wim A. Buurman; Year: 1993; Basel; New York: Karger, 1993; ISBN: 3805556764 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3805556764/icongroupin terna

·

Tumor necrosis factor: structure, mechanism of action, role in disease and therapy. Author: editors, Benjamin Bonavida, Gale Granger; Year: 1990; Basel; New York: Karger, 1990; ISBN: 3805548660

·

Tumor necrosis factor: structure-function relationship and clinical application. Author: 3rd International Conference on Tumor Necrosis Factor and Related Cytokines, Makuhari, Chiba, November 21-25, 1990; editors, Toshiaki Osawa, Benjamin Bonavida; Year: 1992; Basel; New York: Karger, 1992; ISBN: 3805554583 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/3805554583/icongroupin terna

·

Tumor necrosis factor. Author: cachectin and related cytokines / International Conference on Tumor Necrosis Factor and Related Cytotoxins, Heidelberg, September 14-18, 1987; editors, Benjamin Bonavida ... [et al.]; Year: 1988; Basel; New York: Karger, 1988; ISBN: 3805547552 http://www.amazon.com/exec/obidos/ASIN/3805547552/icongroupin terna

·

Tumor necrosis factors: structure, function, and mechanisms of action. Author: edited by Bharart B. Aggarwal, Jan Vilcek; Year: 1992; New York: M. Dekker, c1992; ISBN: 0824785541 (alk. paper) http://www.amazon.com/exec/obidos/ASIN/0824785541/icongroupin terna

·

Tumor necrosis factors: the molecules and their emerging role in medicine. Author: editor, Bruce Beutler; Year: 1992; New York: Raven Press, c1992; ISBN: 088167852X http://www.amazon.com/exec/obidos/ASIN/088167852X/icongroupi nterna

·

Tumour necrosis factor and related cytotoxins. Author: International Conference on Tumor Necrosis Factor and Related Cytokines (2nd: 1989:


Napa, Calif.); Year: 1987; Chichester; New York: Wiley, 1987; ISBN: 047191097X http://www.amazon.com/exec/obidos/ASIN/047191097X/icongroupi nterna

Chapters on Avascular Necrosis Frequently, avascular necrosis will be discussed within a book, perhaps within a specific chapter. In order to find chapters that are specifically dealing with avascular necrosis, an excellent source of abstracts is the Combined Health Information Database. You will need to limit your search to book chapters and avascular necrosis using the “Detailed Search” option. Go to the following hyperlink: http://chid.nih.gov/detail/detail.html. To find book chapters, use the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Book Chapter.” By making these selections and typing in “avascular necrosis” (or synonyms) into the “For these words:” box, you will only receive results on chapters in books. The following is a typical result when searching for book chapters on avascular necrosis: ·

Ischemic Necrosis of Bone Source: in Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 293-297. Contact: Available from B.C. Decker Inc. 20 Hughson Street South, P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7. (905) 522-7017 or (800) 5687281. Fax (905) 522-7839. Email: [email protected]. Website: www.bcdecker.com. PRICE: $129.00 plus shipping and handling. ISBN: 1550091220. Summary: This chapter on ischemic necrosis of bone is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and Ulcerative Colitis (UC), together known as inflammatory bowel disease (IBD). Osteonecrosis (ON) and avascular necrosis of bone (AVN) are the commonly used terms for an entity that also is referred to as ischemic necrosis of bone, aseptic necrosis, and osteochondritis dissecans. Because the bone is truly avascular (no blood flow) only in the end stage of the disease, the term ischemic necrosis of bone is preferred, emphasizing the period of ischemia (reduced or intermittent blood flow) that precedes actual bone death. Pathologically, it is characterized by death of cells in bone, resulting from an interruption of blood supply to bone.

Books 67

Osteonecrosis generally is divided into two major forms: post-traumatic and nontraumatic. Neither minor nor major trauma causes ON unless there has been a fracture or dislocation resulting in physical damage to the arterial circulation. Diseases, such as inflammatory bowel disease (IBD), in which corticosteroids often are used in high doses and for prolonged periods pose an increased risk. Patients with IBD who present with ON may be younger than other patients with ischemic bone changes, and some have ON without having taken steroids. There is a correlation between involvement of the talus (ankle) with the diagnosis of IBD and the long-term administration of glucocorticoids. Multiple sites of bone involvement also correlate with the diagnosis of IBD or systemic lupus erythematosus, perhaps because both diseases often are treated with high doses of steroids for long periods. If the bone disease is untreated, the majority of patients have eventual destruction of the joints. Conservative or medical management consists primarily of non loadbearing in an attempt to prevent collapse while repair is completed. Only about one quarter of patients improve spontaneously and have a tolerable disability. Joint replacement is a possibility, but is not as successful in young and otherwise physically active individuals (which tends to be the case in IBD and osteonecrosis). 1 figure. 2 tables. 11 references.

General Home References In addition to references for avascular necrosis, you may want a general home medical guide that spans all aspects of home healthcare. The following list is a recent sample of such guides (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): · All About Joints by Irwin M. Siegel; Paperback - 224 pages 1st edition (December 15, 2001), Demos Medical Publishing; ISBN: 1888799560; http://www.amazon.com/exec/obidos/ASIN/1888799560/icongroupinterna · Arthritis Sourcebook : Basic Consumer Health Information About Specific Forms of Arthrits and Related Disorders by Allan R. Cook (Editor); Hardcover - 600 pages 1 edition (October 1998), Omnigraphics, Inc.; ISBN: 0780802012; http://www.amazon.com/exec/obidos/ASIN/0780802012/icongroupinterna · Primer on the Rheumatic Diseases by John H. Klippel, et al; Paperback 700 pages, 12th edition (December 2001), National Book Network; ISBN: 0912423293; http://www.amazon.com/exec/obidos/ASIN/0912423293/icongroupinterna


Vocabulary Builder Arterial: Pertaining to an artery or to the arteries. [EU] Cytotoxins: Substances elaborated by microorganisms, plants or animals that are specifically toxic to individual cells; they may be involved in immunity or may be contained in venoms. [NIH] Enteritis: Inflammation of the intestine, applied chiefly to inflammation of the small intestine; see also enterocolitis. [EU] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Palpation: Application of fingers with light pressure to the surface of the body to determine consistence of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. [NIH] Papillary: Pertaining to or resembling papilla, or nipple. [EU] Polypeptide: A peptide which on hydrolysis yields more than two amino acids; called tripeptides, tetrapeptides, etc. according to the number of amino acids contained. [EU] Talus: The second largest of the tarsal bones and occupies the middle and upper part of the tarsus. [NIH] Traumatology: The branch of surgery which deals with wounds and disability from injuries. [NIH]

Multimedia 69

CHAPTER 6. MULTIMEDIA ON AVASCULAR NECROSIS Overview Information on avascular necrosis can come in a variety of formats. Among multimedia sources, video productions, slides, audiotapes, and computer databases are often available. In this chapter, we show you how to keep current on multimedia sources of information on avascular necrosis. We start with sources that have been summarized by federal agencies, and then show you how to find bibliographic information catalogued by the National Library of Medicine. If you see an interesting item, visit your local medical library to check on the availability of the title.

Bibliography: Multimedia on Avascular Necrosis The National Library of Medicine is a rich source of information on healthcare-related multimedia productions including slides, computer software, and databases. To access the multimedia database, go to the following Web site: http://locatorplus.gov/. Select “Search LOCATORplus.” Once in the search area, simply type in avascular necrosis (or synonyms). Then, in the option box provided below the search box, select “Audiovisuals and Computer Files.” From there, you can choose to sort results by publication date, author, or relevance. The following multimedia has been indexed on avascular necrosis. For more information, follow the hyperlink indicated: ·

Absolute peripheral fixation of hip fractures. Source: Medical College of Virginia, Dept. of Orthopedic Surgery; Year: 1961; Format: Motion picture; [Richmond, Va.]: The College; [Chicago: for loan by American Academy of Orthopaedic Surgeons, 1961]


·

Aseptic necrosis of the hips . Year: 1986; Format: Slide; Columbus [Ohio]: Center for Continuing Medical Education, the Ohio State University College of Medicine, [1986]

·

Cancer of the kidney. Source: James M. Holland; Year: 1974; Format: Slide; New York: Medcom, c1974

·

Cell life and cell death. Source: Medical Arts and Photography Branch; Year: 1997; Format: Videorecording; [Bethesda, Md.: National Institutes of Health , 1997]

·

Cellular degeneration and necrosis. Source: Harry I. Lurie; produced in cooperation with the Visual Education Dept., Medical College of Virginia, Virginia Commonwealth University; Year: 1977; Format: Slide; Chapel Hill, N. C.: Health Sciences Consortium, c1977

·

Evaluation of benign bone disease. Source: the Society of Nuclear Medicine; Year: 1992; Format: Slide; New York, NY: The Society, 1992

·

Free vascularized fibula for AVN of the femoral head : surgical technique. Source: the American Academy of Orthopaedic Surgeons; Dept. of Orthopaedics, University of Pittsburgh; Year: 1994; Format: Videorecording; [Rosemont, Ill.]: AAOS, c1994

·

Granulamatous inflammation. Source: University of Missouri, Columbia, Medical Center, Educational Resources Group; Year: 1970; Format: Slide; Columbia: The Group, 1970

·

Hip graft. Source: a presentation of Films for the Humanities & Sciences; produced for the Learning Channel by Advanced Medical Productions; Year: 1996; Format: Videorecording; Princeton, N.J.: Films for the Humanities & Sciences, c1996

·

Hip problems in children. Source: presented by the Department of Pediatrics, Emory University, School of Medicine; Year: 1987; Format: Videorecording; Atlanta, Ga.: The University, 1987

·

Hip. Source: Hospital for Sick Children, Toronto; [produced by] Division of Instructional Media Services Faculty of Medicine University of Toronto; Year: 1975; Format: Motion picture; Toronto: The Division, 1975

·

Imaging arthritic disease. Source: the Radiological Society of North America; Year: 1992; Format: Videorecording; [Oak Brook, Ill.]: RSNA, c1992

·

Internal derangement of the TMJ with loss of condylar mass. Source: [presented by] AAOMS; Year: 1994; Format: Videorecording; [United States]: American Association of Oral and Maxillofacial Surgeons, c1994

·

Limb salvage by femoral-tibial artery bypass with angioscopicallyassisted in-situ saphenous vein graft and vascularized free muscle flap transfer. Source: Southeastern Surgical Congress; produced by Ciné-

Multimedia 71

Med; Year: 1996; Format: Videorecording; Woodbury, Conn.: Ciné-Med, c1996 ·

Mechanics of signaling by tumor necrosis factor receptors. Source: [Medical Arts and Photography Branch]; Year: 1997; Format: Videorecording; [Bethesda, Md.: National Institutes of Health, 1997]

·

MRI of the hip . Year: 1989; Format: Videorecording; [United States: s.n., 1989?]

·

Necrosis. Source: [presented by] the National Library of Medicine, Lister Hill National Center for Biomedical Communications, Educational Technology Branch and Audiovisual Program Development Branch; Year: 1987; Format: Videorecording; [Bethesda, MD: The Library, 1987]

·

Open drainage of infected pancreatic necrosis. Source: American College of Surgeons; Year: 1991; Format: Videorecording; [Atlanta, Ga.]: Emory University, c1991

·

Pathology and pathogenesis of acute myocardial infarctions. Source: [South Carolina Health Communications Network]; Year: 1971; Format: Videorecording; [Charleston, S. C.]: The Network, [1971]

·

Pathology and radiology of the skeletal system. Source: [Gordon E. Madge ... et al.; made by Medical College of Virginia, Visual Education Dept.]; Year: 1972; Format: Slide; [Richmond: The College; for loan by Medical College of Virginia, Learning Resource Center, 1972]

·

Patterns of glomerular injury part I. Source: McMaster University Health Sciences; Year: 1975; Format: Slide; [Hamilton, Ont.: Health Sciences McMaster Univ.], 1972

·

Patterns of glomerular injury. Part II. Source: McMaster University Health Sciences; Year: 1973; Format: Slide; [Hamilton, Ont.: Health Sciences McMaster Univ.], 1973

·

Pediatric nuclear medicine--Legg-Calve-Perthes disease : diagnosis of pyelonephritis. Source: RSNA; Year: 1986; Format: Slide; [Chicago, Ill.]: RSNA, c1986

·

Rapid expansion of the mid-palatal suture with the Hydrax appliance. Source: American Association of Orthodontists; Year: 1969; Format: Slide; St. Louis: The Association, [1969]

·

Rejection of renal transplant. Source: Emory University School of Medicine and National Medical Audiovisual Center; Year: 1969; Format: Motion picture; [Atlanta]: The University: [for loan by National Medical Audiovisual Center; Washington: for sale by National Audiovisual Center], 1969


·

SLAP lesions, adhesive capsulitis, and avascular necrosis. Source: edited by Gary G. Poehling and Stephen S. Burkhart; Year: 2001; Format: Electronic resource; [Saint Louis, Mo.]: Mosby, c2001

·

Surgical technique for core decompression of the femoral head in osteonecrosis. Source: B.N. Stulberg, M. Levine, A.I. Roth; Year: 1986; Format: Slide; [Park Ridge, Ill.]: AAOS, [1986]

·

Total avascular necrosis of the capital femoral epiphysis. Source: the American Academy of Orthopaedic Surgeons; Year: 1974; Format: Slide; [Chicago, Ill.]: The Academy, [1974]

·

Treatment of osteonecrosis of femoral head by vascularized iliac bone graft. Source: American Academy of Orthopaedic Surgeons; produced at National Taiwan University Medical Center; Year: 1995; Format: Videorecording; [Rosemont, Ill.]: AAOS, c1995

·

Tumor necrosis factor. Source: the University of Texas Medical School at Houston; produced by UT-TV, Houston; Year: 1991; Format: Videorecording; [Houston, Tex.: UT/TV], c1991

Vocabulary Builder Benign: Not malignant; not recurrent; favourable for recovery. [EU] Fibula: The bone of the lower leg lateral to and smaller than the tibia. In proportion to its length, it is the most slender of the long bones. [NIH] Glomerular: Pertaining to or of the nature of a glomerulus, especially a renal glomerulus. [EU] Pyelonephritis: Inflammation of the kidney and its pelvis, beginning in the interstitium and rapidly extending to involve the tubules, glomeruli, and blood vessels; due to bacterial infection. [EU]

Periodicals and News 73

CHAPTER 7. PERIODICALS AND NEWS ON AVASCULAR NECROSIS Overview Keeping up on the news relating to avascular necrosis can be challenging. Subscribing to targeted periodicals can be an effective way to stay abreast of recent developments on avascular necrosis. Periodicals include newsletters, magazines, and academic journals. In this chapter, we suggest a number of news sources and present various periodicals that cover avascular necrosis beyond and including those which are published by patient associations mentioned earlier. We will first focus on news services, and then on periodicals. News services, press releases, and newsletters generally use more accessible language, so if you do chose to subscribe to one of the more technical periodicals, make sure that it uses language you can easily follow.

News Services & Press Releases Well before articles show up in newsletters or the popular press, they may appear in the form of a press release or a public relations announcement. One of the simplest ways of tracking press releases on avascular necrosis is to search the news wires. News wires are used by professional journalists, and have existed since the invention of the telegraph. Today, there are several major “wires” that are used by companies, universities, and other organizations to announce new medical breakthroughs. In the following sample of sources, we will briefly describe how to access each service. These services only post recent news intended for public viewing.


PR Newswire Perhaps the broadest of the wires is PR Newswire Association, Inc. To access this archive, simply go to http://www.prnewswire.com. Below the search box, select the option “The last 30 days.” In the search box, type “avascular necrosis” or synonyms. The search results are shown by order of relevance. When reading these press releases, do not forget that the sponsor of the release may be a company or organization that is trying to sell a particular product or therapy. Their views, therefore, may be biased. The following is typical of press releases that can be found on PR Newswire: ·

Medarex Announces Filing of Investigational New Drug Application for MDX-060 Summary: Melbourn, England and Rockville, Md., May 20 /PRNewswire-FirstCall/ -- Cambridge Antibody Technology (Nasdaq: CATG; LSE: CAT) and Human Genome Sciences Inc. (Nasdaq: HGSI) today announce that HGSI has exercised an option to enter into an exclusive development partnership on a human monoclonal antibody to TRAIL Receptor-2 (TRAIL-R2 mAb). TRAIL-R2 mAb is an agonistic antibody that specifically recognises the TRAIL Receptor-2 protein, found on the surface of a number of cancer cell types. In pre-clinical studies, TRAIL-R2 mAb has demonstrated the ability to reduce or prevent the growth of certain tumours in animal models. HGSI discovered TRAIL Receptor-2. TRAIL Receptor-2 is a member of the tumour necrosis factor (TNF) family of receptors, and is called a "death receptor" because of its ability to cause tumour cell death when triggered by the natural ligand TRAIL (tumour necrosis factor-related apoptosis-inducing ligand). TRAIL Receptor-2 has been shown to be expressed on a number of solid tumours, including lung, prostate and breast tumours, and tumours of hematopoietic origin. It has been demonstrated that cell lines derived from such tumours are sensitive to killing by apoptosis induced by binding to TRAIL and TRAIL-R2 mAb. Unlike the natural TRAIL ligand, TRAIL-R2 mAb does not bind to the surface proteins DcR1 and DcR2 or the soluble receptor osteoprotegerin. TRAIL binds to these proteins, but such binding does not trigger cell death. HGSI and CAT announced an antibody product development alliance in early 2000. The agreement provides HGSI with rights to use CAT's antibody technology to develop and sell human antibodies for


therapeutic and diagnostic purposes. In return, CAT is entitled to receive licence fees, clinical development milestones and royalties on product sales from HGSI. TRAIL-R2 mAb is the third HSGI antibody drug candidate to emerge from the collaboration between HGSI and CAT. The others are TRAILR1 mAb, a human monoclonal antibody to TRAIL Receptor-1 for use in treating certain cancers, and LymphoStat-B(TM), a human monoclonal antibody to BLyS(TM) (B-lymphocyte stimulator) for use in treating lupus and rheumatoid arthritis. HGSI holds the commercial rights to all three drugs. These drugs will be produced in the HGSI manufacturing facility located in Rockville, Maryland, USA. Peter Chambre, CAT's CEO, said, "We are delighted that our collaboration with Human Genome Sciences continues to progress rapidly. We are proud to follow the achievements on the TRAIL-R1 human antibody with the successful isolation of the TRAIL-R2 human antibody. Significantly, TRAIL-R2 mAb, like TRAIL-R1 mAb, is directed to a cell-surface receptor protein. We look forward to further success in our collaboration with HGSI." William A. Haseltine PhD, Chairman and Chief Executive Officer of Human Genome Sciences, said, "Our collaboration with Cambridge Antibody Technology is clearly productive. In November 2001, we announced clearance by the US Food and Drug Administration to initiate human testing of LymphoStat-B for use in treating lupus and rheumatoid arthritis. At the end of April 2002, we announced clearance to initiate human testing of TRAIL-R1 mAb for use in treating solid tumours and tumours of hematopoietic origin. TRAIL-R1 mAb is specific to TRAIL Receptor-1, while TRAIL-R2 mAb is specific to TRAIL Receptor-2. The activity of both molecules is novel. Both are designed to mimic the activity of the natural TRAIL ligand, which stimulates these receptors to cause cancer cell death through apoptosis. Both also are designed to have the advantage of a longer half-life and the potential for greater efficacy than TRAIL itself. "We look forward to completing the pre-clinical development of TRAILR2 mAb, and to entering this promising anti-tumour drug candidate into clinical trials." Notes to Editors: Cambridge Antibody Technology (CAT)


* CAT is a UK-based biotechnology company using its proprietary technologies and capabilities in human monoclonal antibodies for drug discovery and drug development. Based near Cambridge, England, CAT currently employs around 270 people. * CAT is a leader in the discovery and development of human therapeutic antibodies and has an advanced proprietary platform technology for rapidly isolating human monoclonal antibodies using phage display systems. CAT has extensive phage antibody libraries, currently incorporating more than 100 billion distinct antibodies. These libraries form the basis for the Company's strategy to develop a portfolio of antibody-based drugs. * Six CAT-derived human therapeutic antibodies are at various stages of clinical trials, with a seventh CAT-derived antibody, D2E7, having been submitted for regulatory review by Abbott (responsible for development and marketing) following the completion of Phase III trials. * CAT has alliances with a large number of pharmaceutical and biotechnology companies to discover, develop and commercialise human monoclonal antibody-based products. CAT has also licensed its proprietary human phage antibody libraries to several companies for target validation and drug discovery. CAT's collaborators include: Abbott, Amrad, Elan, Genzyme, Human Genome Sciences, Immunex, Merck & Co, Pharmacia and Wyeth-Ayerst. * CAT is listed on the London Stock Exchange and on NASDAQ since June 2001. CAT raised 41m pounds in its IPO in March 1997 and 93m pounds in a secondary offering in March 2000.

Human Genome Sciences Inc. (HGSI) * Human Genome Sciences is a company with the mission to treat and cure disease by bringing new gene-based drugs to patients. * HGS, Human Genome Sciences, BLyS, and LymphoStat-B are trademarks of Human Genome Sciences, Inc.

References * Salcedo, Alderson, Basu, et al. TRM-1, a human TRAIL-R1 agonistic monoclonal antibody, displays in vitro and in vivo anti-tumour activity, American Association for Cancer Research 93rd Annual


Meeting, April 2002, Abstract 4240. * Ashkenazi A, Apo-2L/TRAIL in Cytokine Reference, Academic Press; 2000. * Salcedo, Alderson, Basu, et al. TRM-1, a human TRAIL-R1 agonistic monoclonal antibody, displays in vitro and in vivo anti-tumor activity, American Association for Cancer Research 93rd Annual Meeting. April 2002, Abstract 4240. * Ashkanazi A, Dixit VM, 1998, Death Receptors signaling and dulation. Science 281, 1305-1308. * Cambridge Antibody Technology and Human Genome Sciences Inc. Create Major Alliance Dedicated to Developing Human Antibody Therapeutics Against Genomics Targets, 1 March, 2002. * Cambridge Antibody Technology and Human Genome Sciences Inc. Announce Second Drug Partnership, 8 January, 2002. * Cambridge Antibody Technology and Human Genome Sciences Inc. Commit to Exclusive Development of Anti-BLys Antibodies, 30 October 2000 (00/CAT/05). * Human Genome Sciences Inc. Initiates Trial of a New Drug for Systemic Lupus Erythematosus and Other Autoimmune Diseases, 1 November , 2001. * Human Genome Sciences Inc. Initiates Clinical Development of a Novel Anticancer Drug, 30 April, 2002. Application of the Safe Harbor of the Private Securities Litigation Reform Act of 1995: This press release contains statements about Cambridge Antibody Technology Group plc ("CAT") that are forward looking statements. All statements other than statements of historical facts included in this press release may be forward looking statements within the meaning of Section 21E of the Securities Exchange Act of 1934. These forward looking statements are based on numerous assumptions regarding CAT's present and future business strategies and the environment in which CAT will operate in the future. Certain factors that could cause CAT's actual results, performance or achievements to


differ materially from those in the forward looking statements include: market conditions, CAT's ability to enter into and maintain collaborative arrangements, success of product candidates in clinical trials, regulatory developments and competition. Reuters The Reuters' Medical News database can be very useful in exploring news archives relating to avascular necrosis. While some of the listed articles are free to view, others can be purchased for a nominal fee. To access this archive, go to http://www.reutershealth.com/frame2/arch.html and search by “avascular necrosis” (or synonyms). The following was recently listed in this archive for avascular necrosis: ·

FDA, VA to examine link between HIV drugs and avascular necrosis Source: Reuters Medical News Date: November 20, 2001 http://www.reuters.gov/archive/2001/11/20/professional/links/20011 120clin001.html

·

Avascular necrosis of the hip can develop in asymptomatic HIVinfected patients Source: Reuters Medical News Date: September 13, 2000 http://www.reuters.gov/archive/2000/09/13/professional/links/20000 913clin014.html

·

Protease inhibitor use linked to avascular necrosis in HIV-infected patients Source: Reuters Industry Breifing Date: June 19, 2000 http://www.reuters.gov/archive/2000/06/19/business/links/20000619 clin011.html

·

Hip replacement is suitable for SLE patients with avascular necrosis Source: Reuters Medical News Date: May 30, 2000 http://www.reuters.gov/archive/2000/05/30/professional/links/20000 530clin006.html

The NIH Within MEDLINEplus, the NIH has made an agreement with the New York Times Syndicate, the AP News Service, and Reuters to deliver news that can be browsed by the public. Search news releases at


http://www.nlm.nih.gov/medlineplus/alphanews_a.html. MEDLINEplus allows you to browse across an alphabetical index. Or you can search by date at http://www.nlm.nih.gov/medlineplus/newsbydate.html. Often, news items are indexed by MEDLINEplus within their search engine.

Business Wire Business Wire is similar to PR Newswire. To access this archive, simply go to http://www.businesswire.com. You can scan the news by industry category or company name.

Internet Wire Internet Wire is more focused on technology than the other wires. To access this site, go to http://www.internetwire.com and use the “Search Archive” option. Type in “avascular necrosis” (or synonyms). As this service is oriented to technology, you may wish to search for press releases covering diagnostic procedures or tests that you may have read about.

Search Engines Free-to-view news can also be found in the news section of your favorite search engines (see the health news page at Yahoo: http://dir.yahoo.com/Health/News_and_Media/, or use this Web site’s general news search page http://news.yahoo.com/. Type in “avascular necrosis” (or synonyms). If you know the name of a company that is relevant to avascular necrosis, you can go to any stock trading Web site (such as www.etrade.com) and search for the company name there. News items across various news sources are reported on indicated hyperlinks.

BBC Covering news from a more European perspective, the British Broadcasting Corporation (BBC) allows the public free access to their news archive located at http://www.bbc.co.uk/. Search by “avascular necrosis” (or synonyms).


Newsletter Articles If you choose not to subscribe to a newsletter, you can nevertheless find references to newsletter articles. We recommend that you use the Combined Health Information Database, while limiting your search criteria to “newsletter articles.” Again, you will need to use the “Detailed Search” option. Go directly to the following hyperlink: http://chid.nih.gov/detail/detail.html. Go to the bottom of the search page where “You may refine your search by.” Select the dates and language that you prefer. For the format option, select “Newsletter Article.” By making these selections, and typing in “avascular necrosis” (or synonyms) into the “For these words:” box, you will only receive results on newsletter articles. You should check back periodically with this database as it is updated every 3 months. The following is a typical result when searching for newsletter articles on avascular necrosis: ·

Musculoskeletal Manifestations of Thyroid Disease Source: Bulletin on the Rheumatic Diseases. 49(11): 1-4. 2001. Contact: Available from Arthritis Foundation. 1330 West Peachtree Street, Atlanta, GA 30309. (800) 268-6942 or (404) 872-7100. Fax (404) 872-9559. Website: www.arthritis.org. Summary: This newsletter article provides health professionals with information on evaluating and treating the musculoskeletal manifestations of thyroid disease. Thyroid disease can cause musculoskeletal symptoms that mimic known rheumatic syndromes. Hypothyroidism and thyrotoxicosis can affect the musculoskeletal system. The manifestations of congenital hypothyroidism and hypothyroidism occurring in childhood are usually dominated by cognitive deficiencies and developmental delays. In adults, hypothyroidism may result from autoimmune and postablative mechanisms, pituitary failure, or iodine deficiency. Hypothyroid adults usually have manifestations consistent with low basal metabolic rate. An arthropathy may occur, or hypothyroidism may be confused with fibromyalgia. Hypothyroidism is also associated with other musculoskeletal and rheumatic diseases, including polymyositis, carpal tunnel syndrome, avascular necrosis of the hip, polymyalgia rheumatica, giant cell arteritis, rheumatoid arthritis, and systemic lupus erythematosus. Thyrotoxicosis may also have musculoskeletal manifestations, including myopathy, osteoporosis, and shoulder pain. Graves' disease, an autoimmune disease caused by antibodies directed


against the TSH receptor in the thyroid, is associated with pretibial myxedema and thyroid acropachy. 2 tables and 35 references. ·

Hip-Area Pain Source: Mayo Clinic Health Letter. 18(5): 4-5. May 2000. Contact: Available from Mayo Foundation for Medical Education and Research, 200 First Street SW, Rochester, MN 55905. (800) 291-1128 ext. 250. Summary: This newsletter article provides the general public with information on hip pain. The hip includes the hip joint and the area surrounding the joint from the waist to the upper leg. The location of the pain in the hip area can help determine whether the problem is related to the joint. The groin area is the most common location for pain related to hip joint disorders. However, pain from hip joint disorders can also occur on the side of the hip, the upper thigh, the buttock, and, occasionally, the knee. Osteoarthritis is one of the most common causes of hip joint pain. Other causes include inflammatory arthritis, avascular necrosis, fractures, infection, tumor, and congenital defects in the hip joint structure. Hip area pain not related to the joint can be caused by various conditions, including trochanteric bursitis, ischial bursitis, pinched sciatic nerve, sacroiliac joint pain, and hernia. A person needs to see a physician for a physical examination if hip pain causes a limp or significantly interferes with daily activities. Treatments vary depending on the cause of the pain. 1 figure.

Academic Periodicals covering Avascular Necrosis Academic periodicals can be a highly technical yet valuable source of information on avascular necrosis. We have compiled the following list of periodicals known to publish articles relating to avascular necrosis and which are currently indexed within the National Library of Medicine's PubMed database (follow hyperlinks to view more information, summaries, etc., for each). In addition to these sources, to keep current on articles written on avascular necrosis published by any of the periodicals listed below, you can simply follow the hyperlink indicated or go to the following Web site: www.ncbi.nlm.nih.gov/pubmed. Type the periodical's name into the search box to find the latest studies published. If you want complete details about the historical contents of a periodical, you can also visit http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi. Here, type in the name of the journal or its abbreviation, and you will receive an index


of published articles. At http://locatorplus.gov/ you can retrieve more indexing information on medical periodicals (e.g. the name of the publisher). Select the button “Search LOCATORplus.” Then type in the name of the journal and select the advanced search option “Journal Title Search.” The following is a sample of periodicals which publish articles on avascular necrosis: ·

Acta Oncologica (Stockholm, Sweden). (Acta Oncol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Ac ta+Oncologica+(Stockholm,+Sweden)&dispmax=20&dispstart=0

·

American Journal of Hematology. (Am J Hematol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=A merican+Journal+of+Hematology&dispmax=20&dispstart=0

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Annals of Internal Medicine. (Ann Intern Med) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=An nals+of+Internal+Medicine&dispmax=20&dispstart=0

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British Journal of Cancer. (Br J Cancer) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Bri tish+Journal+of+Cancer&dispmax=20&dispstart=0

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British Medical Journal (Clinical Research Ed. . (Br Med J (Clin Res Ed)) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Bri tish+Medical+Journal+(Clinical+Research+Ed.+&dispmax=20&dispstart =0

·

European Journal of Pediatrics. (Eur J Pediatr) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Eu ropean+Journal+of+Pediatrics&dispmax=20&dispstart=0

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Experimental and Molecular Pathology. (Exp Mol Pathol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Ex perimental+and+Molecular+Pathology&dispmax=20&dispstart=0

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Gynecologic Oncology. (Gynecol Oncol) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Gy necologic+Oncology&dispmax=20&dispstart=0


·

Journal of Manipulative and Physiological Therapeutics. (J Manipulative Physiol Ther) http://www.ncbi.nlm.nih.gov/entrez/jrbrowser.cgi?field=0®exp=Jo urnal+of+Manipulative+and+Physiological+Therapeutics&dispmax=20& dispstart=0

Vocabulary Builder Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Allergen: A antigenic substance capable of producing immediate-type hypersensitivity (allergy). [EU] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Arteritis: Inflammation of an artery. [NIH] Asymptomatic: Showing or causing no symptoms. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Groin: The external junctural region between the lower part of the abdomen and the thigh. [NIH] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an abnormal opening. [EU] Hypothyroidism: Deficiency of thyroid activity. In adults, it is most common in women and is characterized by decrease in basal metabolic rate, tiredness and lethargy, sensitivity to cold, and menstrual disturbances. If untreated, it progresses to full-blown myxoedema. In infants, severe hypothyroidism leads to cretinism. In juveniles, the manifestations are intermediate, with less severe mental and developmental retardation and only mild symptoms of the adult form. When due to pituitary deficiency of thyrotropin secretion it is called secondary hypothyroidism. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a


nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Myxedema: A condition characterized by a dry, waxy type of swelling with abnormal deposits of mucin in the skin and other tissues. It is produced by a functional insufficiency of the thyroid gland, resulting in deficiency of thyroid hormone. The skin becomes puffy around the eyes and on the cheeks and the face is dull and expressionless with thickened nose and lips. The congenital form of the disease is cretinism. [NIH] Purpura: Purplish or brownish red discoloration, easily visible through the epidermis, caused by hemorrhage into the tissues. [NIH] Thyrotoxicosis: The condition resulting from presentation to the tissues of excessive quantities of the thyroid hormones, whether the excess results from overproduction by the thyroid gland (as in Graves' disease), originated outside the thyroid, or is due to loss of storage function and leakage from the gland. [EU]

Physician Guidelines and Databases 85

CHAPTER 8. PHYSICIAN GUIDELINES AND DATABASES Overview Doctors and medical researchers rely on a number of information sources to help patients with their conditions. Many will subscribe to journals or newsletters published by their professional associations or refer to specialized textbooks or clinical guides published for the medical profession. In this chapter, we focus on databases and Internet-based guidelines created or written for this professional audience.

NIH Guidelines For the more common diseases, The National Institutes of Health publish guidelines that are frequently consulted by physicians. Publications are typically written by one or more of the various NIH Institutes. For physician guidelines, commonly referred to as “clinical” or “professional” guidelines, you can visit the following Institutes: ·

Office of the Director (OD); guidelines consolidated across agencies available at http://www.nih.gov/health/consumer/conkey.htm

·

National Institute of General Medical Sciences (NIGMS); fact sheets available at http://www.nigms.nih.gov/news/facts/

·

National Library of Medicine (NLM); extensive encyclopedia (A.D.A.M., Inc.) with guidelines: http://www.nlm.nih.gov/medlineplus/healthtopics.html

·

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS); fact sheets and guidelines available at http://www.nih.gov/niams/healthinfo/


NIH Databases In addition to the various Institutes of Health that publish professional guidelines, the NIH has designed a number of databases for professionals.25 Physician-oriented resources provide a wide variety of information related to the biomedical and health sciences, both past and present. The format of these resources varies. Searchable databases, bibliographic citations, full text articles (when available), archival collections, and images are all available. The following are referenced by the National Library of Medicine:26 ·

Bioethics: Access to published literature on the ethical, legal and public policy issues surrounding healthcare and biomedical research. This information is provided in conjunction with the Kennedy Institute of Ethics located at Georgetown University, Washington, D.C.: http://www.nlm.nih.gov/databases/databases_bioethics.html

·

HIV/AIDS Resources: Describes various links and databases dedicated to HIV/AIDS research: http://www.nlm.nih.gov/pubs/factsheets/aidsinfs.html

·

NLM Online Exhibitions: Describes “Exhibitions in the History of Medicine”: http://www.nlm.nih.gov/exhibition/exhibition.html. Additional resources for historical scholarship in medicine: http://www.nlm.nih.gov/hmd/hmd.html

·

Biotechnology Information: Access to public databases. The National Center for Biotechnology Information conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information for the better understanding of molecular processes affecting human health and disease: http://www.ncbi.nlm.nih.gov/

·

Population Information: The National Library of Medicine provides access to worldwide coverage of population, family planning, and related health issues, including family planning technology and programs, fertility, and population law and policy: http://www.nlm.nih.gov/databases/databases_population.html

·

Cancer Information: Access to caner-oriented databases: http://www.nlm.nih.gov/databases/databases_cancer.html

Remember, for the general public, the National Library of Medicine recommends the databases referenced in MEDLINEplus (http://medlineplus.gov/ or http://www.nlm.nih.gov/medlineplus/databases.html). 26 See http://www.nlm.nih.gov/databases/databases.html. 25


·

Profiles in Science: Offering the archival collections of prominent twentieth-century biomedical scientists to the public through modern digital technology: http://www.profiles.nlm.nih.gov/

·

Chemical Information: Provides links to various chemical databases and references: http://sis.nlm.nih.gov/Chem/ChemMain.html

·

Clinical Alerts: Reports the release of findings from the NIH-funded clinical trials where such release could significantly affect morbidity and mortality: http://www.nlm.nih.gov/databases/alerts/clinical_alerts.html

·

Space Life Sciences: Provides links and information to space-based research (including NASA): http://www.nlm.nih.gov/databases/databases_space.html

·

MEDLINE: Bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the healthcare system, and the pre-clinical sciences: http://www.nlm.nih.gov/databases/databases_medline.html

·

Toxicology and Environmental Health Information (TOXNET): Databases covering toxicology and environmental health: http://sis.nlm.nih.gov/Tox/ToxMain.html

·

Visible Human Interface: Anatomically detailed, three-dimensional representations of normal male and female human bodies: http://www.nlm.nih.gov/research/visible/visible_human.html

While all of the above references may be of interest to physicians who study and treat avascular necrosis, the following are particularly noteworthy.

The NLM Gateway27 The NLM (National Library of Medicine) Gateway is a Web-based system that lets users search simultaneously in multiple retrieval systems at the U.S. National Library of Medicine (NLM). It allows users of NLM services to initiate searches from one Web interface, providing “one-stop searching” for many of NLM's information resources or databases.28 One target audience for the Gateway is the Internet user who is new to NLM's online resources and does not know what information is available or how best to search for it. This audience may include physicians and other healthcare providers, Adapted from NLM: http://gateway.nlm.nih.gov/gw/Cmd?Overview.x. The NLM Gateway is currently being developed by the Lister Hill National Center for Biomedical Communications (LHNCBC) at the National Library of Medicine (NLM) of the National Institutes of Health (NIH).

27 28


researchers, librarians, students, and, increasingly, patients, their families, and the public.29 To use the NLM Gateway, simply go to the search site at http://gateway.nlm.nih.gov/gw/Cmd. Type “avascular necrosis” (or synonyms) into the search box and click “Search.” The results will be presented in a tabular form, indicating the number of references in each database category. Results Summary Category Items Found Journal Articles 2535 Books / Periodicals / Audio Visual 15 Consumer Health 3 Meeting Abstracts 14 Other Collections 0 Total 2567

HSTAT30 HSTAT is a free, Web-based resource that provides access to full-text documents used in healthcare decision-making.31 HSTAT's audience includes healthcare providers, health service researchers, policy makers, insurance companies, consumers, and the information professionals who serve these groups. HSTAT provides access to a wide variety of publications, including clinical practice guidelines, quick-reference guides for clinicians, consumer health brochures, evidence reports and technology assessments from the Agency for Healthcare Research and Quality (AHRQ), as well as AHRQ's

Other users may find the Gateway useful for an overall search of NLM's information resources. Some searchers may locate what they need immediately, while others will utilize the Gateway as an adjunct tool to other NLM search services such as PubMed® and MEDLINEplus®. The Gateway connects users with multiple NLM retrieval systems while also providing a search interface for its own collections. These collections include various types of information that do not logically belong in PubMed, LOCATORplus, or other established NLM retrieval systems (e.g., meeting announcements and pre-1966 journal citations). The Gateway will provide access to the information found in an increasing number of NLM retrieval systems in several phases. 30 Adapted from HSTAT: http://www.nlm.nih.gov/pubs/factsheets/hstat.html. 31 The HSTAT URL is http://hstat.nlm.nih.gov/. 29


Put Prevention Into Practice.32 Simply search by “avascular necrosis” (or synonyms) at the following Web site: http://text.nlm.nih.gov.

Coffee Break: Tutorials for Biologists33 Some patients may wish to have access to a general healthcare site that takes a scientific view of the news and covers recent breakthroughs in biology that may one day assist physicians in developing treatments. To this end, we recommend “Coffee Break,” a collection of short reports on recent biological discoveries. Each report incorporates interactive tutorials that demonstrate how bioinformatics tools are used as a part of the research process. Currently, all Coffee Breaks are written by NCBI staff.34 Each report is about 400 words and is usually based on a discovery reported in one or more articles from recently published, peer-reviewed literature.35 This site has new articles every few weeks, so it can be considered an online magazine of sorts, and intended for general background information. You can access the Coffee Break Web site at: http://www.ncbi.nlm.nih.gov/Coffeebreak/.

Other important documents in HSTAT include: the National Institutes of Health (NIH) Consensus Conference Reports and Technology Assessment Reports; the HIV/AIDS Treatment Information Service (ATIS) resource documents; the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (SAMHSA/CSAT) Treatment Improvement Protocols (TIP) and Center for Substance Abuse Prevention (SAMHSA/CSAP) Prevention Enhancement Protocols System (PEPS); the Public Health Service (PHS) Preventive Services Task Force's Guide to Clinical Preventive Services; the independent, nonfederal Task Force on Community Services Guide to Community Preventive Services; and the Health Technology Advisory Committee (HTAC) of the Minnesota Health Care Commission (MHCC) health technology evaluations. 33 Adapted from http://www.ncbi.nlm.nih.gov/Coffeebreak/Archive/FAQ.html. 34 The figure that accompanies each article is frequently supplied by an expert external to NCBI, in which case the source of the figure is cited. The result is an interactive tutorial that tells a biological story. 35 After a brief introduction that sets the work described into a broader context, the report focuses on how a molecular understanding can provide explanations of observed biology and lead to therapies for diseases. Each vignette is accompanied by a figure and hypertext links that lead to a series of pages that interactively show how NCBI tools and resources are used in the research process. 32


Other Commercial Databases In addition to resources maintained by official agencies, other databases exist that are commercial ventures addressing medical professionals. Here are a few examples that may interest you: ·

CliniWeb International: Index and table of contents to selected clinical information on the Internet; see http://www.ohsu.edu/cliniweb/.

·

Image Engine: Multimedia electronic medical record system that integrates a wide range of digitized clinical images with textual data stored in the University of Pittsburgh Medical Center's MARS electronic medical record system; see the following Web site: http://www.cml.upmc.edu/cml/imageengine/imageEngine.html.

·

Medical World Search: Searches full text from thousands of selected medical sites on the Internet; see http://www.mwsearch.com/.

·

MedWeaver: Prototype system that allows users to search differential diagnoses for any list of signs and symptoms, to search medical literature, and to explore relevant Web sites; see http://www.med.virginia.edu/~wmd4n/medweaver.html.

·

Metaphrase: Middleware component intended for use by both caregivers and medical records personnel. It converts the informal language generally used by caregivers into terms from formal, controlled vocabularies; see the following Web site: http://www.lexical.com/Metaphrase.html.

The Genome Project and Avascular Necrosis With all the discussion in the press about the Human Genome Project, it is only natural that physicians, researchers, and patients want to know about how human genes relate to avascular necrosis. In the following section, we will discuss databases and references used by physicians and scientists who work in this area.

Online Mendelian Inheritance in Man (OMIM) The Online Mendelian Inheritance in Man (OMIM) database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere. OMIM was developed for the World Wide Web by the National Center for


Biotechnology Information (NCBI).36 The database contains textual information, pictures, and reference information. It also contains copious links to NCBI's Entrez database of MEDLINE articles and sequence information. Go to http://www.ncbi.nlm.nih.gov/Omim/searchomim.html to search the database. Type “avascular necrosis” (or synonyms) in the search box, and click “Submit Search.” If too many results appear, you can narrow the search by adding the word “clinical.” Each report will have additional links to related research and databases. By following these links, especially the link titled “Database Links,” you will be exposed to numerous specialized databases that are largely used by the scientific community. These databases are overly technical and seldom used by the general public, but offer an abundance of information. The following is an example of the results you can obtain from the OMIM for avascular necrosis: ·

Dyskeratosis Congenita, X-linked Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?305000

·

Epiphyseal Dysplasia, Multiple, 1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?132400

·

Gaucher Disease, Type I Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?230800

·

Hemoglobin--beta Locus Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?141900

·

Inhibitor of Dna Binding 1; Id1 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?600349

·

Inhibitor of Dna Binding 3 Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?600277

Adapted from http://www.ncbi.nlm.nih.gov/. Established in 1988 as a national resource for molecular biology information, NCBI creates public databases, conducts research in computational biology, develops software tools for analyzing genome data, and disseminates biomedical information--all for the better understanding of molecular processes affecting human health and disease.

36


·

Kyphomelic Dysplasia Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?211350

·

Legg-calve-perthes Disease Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?150600

·

Malignant Atrophic Papulosis Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?602248

·

Osteoarthropathy of Fingers, Familial Web site: http://www.ncbi.nlm.nih.gov/htbinpost/Omim/dispmim?165700

Genes and Disease (NCBI - Map) The Genes and Disease database is produced by the National Center for Biotechnology Information of the National Library of Medicine at the National Institutes of Health. This Web site categorizes each disorder by the system of the body associated with it. Go to http://www.ncbi.nlm.nih.gov/disease/, and browse the system pages to have a full view of important conditions linked to human genes. Since this site is regularly updated, you may wish to re-visit it from time to time. The following systems and associated disorders are addressed: ·

Muscle and Bone: Movement and growth. Examples: Duchenne muscular dystrophy, Ellis-van Creveld syndrome, Marfan syndrome, myotonic dystrophy, spinal muscular atrophy. Web site: http://www.ncbi.nlm.nih.gov/disease/Muscle.html

·

Nervous System: Mind and body. Examples: Alzheimer disease, Amyotrophic lateral sclerosis, Angelman syndrome, Charcot-Marie-Tooth disease, epilepsy, essential tremor, Fragile X syndrome, Friedreich's ataxia, Huntington disease, NiemannPick disease, Parkinson disease, Prader-Willi syndrome, Rett syndrome, Spinocerebellar atrophy, Williams syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Brain.html

·

Signals: Cellular messages. Examples: Ataxia telangiectasia, Baldness, Cockayne syndrome, Glaucoma, SRY: sex determination, Tuberous sclerosis, Waardenburg syndrome, Werner syndrome. Web site: http://www.ncbi.nlm.nih.gov/disease/Signals.html


Entrez Entrez is a search and retrieval system that integrates several linked databases at the National Center for Biotechnology Information (NCBI). These databases include nucleotide sequences, protein sequences, macromolecular structures, whole genomes, and MEDLINE through PubMed. Entrez provides access to the following databases: ·

PubMed: Biomedical literature (PubMed), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

·

Nucleotide Sequence Database (Genbank): Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Nucleotide

·

Protein Sequence Database: Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Protein

·

Structure: Three-dimensional macromolecular structures, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Structure

·

Genome: Complete genome assemblies, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Genome

·

PopSet: Population study data sets, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Popset

·

OMIM: Online Mendelian Inheritance in Man, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM

·

Taxonomy: Organisms in GenBank, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Taxonomy

·

Books: Online books, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=books

·

ProbeSet: Gene Expression Omnibus (GEO), Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

3D Domains: Domains from Entrez Structure, Web site: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geo

·

NCBI's Protein Sequence Information Survey Results: Web site: http://www.ncbi.nlm.nih.gov/About/proteinsurvey/

To access the Entrez system at the National Center for Biotechnology Information, go to http://www.ncbi.nlm.nih.gov/entrez, and then select the database that you would like to search. The databases available are listed in


the drop box next to “Search.” In the box next to “for,” enter “avascular necrosis” (or synonyms) and click “Go.”

Jablonski's Multiple Congenital Anomaly/Mental Retardation (MCA/MR) Syndromes Database37 This online resource can be quite useful. It has been developed to facilitate the identification and differentiation of syndromic entities. Special attention is given to the type of information that is usually limited or completely omitted in existing reference sources due to space limitations of the printed form. At http://www.nlm.nih.gov/mesh/jablonski/syndrome_toc/toc_a.html you can also search across syndromes using an alphabetical index. You can also search at http://www.nlm.nih.gov/mesh/jablonski/syndrome_db.html. The Genome Database38 Established at Johns Hopkins University in Baltimore, Maryland in 1990, the Genome Database (GDB) is the official central repository for genomic mapping data resulting from the Human Genome Initiative. In the spring of 1999, the Bioinformatics Supercomputing Centre (BiSC) at the Hospital for Sick Children in Toronto, Ontario assumed the management of GDB. The Human Genome Initiative is a worldwide research effort focusing on structural analysis of human DNA to determine the location and sequence of the estimated 100,000 human genes. In support of this project, GDB stores and curates data generated by researchers worldwide who are engaged in the mapping effort of the Human Genome Project (HGP). GDB's mission is to provide scientists with an encyclopedia of the human genome which is continually revised and updated to reflect the current state of scientific knowledge. Although GDB has historically focused on gene mapping, its focus will broaden as the Genome Project moves from mapping to sequence, and finally, to functional analysis. To access the GDB, simply go to the following hyperlink: http://www.gdb.org/. Search “All Biological Data” by “Keyword.” Type “avascular necrosis” (or synonyms) into the search box, and review the Adapted from the National Library of Medicine: http://www.nlm.nih.gov/mesh/jablonski/about_syndrome.html. 38 Adapted from the Genome Database: http://gdbwww.gdb.org/gdb/aboutGDB.html#mission. 37


results. If more than one word is used in the search box, then separate each one with the word “and” or “or” (using “or” might be useful when using synonyms). This database is extremely technical as it was created for specialists. The articles are the results which are the most accessible to nonprofessionals and often listed under the heading “Citations.” The contact names are also accessible to non-professionals.

Specialized References The following books are specialized references written for professionals interested in avascular necrosis (sorted alphabetically by title, hyperlinks provide rankings, information, and reviews at Amazon.com): · Atlas of Rheumatology by Gene G. Hunder (Editor); Hardcover, 2nd edition (June 2001), Current Medicine; ISBN: 1573401714; http://www.amazon.com/exec/obidos/ASIN/1573401714/icongroupinterna · Clinical Problems in Rheumatology by Dudley; Paperback, 3rd edition (May 2001), Dunitz Martin Ltd; ISBN: 1853175722; http://www.amazon.com/exec/obidos/ASIN/1853175722/icongroupinterna · Diagnosis and Treatment of Movement Impairment Syndromes by Shirley Sahrmann; Hardcover - 384 pages, 1st edition (September 4, 2001), Mosby, Inc.; ISBN: 0801672058; http://www.amazon.com/exec/obidos/ASIN/0801672058/icongroupinterna · Diagnosis of Bone and Joint Disorders (5-Volume Set) by Donald Resnick; Hardcover - 5472 pages, 4th edition (March 8, 2002); W B Saunders Co.; ISBN: 0721689213; http://www.amazon.com/exec/obidos/ASIN/0721689213/icongroupinterna · Kelley's Textbook of Rheumatology (2-Volume Set) by Shaun Ruddy (Editor), et al; Hardcover - 1788 pages, 6th edition (January 15, 2001), W B Saunders Co.; ISBN: 0721680089; http://www.amazon.com/exec/obidos/ASIN/0721680089/icongroupinterna · Kelley's Textbook of Rheumatology CD-ROM by Shaun Ruddy (Editor), et al; 6th edition (July 15, 2001), W B Saunders Co.; ISBN: 0721690327; http://www.amazon.com/exec/obidos/ASIN/0721690327/icongroupinterna · Mechanical Loading of Bones and Joints by Hideaki Takahashi (Editor); Hardcover - 324 pages, 1st edition (July 15, 1999), Springer Verlag; ISBN: 4431702423; http://www.amazon.com/exec/obidos/ASIN/4431702423/icongroupinterna · Modern Therapeutics in Rheumatic Diseases by George C. Tsokos (Editor), Steffen Gay (Editor); Hardcover - 655 pages, 1st edition (January


15, 2002), Humana Press; ISBN: 0896039161; http://www.amazon.com/exec/obidos/ASIN/0896039161/icongroupinterna · Oxford Handbook of Rheumatology by Alan Hakim (Editor), Gavin Clunie (Editor); Paperback, 1st edition (March 15, 2002); Oxford University Press; ISBN: 0192630547; http://www.amazon.com/exec/obidos/ASIN/0192630547/icongroupinterna · Pathology and Pathobiology of Rheumatic Diseases by H. G. Fassbender; Hardcover (September 2001), Springer Verlag; ISBN: 3540629424; http://www.amazon.com/exec/obidos/ASIN/3540629424/icongroupint erna · Rehabilitation Techniques in Rheumatology by Clarke; Hardcover, 2nd edition (March 15, 2001), Dunitz Martin Ltd.; ISBN: 1853171204; http://www.amazon.com/exec/obidos/ASIN/1853171204/icongroupinterna · Rheumatology Secrets by Sterling G. West, M.D.; Paperback, 2nd edition (February 15, 2002), Lippincott, Williams & Wilkins Publishers; ISBN: 1560534745; http://www.amazon.com/exec/obidos/ASIN/1560534745/icongroupinterna · Treatment of the Rheumatic Diseases: Companion to Kelley's Textbook of Rheumatology by Michael H. Weisman, et al; Hardcover - 563 pages, 2nd edition (January 15, 2001), W B Saunders Co.; ISBN: 0721684645; http://www.amazon.com/exec/obidos/ASIN/0721684645/icongroupinterna

97

PART III. APPENDICES

ABOUT PART III Part III is a collection of appendices on general medical topics which may be of interest to patients with avascular necrosis and related conditions.

Researching Alternative Medicine 99

APPENDIX A. RESEARCHING YOUR MEDICATIONS Overview There are a number of sources available on new or existing medications which could be prescribed to patients with avascular necrosis. While a number of hard copy or CD-Rom resources are available to patients and physicians for research purposes, a more flexible method is to use Internetbased databases. In this chapter, we will begin with a general overview of medications. We will then proceed to outline official recommendations on how you should view your medications. You may also want to research medications that you are currently taking for other conditions as they may interact with medications for avascular necrosis. Research can give you information on the side effects, interactions, and limitations of prescription drugs used in the treatment of avascular necrosis. Broadly speaking, there are two sources of information on approved medications: public sources and private sources. We will emphasize free-to-use public sources.


Your Medications: The Basics39 The Agency for Health Care Research and Quality has published extremely useful guidelines on how you can best participate in the medication aspects of avascular necrosis. Taking medicines is not always as simple as swallowing a pill. It can involve many steps and decisions each day. The AHCRQ recommends that patients with avascular necrosis take part in treatment decisions. Do not be afraid to ask questions and talk about your concerns. By taking a moment to ask questions early, you may avoid problems later. Here are some points to cover each time a new medicine is prescribed: ·

Ask about all parts of your treatment, including diet changes, exercise, and medicines.

·

Ask about the risks and benefits of each medicine or other treatment you might receive.

·

Ask how often you or your doctor will check for side effects from a given medication.

Do not hesitate to ask what is important to you about your medicines. You may want a medicine with the fewest side effects, or the fewest doses to take each day. You may care most about cost, or how the medicine might affect how you live or work. Or, you may want the medicine your doctor believes will work the best. Telling your doctor will help him or her select the best treatment for you. Do not be afraid to “bother” your doctor with your concerns and questions about medications for avascular necrosis. You can also talk to a nurse or a pharmacist. They can help you better understand your treatment plan. Feel free to bring a friend or family member with you when you visit your doctor. Talking over your options with someone you trust can help you make better choices, especially if you are not feeling well. Specifically, ask your doctor the following: ·

The name of the medicine and what it is supposed to do.

·

How and when to take the medicine, how much to take, and for how long.

·

What food, drinks, other medicines, or activities you should avoid while taking the medicine.

·

What side effects the medicine may have, and what to do if they occur.

39

This section is adapted from AHCRQ: http://www.ahcpr.gov/consumer/ncpiebro.htm.


·

If you can get a refill, and how often.

·

About any terms or directions you do not understand.

·

What to do if you miss a dose.

·

If there is written information you can take home (most pharmacies have information sheets on your prescription medicines; some even offer large-print or Spanish versions).

Do not forget to tell your doctor about all the medicines you are currently taking (not just those for avascular necrosis). This includes prescription medicines and the medicines that you buy over the counter. Then your doctor can avoid giving you a new medicine that may not work well with the medications you take now. When talking to your doctor, you may wish to prepare a list of medicines you currently take, the reason you take them, and how you take them. Be sure to include the following information for each: ·

Name of medicine

·

Reason taken

·

Dosage

·

Time(s) of day

Also include any over-the-counter medicines, such as: ·

Laxatives

·

Diet pills

·

Vitamins

·

Cold medicine

·

Aspirin or other pain, headache, or fever medicine

·

Cough medicine

·

Allergy relief medicine

·

Antacids

·

Sleeping pills

·

Others (include names)


Learning More about Your Medications Because of historical investments by various organizations and the emergence of the Internet, it has become rather simple to learn about the medications your doctor has recommended for avascular necrosis. One such source is the United States Pharmacopeia. In 1820, eleven physicians met in Washington, D.C. to establish the first compendium of standard drugs for the United States. They called this compendium the “U.S. Pharmacopeia (USP).” Today, the USP is a non-profit organization consisting of 800 volunteer scientists, eleven elected officials, and 400 representatives of state associations and colleges of medicine and pharmacy. The USP is located in Rockville, Maryland, and its home page is located at www.usp.org. The USP currently provides standards for over 3,700 medications. The resulting USP DIÒ Advice for the PatientÒ can be accessed through the National Library of Medicine of the National Institutes of Health. The database is partially derived from lists of federally approved medications in the Food and Drug Administration's (FDA) Drug Approvals database.40 While the FDA database is rather large and difficult to navigate, the Phamacopeia is both user-friendly and free to use. It covers more than 9,000 prescription and over-the-counter medications. To access this database, simply type the following hyperlink into your Web browser: http://www.nlm.nih.gov/medlineplus/druginformation.html. To view examples of a given medication (brand names, category, description, preparation, proper use, precautions, side effects, etc.), simply follow the hyperlinks indicated within the United States Pharmacopoeia. It is important to read the disclaimer by the United States Pharmacopoeia (http://www.nlm.nih.gov/medlineplus/drugdisclaimer.html) before using the information provided.

Commercial Databases In addition to the medications listed in the USP above, a number of commercial sites are available by subscription to physicians and their institutions. You may be able to access these sources from your local medical library or your doctor's office.

Though cumbersome, the FDA database can be freely browsed at the following site: www.fda.gov/cder/da/da.htm.

40


Reuters Health Drug Database The Reuters Health Drug Database can be searched by keyword at the hyperlink: http://www.reutershealth.com/frame2/drug.html. The following medications are listed in the Reuters' database as associated with avascular necrosis (including those with contraindications):41 ·

Betamethasone http://www.reutershealth.com/atoz/html/Betamethasone.htm

·

Corticotropin http://www.reutershealth.com/atoz/html/Corticotropin.htm

·

Corticotropin (Adrenocorticotropic hormone; ACTH) http://www.reutershealth.com/atoz/html/Corticotropin_(Adrenocortic otropic_hormone;_ACTH).htm

·

Cortisone http://www.reutershealth.com/atoz/html/Cortisone.htm

·

Cortisone (Cortisone Acetate) http://www.reutershealth.com/atoz/html/Cortisone_(Cortisone_Acetat e).htm

·

Dexamethasone http://www.reutershealth.com/atoz/html/Dexamethasone.htm

·

Methylprednisolone http://www.reutershealth.com/atoz/html/Methylprednisolone.htm

·

Prednisolone http://www.reutershealth.com/atoz/html/Prednisolone.htm

·

Prednisone http://www.reutershealth.com/atoz/html/Prednisone.htm

·

Triamcinolone http://www.reutershealth.com/atoz/html/Triamcinolone.htm Mosby's GenRx

Mosby's GenRx database (also available on CD-Rom and book format) covers 45,000 drug products including generics and international brands. It provides prescribing information, drug interactions, and patient information. Information in Mosby's GenRx database can be obtained at the following hyperlink: http://www.genrx.com/Mosby/PhyGenRx/group.html. 41

Adapted from A to Z Drug Facts by Facts and Comparisons.


Physicians Desk Reference The Physicians Desk Reference database (also available in CD-Rom and book format) is a full-text drug database. The database is searchable by brand name, generic name or by indication. It features multiple drug interactions reports. Information can be obtained at the following hyperlink: http://physician.pdr.net/physician/templates/en/acl/psuser_t.htm.

Other Web Sites A number of additional Web sites discuss drug information. As an example, you may like to look at www.drugs.com which reproduces the information in the Pharmacopeia as well as commercial information. You may also want to consider the Web site of the Medical Letter, Inc. which allows users to download articles on various drugs and therapeutics for a nominal fee: http://www.medletter.com/.

Contraindications and Interactions (Hidden Dangers) Some of the medications mentioned in the previous discussions can be problematic for patients with avascular necrosis--not because they are used in the treatment process, but because of contraindications, or side effects. Medications with contraindications are those that could react with drugs used to treat avascular necrosis or potentially create deleterious side effects in patients with avascular necrosis. You should ask your physician about any contraindications, especially as these might apply to other medications that you may be taking for common ailments. Drug-drug interactions occur when two or more drugs react with each other. This drug-drug interaction may cause you to experience an unexpected side effect. Drug interactions may make your medications less effective, cause unexpected side effects, or increase the action of a particular drug. Some drug interactions can even be harmful to you. Be sure to read the label every time you use a nonprescription or prescription drug, and take the time to learn about drug interactions. These precautions may be critical to your health. You can reduce the risk of potentially harmful drug interactions and side effects with a little bit of knowledge and common sense.


Drug labels contain important information about ingredients, uses, warnings, and directions which you should take the time to read and understand. Labels also include warnings about possible drug interactions. Further, drug labels may change as new information becomes available. This is why it's especially important to read the label every time you use a medication. When your doctor prescribes a new drug, discuss all over-thecounter and prescription medications, dietary supplements, vitamins, botanicals, minerals and herbals you take as well as the foods you eat. Ask your pharmacist for the package insert for each prescription drug you take. The package insert provides more information about potential drug interactions.

A Final Warning At some point, you may hear of alternative medications from friends, relatives, or in the news media. Advertisements may suggest that certain alternative drugs can produce positive results for patients with avascular necrosis. Exercise caution--some of these drugs may have fraudulent claims, and others may actually hurt you. The Food and Drug Administration (FDA) is the official U.S. agency charged with discovering which medications are likely to improve the health of patients with avascular necrosis. The FDA warns patients to watch out for42: ·

Secret formulas (real scientists share what they know)

·

Amazing breakthroughs or miracle cures (real breakthroughs don't happen very often; when they do, real scientists do not call them amazing or miracles)

·

Quick, painless, or guaranteed cures

·

If it sounds too good to be true, it probably isn't true.

If you have any questions about any kind of medical treatment, the FDA may have an office near you. Look for their number in the blue pages of the phone book. You can also contact the FDA through its toll-free number, 1888-INFO-FDA (1-888-463-6332), or on the World Wide Web at www.fda.gov.

This section has been adapted from http://www.fda.gov/opacom/lowlit/medfraud.html.

42


General References In addition to the resources provided earlier in this chapter, the following general references describe medications (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Complete Guide to Prescription and Nonprescription Drugs 2001 (Complete Guide to Prescription and Nonprescription Drugs, 2001) by H. Winter Griffith, Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/039952634X/icongroupinterna

·

The Essential Guide to Prescription Drugs, 2001 by James J. Rybacki, James W. Long; Paperback - 1274 pages (2001), Harper Resource; ISBN: 0060958162; http://www.amazon.com/exec/obidos/ASIN/0060958162/icongroupinterna

·

Handbook of Commonly Prescribed Drugs by G. John Digregorio, Edward J. Barbieri; Paperback 16th edition (2001), Medical Surveillance; ISBN: 0942447417; http://www.amazon.com/exec/obidos/ASIN/0942447417/icongroupinterna

·

Johns Hopkins Complete Home Encyclopedia of Drugs 2nd ed. by Simeon Margolis (Ed.), Johns Hopkins; Hardcover - 835 pages (2000), Rebus; ISBN: 0929661583; http://www.amazon.com/exec/obidos/ASIN/0929661583/icongroupinterna

·

Medical Pocket Reference: Drugs 2002 by Springhouse Paperback 1st edition (2001), Lippincott Williams & Wilkins Publishers; ISBN: 1582550964; http://www.amazon.com/exec/obidos/ASIN/1582550964/icongroupinterna

·

PDR by Medical Economics Staff, Medical Economics Staff Hardcover 3506 pages 55th edition (2000), Medical Economics Company; ISBN: 1563633752; http://www.amazon.com/exec/obidos/ASIN/1563633752/icongroupinterna

·

Pharmacy Simplified: A Glossary of Terms by James Grogan; Paperback 432 pages, 1st edition (2001), Delmar Publishers; ISBN: 0766828581; http://www.amazon.com/exec/obidos/ASIN/0766828581/icongroupinterna

·

Physician Federal Desk Reference by Christine B. Fraizer; Paperback 2nd edition (2001), Medicode Inc; ISBN: 1563373971; http://www.amazon.com/exec/obidos/ASIN/1563373971/icongroupinterna

·

Physician's Desk Reference Supplements Paperback - 300 pages, 53 edition (1999), ISBN: 1563632950; http://www.amazon.com/exec/obidos/ASIN/1563632950/icongroupinterna


APPENDIX B. RESEARCHING ALTERNATIVE MEDICINE Overview Complementary and alternative medicine (CAM) is one of the most contentious aspects of modern medical practice. You may have heard of these treatments on the radio or on television. Maybe you have seen articles written about these treatments in magazines, newspapers, or books. Perhaps your friends or doctor have mentioned alternatives. In this chapter, we will begin by giving you a broad perspective on complementary and alternative therapies. Next, we will introduce you to official information sources on CAM relating to avascular necrosis. Finally, at the conclusion of this chapter, we will provide a list of readings on avascular necrosis from various authors. We will begin, however, with the National Center for Complementary and Alternative Medicine's (NCCAM) overview of complementary and alternative medicine.

What Is CAM?43 Complementary and alternative medicine (CAM) covers a broad range of healing philosophies, approaches, and therapies. Generally, it is defined as those treatments and healthcare practices which are not taught in medical schools, used in hospitals, or reimbursed by medical insurance companies. Many CAM therapies are termed “holistic,” which generally means that the healthcare practitioner considers the whole person, including physical, mental, emotional, and spiritual health. Some of these therapies are also 43

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/faq/index.html#what-is.


known as “preventive,” which means that the practitioner educates and treats the person to prevent health problems from arising, rather than treating symptoms after problems have occurred. People use CAM treatments and therapies in a variety of ways. Therapies are used alone (often referred to as alternative), in combination with other alternative therapies, or in addition to conventional treatment (sometimes referred to as complementary). Complementary and alternative medicine, or “integrative medicine,” includes a broad range of healing philosophies, approaches, and therapies. Some approaches are consistent with physiological principles of Western medicine, while others constitute healing systems with non-Western origins. While some therapies are far outside the realm of accepted Western medical theory and practice, others are becoming established in mainstream medicine. Complementary and alternative therapies are used in an effort to prevent illness, reduce stress, prevent or reduce side effects and symptoms, or control or cure disease. Some commonly used methods of complementary or alternative therapy include mind/body control interventions such as visualization and relaxation, manual healing including acupressure and massage, homeopathy, vitamins or herbal products, and acupuncture.

What Are the Domains of Alternative Medicine?44 The list of CAM practices changes continually. The reason being is that these new practices and therapies are often proved to be safe and effective, and therefore become generally accepted as “mainstream” healthcare practices. Today, CAM practices may be grouped within five major domains: (1) alternative medical systems, (2) mind-body interventions, (3) biologicallybased treatments, (4) manipulative and body-based methods, and (5) energy therapies. The individual systems and treatments comprising these categories are too numerous to list in this sourcebook. Thus, only limited examples are provided within each.

Alternative Medical Systems Alternative medical systems involve complete systems of theory and practice that have evolved independent of, and often prior to, conventional biomedical approaches. Many are traditional systems of medicine that are 44

Adapted from the NCCAM: http://nccam.nih.gov/nccam/fcp/classify/index.html.


practiced by individual cultures throughout the world, including a number of venerable Asian approaches. Traditional oriental medicine emphasizes the balance or disturbances of qi (pronounced chi) or vital energy in health and disease, respectively. Traditional oriental medicine consists of a group of techniques and methods including acupuncture, herbal medicine, oriental massage, and qi gong (a form of energy therapy). Acupuncture involves stimulating specific anatomic points in the body for therapeutic purposes, usually by puncturing the skin with a thin needle. Ayurveda is India's traditional system of medicine. Ayurvedic medicine (meaning “science of life”) is a comprehensive system of medicine that places equal emphasis on body, mind, and spirit. Ayurveda strives to restore the innate harmony of the individual. Some of the primary Ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Other traditional healing systems have been developed by the world’s indigenous populations. These populations include Native American, Aboriginal, African, Middle Eastern, Tibetan, and Central and South American cultures. Homeopathy and naturopathy are also examples of complete alternative medicine systems. Homeopathic medicine is an unconventional Western system that is based on the principle that “like cures like,” i.e., that the same substance that in large doses produces the symptoms of an illness, in very minute doses cures it. Homeopathic health practitioners believe that the more dilute the remedy, the greater its potency. Therefore, they use small doses of specially prepared plant extracts and minerals to stimulate the body's defense mechanisms and healing processes in order to treat illness. Naturopathic medicine is based on the theory that disease is a manifestation of alterations in the processes by which the body naturally heals itself and emphasizes health restoration rather than disease treatment. Naturopathic physicians employ an array of healing practices, including the following: diet and clinical nutrition, homeopathy, acupuncture, herbal medicine, hydrotherapy (the use of water in a range of temperatures and methods of applications), spinal and soft-tissue manipulation, physical therapies (such as those involving electrical currents, ultrasound, and light), therapeutic counseling, and pharmacology.


Mind-Body Interventions Mind-body interventions employ a variety of techniques designed to facilitate the mind's capacity to affect bodily function and symptoms. Only a select group of mind-body interventions having well-documented theoretical foundations are considered CAM. For example, patient education and cognitive-behavioral approaches are now considered “mainstream.” On the other hand, complementary and alternative medicine includes meditation, certain uses of hypnosis, dance, music, and art therapy, as well as prayer and mental healing.

Biological-Based Therapies This category of CAM includes natural and biological-based practices, interventions, and products, many of which overlap with conventional medicine's use of dietary supplements. This category includes herbal, special dietary, orthomolecular, and individual biological therapies. Herbal therapy employs an individual herb or a mixture of herbs for healing purposes. An herb is a plant or plant part that produces and contains chemical substances that act upon the body. Special diet therapies, such as those proposed by Drs. Atkins, Ornish, Pritikin, and Weil, are believed to prevent and/or control illness as well as promote health. Orthomolecular therapies aim to treat disease with varying concentrations of chemicals such as magnesium, melatonin, and mega-doses of vitamins. Biological therapies include, for example, the use of laetrile and shark cartilage to treat cancer and the use of bee pollen to treat autoimmune and inflammatory diseases.

Manipulative and Body-Based Methods This category includes methods that are based on manipulation and/or movement of the body. For example, chiropractors focus on the relationship between structure and function, primarily pertaining to the spine, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool. In contrast, osteopaths place particular emphasis on the musculoskeletal system and practice osteopathic manipulation. Osteopaths believe that all of the body's systems work together and that disturbances in one system may have an impact upon function elsewhere in the body. Massage therapists manipulate the soft tissues of the body to normalize those tissues.


Energy Therapies Energy therapies focus on energy fields originating within the body (biofields) or those from other sources (electromagnetic fields). Biofield therapies are intended to affect energy fields (the existence of which is not yet experimentally proven) that surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in or through these fields. Examples include Qi gong, Reiki and Therapeutic Touch. Qi gong is a component of traditional oriental medicine that combines movement, meditation, and regulation of breathing to enhance the flow of vital energy (qi) in the body, improve blood circulation, and enhance immune function. Reiki, the Japanese word representing Universal Life Energy, is based on the belief that, by channeling spiritual energy through the practitioner, the spirit is healed and, in turn, heals the physical body. Therapeutic Touch is derived from the ancient technique of “laying-on of hands.” It is based on the premises that the therapist’s healing force affects the patient's recovery and that healing is promoted when the body's energies are in balance. By passing their hands over the patient, these healers identify energy imbalances. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields to treat illnesses or manage pain. These therapies are often used to treat asthma, cancer, and migraine headaches. Types of electromagnetic fields which are manipulated in these therapies include pulsed fields, magnetic fields, and alternating current or direct current fields.

Can Alternatives Affect My Treatment? A critical issue in pursuing complementary alternatives mentioned thus far is the risk that these might have undesirable interactions with your medical treatment. It becomes all the more important to speak with your doctor who can offer advice on the use of alternatives. Official sources confirm this view. Though written for women, we find that the National Women’s Health Information Center’s advice on pursuing alternative medicine is appropriate for patients of both genders and all ages.45

45

Adapted from http://www.4woman.gov/faq/alternative.htm.


Is It Okay to Want Both Traditional and Alternative Medicine? Should you wish to explore non-traditional types of treatment, be sure to discuss all issues concerning treatments and therapies with your healthcare provider, whether a physician or practitioner of complementary and alternative medicine. Competent healthcare management requires knowledge of both conventional and alternative therapies you are taking for the practitioner to have a complete picture of your treatment plan. The decision to use complementary and alternative treatments is an important one. Consider before selecting an alternative therapy, the safety and effectiveness of the therapy or treatment, the expertise and qualifications of the healthcare practitioner, and the quality of delivery. These topics should be considered when selecting any practitioner or therapy.

Finding CAM References on Avascular Necrosis Having read the previous discussion, you may be wondering which complementary or alternative treatments might be appropriate for avascular necrosis. For the remainder of this chapter, we will direct you to a number of official sources which can assist you in researching studies and publications. Some of these articles are rather technical, so some patience may be required.

National Center for Complementary and Alternative Medicine The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (http://nccam.nih.gov) has created a link to the National Library of Medicine's databases to allow patients to search for articles that specifically relate to avascular necrosis and complementary medicine. To search the database, go to the following Web site: www.nlm.nih.gov/nccam/camonpubmed.html. Select “CAM on PubMed.” Enter “avascular necrosis” (or synonyms) into the search box. Click “Go.” The following references provide information on particular aspects of complementary and alternative medicine (CAM) that are related to avascular necrosis: ·

Augmented Berlin-Frankfurt-Munster therapy abrogates the adverse prognostic significance of slow early response to induction chemotherapy for children and adolescents with acute lymphoblastic leukemia and unfavorable presenting features: a report from the Children's Cancer Group.


Author(s): Nachman J, Sather HN, Gaynon PS, Lukens JN, Wolff L, Trigg ME. Source: Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 1997 June; 15(6): 2222-30. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9196134&dopt=Abstract ·

Avascular necrosis following extensive chemotherapy and dexamethasone treatment in a patient with advanced ovarian cancer: case report and review of the literature. Author(s): Gogas H, Fennelly D. Source: Gynecologic Oncology. 1996 December; 63(3): 379-81. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8946875&dopt=Abstract

·

Avascular necrosis in patients treated with BEP chemotherapy for testicular tumours. Author(s): Coles C, Williams M. Source: Clin Oncol (R Coll Radiol). 2000; 12(1): 69. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10749025&dopt=Abstract

·

Avascular necrosis in patients treated with BEP chemotherapy for testicular tumours. Author(s): Cook AM, Patterson H, Nicholls J, Huddart RA. Source: Clin Oncol (R Coll Radiol). 1999; 11(2): 126-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10378640&dopt=Abstract

·

Avascular necrosis of bone after adult acute lymphocytic leukemia treatment with methotrexate, vincristine, L-asparaginase, and dexamethasone (MOAD). Author(s): Hui L, Wiernik PH. Source: American Journal of Hematology. 1996 July; 52(3): 184-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=8756084&dopt=Abstract

·

Avascular necrosis of bone caused by combination chemotherapy without corticosteroids. Author(s): Harper PG, Trask C, Souhami RL.


Source: British Medical Journal (Clinical Research Ed.). 1984 January 28; 288(6413): 267-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6198019&dopt=Abstract ·

Avascular necrosis of bone in Hodgkin's disease patients treated with combined modality therapy. Author(s): Prosnitz LR, Lawson JP, Friedlaender GE, Farber LR, Pezzimenti JF. Source: Cancer. 1981 June 15; 47(12): 2793-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=7260869&dopt=Abstract

·

Avascular necrosis of bone in neuroblastoma treated with combination chemotherapy. Author(s): Ishii E, Yoshida N, Miyazaki S. Source: European Journal of Pediatrics. 1984 December; 143(2): 152-3. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6519114&dopt=Abstract

·

Avascular necrosis of bone mimicking symmetric polyarthritis in a patient with malignant lymphoma treated with high-dose steroids. Author(s): Buskila D, Thomson GT, Klein M, Keystone EC. Source: Isr J Med Sci. 1992 November; 28(11): 804-5. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1281809&dopt=Abstract

·

Avascular necrosis of the carpal lunate: a case report. Author(s): Irowa GO. Source: Journal of Manipulative and Physiological Therapeutics. 1987 December; 10(6): 323-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3437236&dopt=Abstract

·

Avascular necrosis of the femoral head after treatment of Hodgkin's disease. Author(s): Tombolini V, Capua A, Pompili E.


Source: Acta Oncologica (Stockholm, Sweden). 1992; 31(1): 64-5. No Abstract Available. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1375043&dopt=Abstract ·

Avascular necrosis of the femoral head with combination therapy. Author(s): Sweet DL Jr, Roth DG, Desser RK, Miller JB, Ultmann JE. Source: Annals of Internal Medicine. 1976 July; 85(1): 67-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=937924&dopt=Abstract

·

Avascular necrosis of the femur head. Author(s): Fried NR, Gerow G. Source: Journal of Manipulative and Physiological Therapeutics. 1989 June; 12(3): 228-30. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=2746146&dopt=Abstract

·

Bilateral aseptic necrosis of the humeral head following combined therapy for Hodgkin's lymphoma. Author(s): Virgolini L, De Maglio A. Source: Ital J Orthop Traumatol. 1992; 18(4): 543-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=1345650&dopt=Abstract

·

Chiropractic radiologists: a survey of demographics, abilities, educational attitudes and practice trends. Author(s): Marchiori DM, Hawk C, Howe J. Source: Journal of Manipulative and Physiological Therapeutics. 1998 July-August; 21(6): 392-8. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=9726066&dopt=Abstract

·

Combined modality therapy for advanced Hodgkin's disease: longterm followup data. Author(s): Prosnitz LR, Farber LR, Kapp DS, Bertino JR, Nordlund M, Lawrence R. Source: Cancer Treat Rep. 1982 April; 66(4): 871-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=6176322&dopt=Abstract


·

Hass' disease. Author(s): Terrett AG, Molyneux TP. Source: Journal of Manipulative and Physiological Therapeutics. 1988 February; 11(1): 43-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3351400&dopt=Abstract

·

Hip and pelvic injuries in the young athlete. Author(s): Waters PM, Millis MB. Source: Clinics in Sports Medicine. 1988 July; 7(3): 513-26. Review. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3042159&dopt=Abstract

·

Magnetic resonance imaging detection of avascular necrosis of the bone in children receiving intensive prednisone therapy for acute lymphoblastic leukemia or non-Hodgkin lymphoma. Author(s): Ribeiro RC, Fletcher BD, Kennedy W, Harrison PL, Neel MD, Kaste SC, Sandlund JT, Rubnitz JE, Razzouk BI, Relling MV, Pui CH. Source: Leukemia : Official Journal of the Leukemia Society of America, Leukemia Research Fund, U.K. 2001 June; 15(6): 891-7. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11417473&dopt=Abstract

·

Resolution of a photopenic lesion on bone imaging following chemotherapy for metastatic disease. Author(s): Rosen JM, MacLaughlin WW, Jaffe RM. Source: Clinical Nuclear Medicine. 1987 July; 12(7): 552-3. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3038448&dopt=Abstract

·

The prevalence of avascular necrosis in patients treated with chemotherapy for testicular tumours. Author(s): Cook AM, Dzik-Jurasz AS, Padhani AR, Norman A, Huddart RA. Source: British Journal of Cancer. 2001 November 30; 85(11): 1624-6. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=11742478&dopt=Abstract

·

Treatment of experimental avascular necrosis of the femoral head with hyperbaric oxygen in rats: histological evaluation of the femoral heads during the early phase of the reparative process.


Author(s): Levin D, Norman D, Zinman C, Rubinstein L, Sabo E, Misselevich I, Reis D, Boss JH. Source: Experimental and Molecular Pathology. 1999 October; 67(2): 99108. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=10527761&dopt=Abstract ·

Treatment of neglected femoral neck fractures in young adults. Author(s): Huang CH. Source: Clinical Orthopaedics and Related Research. 1986 May; (206): 117-26. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3708964&dopt=Abstract

·

Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast. Author(s): Frykman GK, Taleisnik J, Peters G, Kaufman R, Helal B, Wood VE, Unsell RS. Source: The Journal of Hand Surgery. 1986 May; 11(3): 344-9. http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db= PubMed&list_uids=3711607&dopt=Abstract

Additional Web Resources A number of additional Web sites offer encyclopedic information covering CAM and related topics. The following is a representative sample: ·

Alternative Medicine Foundation, Inc.: http://www.herbmed.org/

·


·

Chinese Medicine: http://www.newcenturynutrition.com/

·

drkoop.comÒ: http://www.drkoop.com/InteractiveMedicine/IndexC.html

·

Family Village: http://www.familyvillage.wisc.edu/med_altn.htm

·

Google: http://directory.google.com/Top/Health/Alternative/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Alternative/

·

TPN.com: http://www.tnp.com/

·

Yahoo.com: http://dir.yahoo.com/Health/Alternative_Medicine/


·

WebMDÒHealth: http://my.webmd.com/drugs_and_herbs

·

WellNet: http://www.wellnet.ca/herbsa-c.htm

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

General References A good place to find general background information on CAM is the National Library of Medicine. It has prepared within the MEDLINEplus system an information topic page dedicated to complementary and alternative medicine. To access this page, go to the MEDLINEplus site at: www.nlm.nih.gov/medlineplus/alternativemedicine.html. This Web site provides a general overview of various topics and can lead to a number of general sources. The following additional references describe, in broad terms, alternative and complementary medicine (sorted alphabetically by title; hyperlinks provide rankings, information, and reviews at Amazon.com): ·

The Arthritis Bible: A Comprehensive Guide to Alternative Therapies and Conventional Treatments for Arthritic Diseases by Leonid Gordin, Craig Weatherby; Paperback - 244 pages, 1st edition (April 15, 1999), Inner Traditions Int’l Ltd.; ISBN: 0892818255; http://www.amazon.com/exec/obidos/ASIN/0892818255/icongroupin terna

·

Healing Joint Pain Naturally : Safe and Effective Ways to Treat Arthritis, Fibromyalgia, and Other Joint Diseases by Ellen Hodgson Brown; Paperback - 262 pages (June 2001), Broadway Books; ISBN: 076790561X; http://www.amazon.com/exec/obidos/ASIN/076790561X/icongroupi nterna

·

Healthy Bones & Joints: A Natural Approach to Treating Arthritis, Osteoporosis, Tendinitis, Myalgia & Bursitis by David Hoffmann; Paperback - 128 pages (July 15, 2000), Storey Books; ISBN: 1580172539; http://www.amazon.com/exec/obidos/ASIN/1580172539/icongroupin terna

·

Joint Pains: A Guide to Successful Herbal Remedies by Penelope Ody; Paperback - 172 pages (April 2002), Souvenir Press Ltd; ISBN: 0285636227; http://www.amazon.com/exec/obidos/ASIN/0285636227/icongroupin terna


·

Living Life Free from Pain: Treating Arthritis, Joint Pain, Muscle Pain, and Fibromyalgia with Maharishi Vedic Medicine by Kumuda Reddy, et al; Paperback - 350 pages (August 2001), Lantern Books; ISBN: 1930051549; http://www.amazon.com/exec/obidos/ASIN/1930051549/icongroupin terna

·

The Posture Prescription : A Doctor's Rx for Eliminating Back, Muscle, and Joint Pain, Achieving Optimum Strength and Mobility, Living a Life of Fitne by Arthur White, MD, et al; Paperback - 256 pages, 1st edition (January 8, 2002), Three Rivers Pr; ISBN: 0609806319; http://www.amazon.com/exec/obidos/ASIN/0609806319/icongroupin terna

For additional information on complementary and alternative medicine, ask your doctor or write to: National Institutes of Health National Center for Complementary and Alternative Medicine Clearinghouse P. O. Box 8218 Silver Spring, MD 20907-8218

Researching Nutrition 121

APPENDIX C. RESEARCHING NUTRITION Overview Since the time of Hippocrates, doctors have understood the importance of diet and nutrition to patients’ health and well-being. Since then, they have accumulated an impressive archive of studies and knowledge dedicated to this subject. Based on their experience, doctors and healthcare providers may recommend particular dietary supplements to patients with avascular necrosis. Any dietary recommendation is based on a patient's age, body mass, gender, lifestyle, eating habits, food preferences, and health condition. It is therefore likely that different patients with avascular necrosis may be given different recommendations. Some recommendations may be directly related to avascular necrosis, while others may be more related to the patient's general health. These recommendations, themselves, may differ from what official sources recommend for the average person. In this chapter we will begin by briefly reviewing the essentials of diet and nutrition that will broadly frame more detailed discussions of avascular necrosis. We will then show you how to find studies dedicated specifically to nutrition and avascular necrosis.


Food and Nutrition: General Principles What Are Essential Foods? Food is generally viewed by official sources as consisting of six basic elements: (1) fluids, (2) carbohydrates, (3) protein, (4) fats, (5) vitamins, and (6) minerals. Consuming a combination of these elements is considered to be a healthy diet: ·

Fluids are essential to human life as 80-percent of the body is composed of water. Water is lost via urination, sweating, diarrhea, vomiting, diuretics (drugs that increase urination), caffeine, and physical exertion.

·

Carbohydrates are the main source for human energy (thermoregulation) and the bulk of typical diets. They are mostly classified as being either simple or complex. Simple carbohydrates include sugars which are often consumed in the form of cookies, candies, or cakes. Complex carbohydrates consist of starches and dietary fibers. Starches are consumed in the form of pastas, breads, potatoes, rice, and other foods. Soluble fibers can be eaten in the form of certain vegetables, fruits, oats, and legumes. Insoluble fibers include brown rice, whole grains, certain fruits, wheat bran and legumes.

·

Proteins are eaten to build and repair human tissues. Some foods that are high in protein are also high in fat and calories. Food sources for protein include nuts, meat, fish, cheese, and other dairy products.

·

Fats are consumed for both energy and the absorption of certain vitamins. There are many types of fats, with many general publications recommending the intake of unsaturated fats or those low in cholesterol.

Vitamins and minerals are fundamental to human health, growth, and, in some cases, disease prevention. Most are consumed in your diet (exceptions being vitamins K and D which are produced by intestinal bacteria and sunlight on the skin, respectively). Each vitamin and mineral plays a different role in health. The following outlines essential vitamins: ·

Vitamin A is important to the health of your eyes, hair, bones, and skin; sources of vitamin A include foods such as eggs, carrots, and cantaloupe.

·

Vitamin B1, also known as thiamine, is important for your nervous system and energy production; food sources for thiamine include meat, peas, fortified cereals, bread, and whole grains.

·

Vitamin B2, also known as riboflavin, is important for your nervous system and muscles, but is also involved in the release of proteins from


nutrients; food sources for riboflavin include dairy products, leafy vegetables, meat, and eggs. ·

Vitamin B3, also known as niacin, is important for healthy skin and helps the body use energy; food sources for niacin include peas, peanuts, fish, and whole grains

·

Vitamin B6, also known as pyridoxine, is important for the regulation of cells in the nervous system and is vital for blood formation; food sources for pyridoxine include bananas, whole grains, meat, and fish.

·

Vitamin B12 is vital for a healthy nervous system and for the growth of red blood cells in bone marrow; food sources for vitamin B12 include yeast, milk, fish, eggs, and meat.

·

Vitamin C allows the body's immune system to fight various diseases, strengthens body tissue, and improves the body's use of iron; food sources for vitamin C include a wide variety of fruits and vegetables.

·

Vitamin D helps the body absorb calcium which strengthens bones and teeth; food sources for vitamin D include oily fish and dairy products.

·

Vitamin E can help protect certain organs and tissues from various degenerative diseases; food sources for vitamin E include margarine, vegetables, eggs, and fish.

·

Vitamin K is essential for bone formation and blood clotting; common food sources for vitamin K include leafy green vegetables.

·

Folic Acid maintains healthy cells and blood and, when taken by a pregnant woman, can prevent her fetus from developing neural tube defects; food sources for folic acid include nuts, fortified breads, leafy green vegetables, and whole grains.

It should be noted that one can overdose on certain vitamins which become toxic if consumed in excess (e.g. vitamin A, D, E and K). Like vitamins, minerals are chemicals that are required by the body to remain in good health. Because the human body does not manufacture these chemicals internally, we obtain them from food and other dietary sources. The more important minerals include: ·

Calcium is needed for healthy bones, teeth, and muscles, but also helps the nervous system function; food sources for calcium include dry beans, peas, eggs, and dairy products.

·

Chromium is helpful in regulating sugar levels in blood; food sources for chromium include egg yolks, raw sugar, cheese, nuts, beets, whole grains, and meat.


·

Fluoride is used by the body to help prevent tooth decay and to reinforce bone strength; sources of fluoride include drinking water and certain brands of toothpaste.

·

Iodine helps regulate the body's use of energy by synthesizing into the hormone thyroxine; food sources include leafy green vegetables, nuts, egg yolks, and red meat.

·

Iron helps maintain muscles and the formation of red blood cells and certain proteins; food sources for iron include meat, dairy products, eggs, and leafy green vegetables.

·

Magnesium is important for the production of DNA, as well as for healthy teeth, bones, muscles, and nerves; food sources for magnesium include dried fruit, dark green vegetables, nuts, and seafood.

·

Phosphorous is used by the body to work with calcium to form bones and teeth; food sources for phosphorous include eggs, meat, cereals, and dairy products.

·

Selenium primarily helps maintain normal heart and liver functions; food sources for selenium include wholegrain cereals, fish, meat, and dairy products.

·

Zinc helps wounds heal, the formation of sperm, and encourage rapid growth and energy; food sources include dried beans, shellfish, eggs, and nuts.

The United States government periodically publishes recommended diets and consumption levels of the various elements of food. Again, your doctor may encourage deviations from the average official recommendation based on your specific condition. To learn more about basic dietary guidelines, visit the Web site: http://www.health.gov/dietaryguidelines/. Based on these guidelines, many foods are required to list the nutrition levels on the food’s packaging. Labeling Requirements are listed at the following site maintained by the Food and Drug Administration: http://www.cfsan.fda.gov/~dms/labcons.html. When interpreting these requirements, the government recommends that consumers become familiar with the following abbreviations before reading FDA literature:46 ·

DVs (Daily Values): A new dietary reference term that will appear on the food label. It is made up of two sets of references, DRVs and RDIs.

·

DRVs (Daily Reference Values): A set of dietary references that applies to fat, saturated fat, cholesterol, carbohydrate, protein, fiber, sodium, and potassium.

46

Adapted from the FDA: http://www.fda.gov/fdac/special/foodlabel/dvs.html.


·

RDIs (Reference Daily Intakes): A set of dietary references based on the Recommended Dietary Allowances for essential vitamins and minerals and, in selected groups, protein. The name “RDI” replaces the term “U.S. RDA.”

·

RDAs (Recommended Dietary Allowances): A set of estimated nutrient allowances established by the National Academy of Sciences. It is updated periodically to reflect current scientific knowledge. What Are Dietary Supplements?47

Dietary supplements are widely available through many commercial sources, including health food stores, grocery stores, pharmacies, and by mail. Dietary supplements are provided in many forms including tablets, capsules, powders, gel-tabs, extracts, and liquids. Historically in the United States, the most prevalent type of dietary supplement was a multivitamin/mineral tablet or capsule that was available in pharmacies, either by prescription or “over the counter.” Supplements containing strictly herbal preparations were less widely available. Currently in the United States, a wide array of supplement products are available, including vitamin, mineral, other nutrients, and botanical supplements as well as ingredients and extracts of animal and plant origin. The Office of Dietary Supplements (ODS) of the National Institutes of Health is the official agency of the United States which has the expressed goal of acquiring “new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold.”48 According to the ODS, dietary supplements can have an important impact on the prevention and management of disease and on the maintenance of health.49 The ODS notes that considerable research on the effects of dietary supplements has been conducted in Asia and Europe where the use of plant products, in particular, has a long tradition. However, the overwhelming majority of supplements have not been studied scientifically. This discussion has been adapted from the NIH: http://ods.od.nih.gov/whatare/whatare.html. 48 Contact: The Office of Dietary Supplements, National Institutes of Health, Building 31, Room 1B29, 31 Center Drive, MSC 2086, Bethesda, Maryland 20892-2086, Tel: (301) 435-2920, Fax: (301) 480-1845, E-mail: [email protected]. 49 Adapted from http://ods.od.nih.gov/about/about.html. The Dietary Supplement Health and Education Act defines dietary supplements as “a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, mineral, amino acid, herb or other botanical; or a dietary substance for use to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient described above; and intended for ingestion in the form of a capsule, powder, softgel, or gelcap, and not represented as a conventional food or as a sole item of a meal or the diet.” 47


To explore the role of dietary supplements in the improvement of health care, the ODS plans, organizes, and supports conferences, workshops, and symposia on scientific topics related to dietary supplements. The ODS often works in conjunction with other NIH Institutes and Centers, other government agencies, professional organizations, and public advocacy groups. To learn more about official information on dietary supplements, visit the ODS site at http://ods.od.nih.gov/whatare/whatare.html. Or contact: The Office of Dietary Supplements National Institutes of Health Building 31, Room 1B29 31 Center Drive, MSC 2086 Bethesda, Maryland 20892-2086 Tel: (301) 435-2920 Fax: (301) 480-1845 E-mail: [email protected]

Finding Studies on Avascular Necrosis The NIH maintains an office dedicated to patient nutrition and diet. The National Institutes of Health’s Office of Dietary Supplements (ODS) offers a searchable bibliographic database called the IBIDS (International Bibliographic Information on Dietary Supplements). The IBIDS contains over 460,000 scientific citations and summaries about dietary supplements and nutrition as well as references to published international, scientific literature on dietary supplements such as vitamins, minerals, and botanicals.50 IBIDS is available to the public free of charge through the ODS Internet page: http://ods.od.nih.gov/databases/ibids.html. After entering the search area, you have three choices: (1) IBIDS Consumer Database, (2) Full IBIDS Database, or (3) Peer Reviewed Citations Only. We recommend that you start with the Consumer Database. While you may not find references for the topics that are of most interest to you, check back periodically as this database is frequently updated. More studies can be found by searching the Full IBIDS Database. Healthcare professionals and Adapted from http://ods.od.nih.gov. IBIDS is produced by the Office of Dietary Supplements (ODS) at the National Institutes of Health to assist the public, healthcare providers, educators, and researchers in locating credible, scientific information on dietary supplements. IBIDS was developed and will be maintained through an interagency partnership with the Food and Nutrition Information Center of the National Agricultural Library, U.S. Department of Agriculture.

50


researchers generally use the third option, which lists peer-reviewed citations. In all cases, we suggest that you take advantage of the “Advanced Search” option that allows you to retrieve up to 100 fully explained references in a comprehensive format. Type “avascular necrosis” (or synonyms) into the search box. To narrow the search, you can also select the “Title” field. The following information is typical of that found when using the “Full IBIDS Database” when searching using “avascular necrosis” (or a synonym): ·

A preliminary pilot study of treatment of thrombophilia and hypofibrinolysis and amelioration of the pain of osteonecrosis of the jaws. Author(s): Cincinnati Jewish Hospital, Cholesterol Center, Ohio, USA. Source: Glueck, C J McMahon, R E Bouquot, J E Tracy, T Sieve Smith, L Wang, P Oral-Surg-Oral-Med-Oral-Pathol-Oral-Radiol-Endod. 1998 January; 85(1): 64-73 1079-2104

·

Anticardiolipin antibodies and osteonecrosis of the femoral head. Author(s): Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA. Source: Korompilias, A V Gilkeson, G S Ortel, T L Seaber, A V Urbaniak, J R Clin-Orthopage 1997 December; (345): 174-80 0009-921X

·

Avascular necrosis following extensive chemotherapy and dexamethasone treatment in a patient with advanced ovarian cancer: case report and review of the literature. Author(s): Gynecological Oncology Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. Source: Gogas, H Fennelly, D Gynecol-Oncol. 1996 December; 63(3): 37981 0090-8258

·

Avascular necrosis of bone after adult acute lymphocytic leukemia treatment with methotrexate, vincristine, L-asparaginase, and dexamethasone (MOAD). Author(s): Albert Einstein Cancer Center, Bronx, NY 10467, USA. Source: Hui, L Wiernik, P H Am-J-Hematol. 1996 July; 52(3): 184-8 03618609

·

Clinical observation on therapeutic effects of guzhizaisheng wan for treatment of aseptic necrosis of the head of femur. Author(s): Dong Ya Institute of Osteopathy, East District, Beijing. Source: Wang, L J-Tradit-Chin-Med. 1997 June; 17(2): 127-9 0254-6272

·

Corticosteroid-induced avascular necrosis of the talus. Author(s): Department of Podiatric Surgery, Hospital/Parkview Division, Philadelphia, PA 19135.

Metropolitan


Source: Adleberg, J S Smith, G H J-Foot-Surg. 1991 Jan-February; 30(1): 66-9 0449-2544 ·

Dietary restriction reduces the prevalence of osteonecrosis of the caput femoris in spontaneously hypertensive rats. Author(s): Department of Pathology, Nagasaki University School of Medicine, 1-1 2-4 Sakamoto, Nagasaki City 852-8523, Japan. Source: Tomita, M Shimokawa, I Maeda, H Higami, Y Kawahara, T Ikeda, T Hirano, T Calcif-Tissue-Int. 1999 March; 64(3): 259-62 0171-967X

·

Dysbaric osteonecrosis (caisson disease of bone): are active oxygen species and the endocrine system responsible, and can control of the production of free radicals and their reaction products confer protection? Author(s): Department of Biochemistry, University of Surrey, Guildford, UK. Source: Jones, G R Free-Radic-Res-Commun. 1987; 4(3): 139-47 8755-0199

·

Hip osteonecrosis secondary to the administration of corticosteroids for feigned bronchial asthma. The clinical spectrum of the factitious disorders. Author(s): Department of Medicine, University of Alabama at Birmingham 35294. Source: Alarcon, G S Mikhail, I Jaffe, K A Bradley, L A Bailey, W C Arthritis-Rheum. 1994 January; 37(1): 139-41 0004-3591

·

Imaging study on the mode of development and changes in avascular necrosis of the femoral head in systemic lupus erythematosus: longterm observations. Author(s): First Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan. Source: Nagasawa, K Tsukamoto, H Tada, Y Mayumi, T Satoh, H Onitsuka, H Kuwabara, Y Niho, Y Br-J-Rheumatol. 1994 April; 33(4): 3437 0263-7103

·

Magnetic resonance imaging-detected avascular osteonecrosis in systemic lupus erythematosus: lack of correlation with antiphospholipid antibodies. Author(s): Department of Rheumatology, Saint-Luc University Hospital, Louvain Medical School, Brussels, Belgium. Source: Houssiau, F A N'Zeusseu Toukap, A Depresseux, G Maldague, B E Malghem, J Devogelaer, J P Vande Berg, B C Br-J-Rheumatol. 1998 April; 37(4): 448-53 0263-7103


·

MRI evaluation of steroid- or alcohol-related osteonecrosis of the femoral condyle. Author(s): Department of Orthopedic Surgery, Osaka University Medical School, Suita, Japan. Source: Sakai, T Sugano, N Ohzono, K Matsui, M Hiroshima, K Ochi, T Acta-Orthop-Scand. 1998 December; 69(6): 598-602 0001-6470

·

Multifocal osteonecrosis following chemotherapy and short-term corticosteroid therapy in a patient with small-cell bronchogenic carcinoma. Author(s): Department of Radiology, Duke University Medical Center, Durham, NC 27710. Source: Jones, D N J-Nucl-Med. 1994 August; 35(8): 1347-50 0161-5505

·

Osteonecrosis of the femoral and humeral heads after intraarticular corticosteroid injections. Author(s): Service de Rhumatologie, Hopital Rangueil, Toulouse, France. Source: Laroche, M Arlet, J Mazieres, B J-Rheumatol. 1990 April; 17(4): 549-51 0315-162X

·

Osteonecrosis of the femoral head in patients with inflammatory arthritis or asthma receiving corticosteroid therapy. Author(s): Division of Orthopedic Surgery, Scripps Clinic and Research Foundation, La Jolla, Calif 92037, USA. Source: Colwell, C W Robinson, C A Stevenson, D D Vint, V C Morris, B A Orthopedics. 1996 November; 19(11): 941-6 0147-7447

·

Osteonecrosis of the femoral head in refractory coeliac disease. Author(s): Department of Medical Pathology I, University of Bologna, Italy. Source: Di Sario, A Corazza, G R Cecchetti, L Tarozzi, C Gasbarrini, G JIntern-Med. 1994 February; 235(2): 185-9 0954-6820

·

Predictive factors for symptomatic osteonecrosis in patients with systemic lupus erythematosus. Author(s): Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto Western Hospital, Ontario, Canada. Source: Gladman, D D Urowitz, M B Chaudhry Ahluwalia, V Hallet, D C Cook, R J J-Rheumatol. 2001 April; 28(4): 761-5 0315-162X

·

Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Author(s): Department of Orthopaedic Surgery, University of Washington, Seattle 98104, USA. Source: Pritchett, J W Clin-Orthopage 2001 May; (386): 173-8 0009-921X


·

Synovial fluid cartilage metabolism marker concentrations in osteonecrosis of the femoral head compared with osteoarthrosis of the hip. Author(s): Department of Orthopaedic Surgery, Nagoya University School of Medicine, Japan. Source: Iwase, T Hasegawa, Y Ishiguro, N Ito, T Iwasada, S Kitamura, S Iwata, H J-Rheumatol. 1998 March; 25(3): 527-31 0315-162X

·

Thrombophilia and hypofibrinolysis: pathophysiologies of osteonecrosis. Author(s): Cholesterol Center, Jewish Hospital, Cincinnati, OH 45229, USA. Source: Glueck, C J Freiberg, R Tracy, T Stroop, D Wang, P ClinOrthopage 1997 January; (334): 43-56 0009-921X

Federal Resources on Nutrition In addition to the IBIDS, the United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) provide many sources of information on general nutrition and health. Recommended resources include: ·

healthfinder®, HHS's gateway to health information, including diet and nutrition: http://www.healthfinder.gov/scripts/SearchContext.asp?topic=238&page=0

·

The United States Department of Agriculture's Web site dedicated to nutrition information: www.nutrition.gov

·

The Food and Drug Administration's Web site for federal food safety information: www.foodsafety.gov

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The National Action Plan on Overweight and Obesity sponsored by the United States Surgeon General: http://www.surgeongeneral.gov/topics/obesity/

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The Center for Food Safety and Applied Nutrition has an Internet site sponsored by the Food and Drug Administration and the Department of Health and Human Services: http://vm.cfsan.fda.gov/

·

Center for Nutrition Policy and Promotion sponsored by the United States Department of Agriculture: http://www.usda.gov/cnpp/

·

Food and Nutrition Information Center, National Agricultural Library sponsored by the United States Department of Agriculture: http://www.nal.usda.gov/fnic/


·

Food and Nutrition Service sponsored by the United States Department of Agriculture: http://www.fns.usda.gov/fns/

Additional Web Resources A number of additional Web sites offer encyclopedic information covering food and nutrition. The following is a representative sample: ·


·

Family Village: http://www.familyvillage.wisc.edu/med_nutrition.html

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Google: http://directory.google.com/Top/Health/Nutrition/

·

Healthnotes: http://www.thedacare.org/healthnotes/

·

Open Directory Project: http://dmoz.org/Health/Nutrition/

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Yahoo.com: http://dir.yahoo.com/Health/Nutrition/

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WebMDÒHealth: http://my.webmd.com/nutrition

·

WholeHealthMD.com: http://www.wholehealthmd.com/reflib/0,1529,,00.html

Vocabulary Builder The following vocabulary builder defines words used in the references in this chapter that have not been defined in previous chapters: Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Orthopedics: A surgical specialty which utilizes medical, surgical, and physical methods to treat and correct deformities, diseases, and injuries to


the skeletal system, its articulations, and associated structures. [NIH] Overdose: 1. to administer an excessive dose. 2. an excessive dose. [EU] Refractory: Not readily yielding to treatment. [EU] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Synovial: Of pertaining to, or secreting synovia. [EU] Thermoregulation: Heat regulation. [EU] Thrombophilia: A disorder of hemostasis in which there is a tendency for the occurrence of thrombosis. [NIH] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]

Finding Medical Libraries 133

APPENDIX D. FINDING MEDICAL LIBRARIES Overview At a medical library you can find medical texts and reference books, consumer health publications, specialty newspapers and magazines, as well as medical journals. In this Appendix, we show you how to quickly find a medical library in your area.

Preparation Before going to the library, highlight the references mentioned in this sourcebook that you find interesting. Focus on those items that are not available via the Internet, and ask the reference librarian for help with your search. He or she may know of additional resources that could be helpful to you. Most importantly, your local public library and medical libraries have Interlibrary Loan programs with the National Library of Medicine (NLM), one of the largest medical collections in the world. According to the NLM, most of the literature in the general and historical collections of the National Library of Medicine is available on interlibrary loan to any library. NLM's interlibrary loan services are only available to libraries. If you would like to access NLM medical literature, then visit a library in your area that can request the publications for you.51

51

Adapted from the NLM: http://www.nlm.nih.gov/psd/cas/interlibrary.html.


Finding a Local Medical Library The quickest method to locate medical libraries is to use the Internet-based directory published by the National Network of Libraries of Medicine (NN/LM). This network includes 4626 members and affiliates that provide many services to librarians, health professionals, and the public. To find a library in your area, simply visit http://nnlm.gov/members/adv.html or call 1-800-338-7657.

Medical Libraries Open to the Public In addition to the NN/LM, the National Library of Medicine (NLM) lists a number of libraries that are generally open to the public and have reference facilities. The following is the NLM’s list plus hyperlinks to each library Web site. These Web pages can provide information on hours of operation and other restrictions. The list below is a small sample of libraries recommended by the National Library of Medicine (sorted alphabetically by name of the U.S. state or Canadian province where the library is located):52 ·

Alabama: Health InfoNet of Jefferson County (Jefferson County Library Cooperative, Lister Hill Library of the Health Sciences), http://www.uab.edu/infonet/

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Alabama: Richard M. Scrushy Library (American Sports Medicine Institute), http://www.asmi.org/LIBRARY.HTM

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Arizona: Samaritan Regional Medical Center: The Learning Center (Samaritan Health System, Phoenix, Arizona), http://www.samaritan.edu/library/bannerlibs.htm

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California: Kris Kelly Health Information Center (St. Joseph Health System), http://www.humboldt1.com/~kkhic/index.html

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California: Community Health Library of Los Gatos (Community Health Library of Los Gatos), http://www.healthlib.org/orgresources.html

·

California: Consumer Health Program and Services (CHIPS) (County of Los Angeles Public Library, Los Angeles County Harbor-UCLA Medical Center Library) - Carson, CA, http://www.colapublib.org/services/chips.html

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California: Gateway Health Library (Sutter Gould Medical Foundation)

·

California: Health Library (Stanford University Medical Center), http://www-med.stanford.edu/healthlibrary/

52

Abstracted from http://www.nlm.nih.gov/medlineplus/libraries.html.


·

California: Patient Education Resource Center - Health Information and Resources (University of California, San Francisco), http://sfghdean.ucsf.edu/barnett/PERC/default.asp

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California: Redwood Health Library (Petaluma Health Care District), http://www.phcd.org/rdwdlib.html

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California: San José PlaneTree Health Library, http://planetreesanjose.org/

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California: Sutter Resource Library (Sutter Hospitals Foundation), http://go.sutterhealth.org/comm/resc-library/sac-resources.html

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California: University of California, Davis. Health Sciences Libraries

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California: ValleyCare Health Library & Ryan Comer Cancer Resource Center (ValleyCare Health System), http://www.valleycare.com/library.html

·

California: Washington Community Health Resource Library (Washington Community Health Resource Library), http://www.healthlibrary.org/

·

Colorado: William V. Gervasini Memorial Library (Exempla Healthcare), http://www.exempla.org/conslib.htm

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Connecticut: Hartford Hospital Health Science Libraries (Hartford Hospital), http://www.harthosp.org/library/

·

Connecticut: Healthnet: Connecticut Consumer Health Information Center (University of Connecticut Health Center, Lyman Maynard Stowe Library), http://library.uchc.edu/departm/hnet/

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Connecticut: Waterbury Hospital Health Center Library (Waterbury Hospital), http://www.waterburyhospital.com/library/consumer.shtml

·

Delaware: Consumer Health Library (Christiana Care Health System, Eugene du Pont Preventive Medicine & Rehabilitation Institute), http://www.christianacare.org/health_guide/health_guide_pmri_health _info.cfm

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Delaware: Lewis B. Flinn Library (Delaware Academy of Medicine), http://www.delamed.org/chls.html

·

Georgia: Family Resource Library (Medical College of Georgia), http://cmc.mcg.edu/kids_families/fam_resources/fam_res_lib/frl.htm

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Georgia: Health Resource Center (Medical Center of Central Georgia), http://www.mccg.org/hrc/hrchome.asp

·

Hawaii: Hawaii Medical Library: Consumer Health Information Service (Hawaii Medical Library), http://hml.org/CHIS/


·

Idaho: DeArmond Consumer Health Library (Kootenai Medical Center), http://www.nicon.org/DeArmond/index.htm

·

Illinois: Health Learning Center of Northwestern Memorial Hospital (Northwestern Memorial Hospital, Health Learning Center), http://www.nmh.org/health_info/hlc.html

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Illinois: Medical Library (OSF Saint Francis Medical Center), http://www.osfsaintfrancis.org/general/library/

·

Kentucky: Medical Library - Services for Patients, Families, Students & the Public (Central Baptist Hospital), http://www.centralbap.com/education/community/library.htm

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Kentucky: University of Kentucky - Health Information Library (University of Kentucky, Chandler Medical Center, Health Information Library), http://www.mc.uky.edu/PatientEd/

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Louisiana: Alton Ochsner Medical Foundation Library (Alton Ochsner Medical Foundation), http://www.ochsner.org/library/

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Louisiana: Louisiana State University Health Sciences Center Medical Library-Shreveport, http://lib-sh.lsuhsc.edu/

·

Maine: Franklin Memorial Hospital Medical Library (Franklin Memorial Hospital), http://www.fchn.org/fmh/lib.htm

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Maine: Gerrish-True Health Sciences Library (Central Maine Medical Center), http://www.cmmc.org/library/library.html

·

Maine: Hadley Parrot Health Science Library (Eastern Maine Healthcare), http://www.emh.org/hll/hpl/guide.htm

·

Maine: Maine Medical Center Library (Maine Medical Center), http://www.mmc.org/library/

·

Maine: Parkview Hospital, http://www.parkviewhospital.org/communit.htm#Library

·

Maine: Southern Maine Medical Center Health Sciences Library (Southern Maine Medical Center), http://www.smmc.org/services/service.php3?choice=10

·

Maine: Stephens Memorial Hospital Health Information Library (Western Maine Health), http://www.wmhcc.com/hil_frame.html

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Manitoba, Canada: Consumer & Patient Health Information Service (University of Manitoba Libraries), http://www.umanitoba.ca/libraries/units/health/reference/chis.html

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Manitoba, Canada: J.W. Crane Memorial Library (Deer Lodge Centre), http://www.deerlodge.mb.ca/library/libraryservices.shtml


·

Maryland: Health Information Center at the Wheaton Regional Library (Montgomery County, Md., Dept. of Public Libraries, Wheaton Regional Library), http://www.mont.lib.md.us/healthinfo/hic.asp

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Massachusetts: Baystate Medical Center Library (Baystate Health System), http://www.baystatehealth.com/1024/

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Massachusetts: Boston University Medical Center Alumni Medical Library (Boston University Medical Center), http://medlibwww.bu.edu/library/lib.html

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Massachusetts: Lowell General Hospital Health Sciences Library (Lowell General Hospital), http://www.lowellgeneral.org/library/HomePageLinks/WWW.htm

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Massachusetts: Paul E. Woodard Health Sciences Library (New England Baptist Hospital), http://www.nebh.org/health_lib.asp

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Massachusetts: St. Luke's Hospital Health Sciences Library (St. Luke's Hospital), http://www.southcoast.org/library/

·

Massachusetts: Treadwell Library Consumer Health Reference Center (Massachusetts General Hospital), http://www.mgh.harvard.edu/library/chrcindex.html

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Massachusetts: UMass HealthNet (University of Massachusetts Medical School), http://healthnet.umassmed.edu/

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Michigan: Botsford General Hospital Library - Consumer Health (Botsford General Hospital, Library & Internet Services), http://www.botsfordlibrary.org/consumer.htm

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Michigan: Helen DeRoy Medical Library (Providence Hospital and Medical Centers), http://www.providence-hospital.org/library/

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Michigan: Marquette General Hospital - Consumer Health Library (Marquette General Hospital, Health Information Center), http://www.mgh.org/center.html

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Michigan: Patient Education Resouce Center - University of Michigan Cancer Center (University of Michigan Comprehensive Cancer Center), http://www.cancer.med.umich.edu/learn/leares.htm

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Michigan: Sladen Library & Center for Health Information Resources Consumer Health Information, http://www.sladen.hfhs.org/library/consumer/index.html

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Montana: Center for Health Information (St. Patrick Hospital and Health Sciences Center), http://www.saintpatrick.org/chi/librarydetail.php3?ID=41


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National: Consumer Health Library Directory (Medical Library Association, Consumer and Patient Health Information Section), http://caphis.mlanet.org/directory/index.html

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National: National Network of Libraries of Medicine (National Library of Medicine) - provides library services for health professionals in the United States who do not have access to a medical library, http://nnlm.gov/

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National: NN/LM List of Libraries Serving the Public (National Network of Libraries of Medicine), http://nnlm.gov/members/

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Nevada: Health Science Library, West Charleston Library (Las Vegas Clark County Library District), http://www.lvccld.org/special_collections/medical/index.htm

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New Hampshire: Dartmouth Biomedical Libraries (Dartmouth College Library), http://www.dartmouth.edu/~biomed/resources.htmld/conshealth.htmld/

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New Jersey: Consumer Health Library (Rahway Hospital), http://www.rahwayhospital.com/library.htm

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New Jersey: Dr. Walter Phillips Health Sciences Library (Englewood Hospital and Medical Center), http://www.englewoodhospital.com/links/index.htm

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New Jersey: Meland Foundation (Englewood Hospital and Medical Center), http://www.geocities.com/ResearchTriangle/9360/

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New York: Choices in Health Information (New York Public Library) NLM Consumer Pilot Project participant, http://www.nypl.org/branch/health/links.html

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New York: Health Information Center (Upstate Medical University, State University of New York), http://www.upstate.edu/library/hic/

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New York: Health Sciences Library (Long Island Jewish Medical Center), http://www.lij.edu/library/library.html

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New York: ViaHealth Medical Library (Rochester General Hospital), http://www.nyam.org/library/

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Ohio: Consumer Health Library (Akron General Medical Center, Medical & Consumer Health Library), http://www.akrongeneral.org/hwlibrary.htm

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Oklahoma: Saint Francis Health System Patient/Family Resource Center (Saint Francis Health System), http://www.sfhtulsa.com/patientfamilycenter/default.asp


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Oregon: Planetree Health Resource Center (Mid-Columbia Medical Center), http://www.mcmc.net/phrc/

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Pennsylvania: Community Health Information Library (Milton S. Hershey Medical Center), http://www.hmc.psu.edu/commhealth/

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Pennsylvania: Community Health Resource Library (Geisinger Medical Center), http://www.geisinger.edu/education/commlib.shtml

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Pennsylvania: HealthInfo Library (Moses Taylor Hospital), http://www.mth.org/healthwellness.html

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Pennsylvania: Hopwood Library (University of Pittsburgh, Health Sciences Library System), http://www.hsls.pitt.edu/chi/hhrcinfo.html

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Pennsylvania: Koop Community Health Information Center (College of Physicians of Philadelphia), http://www.collphyphil.org/kooppg1.shtml

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Pennsylvania: Learning Resources Center - Medical Library (Susquehanna Health System), http://www.shscares.org/services/lrc/index.asp

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Pennsylvania: Medical Library (UPMC Health System), http://www.upmc.edu/passavant/library.htm

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Quebec, Canada: Medical Library (Montreal General Hospital), http://ww2.mcgill.ca/mghlib/

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South Dakota: Rapid City Regional Hospital - Health Information Center (Rapid City Regional Hospital, Health Information Center), http://www.rcrh.org/education/LibraryResourcesConsumers.htm

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Texas: Houston HealthWays (Houston Academy of Medicine-Texas Medical Center Library), http://hhw.library.tmc.edu/

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Texas: Matustik Family Resource Center (Cook Children's Health Care System), http://www.cookchildrens.com/Matustik_Library.html

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Washington: Community Health Library (Kittitas Valley Community Hospital), http://www.kvch.com/

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Washington: Southwest Washington Medical Center Library (Southwest Washington Medical Center), http://www.swmedctr.com/Home/

NIH Consensus Statement on Total Hip Replacement 141

APPENDIX E. NIH CONSENSUS STATEMENT ON TOTAL HIP REPLACEMENT Abstract NIH Consensus Development Conferences are convened to evaluate available scientific information and resolve safety and efficacy issues related to biomedical technology. The resultant NIH Consensus Statements are intended to advance understanding of the technology or issue in question and to be useful to health professionals and the public.53 Each NIH consensus statement is the product of an independent, non-Federal panel of experts and is based on the panel's assessment of medical knowledge available at the time the statement was written. Therefore, a consensus statement provides a “snapshot in time” of the state of knowledge of the conference topic. The NIH makes the following caveat: “When reading or downloading NIH consensus statements, keep in mind that new knowledge is inevitably accumulating through medical research. Nevertheless, each NIH consensus statement is retained on this website in its original form as a record of the NIH Consensus Development Program.”54 The following concensus statement was posted on the NIH site and not indicated as “out of date” in March 2002. It was originally published, however, in September 1994.55

53 This paragraph is adapted from the NIH: http://odp.od.nih.gov/consensus/cons/cons.htm. 54 Adapted from the NIH: http://odp.od.nih.gov/consensus/cons/consdate.htm. 55 Total Hip Replacement. NIH Consens Statement Online 1994 September 12-14 [cited 2002 February 21]; 12(5): 1-31. http://consensus.nih.gov/cons/098/098_statement.htm.


Objective To provide physicians with a current consensus on total hip replacement.

Participants A non-Federal, nonadvocate, 13-member consensus panel representing the fields of orthopedic surgery, rehabilitation and physical medicine, biomechanics and biomaterials, internal medicine, public health, geriatrics and biostatistics, and a public representative. In addition, 27 experts in orthopedic surgery, rehabilitation and physical medicine, biomechanics and biomaterials, rheumatology, geriatrics, and epidemiology presented data to the consensus panel and a conference audience of 425.

Evidence The literature was searched through Medline and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience.

Consensus The panel, answering predefined consensus questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. Consensus Statement The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference.


Conclusions Total hip replacement is an option for nearly all patients with diseases of the hip that cause chronic discomfort and significant functional impairment. Most patients have an excellent prognosis for long-term improvement in symptoms and physical function. At this time, a cemented femoral component using modern cementing techniques, paired with a porouscoated acetabular component, can give excellent long-term results. Revision of a total hip replacement is indicated when mechanical failure occurs. Continued periodic follow-up is necessary to identify early evidence of impending failure so as to permit remedial action before a catastrophic event.

What Is Total Hip Replacement? More than 120,000 artificial hip joints are being implanted annually in the United States. Successful replacement of deteriorated, arthritic, and severely injured hips has contributed to enhanced mobility and comfortable, independent living for many people who would otherwise be substantially disabled. New technology involving prosthetic devices for replacement of the hip, along with advances in surgical techniques, has diminished the risks associated with the operation and improved the immediate and long-term outcome of hip replacement surgery. Questions remain, however, concerning which prosthetic designs and materials are most effective for specific groups of patients and which surgical techniques and rehabilitation approaches yield the best long-term outcomes. Issues also exist regarding the best indications and approaches for revision surgery. As a follow-up to the National Institutes of Health (NIH) Consensus Development Conference (CDC) on Total Hip Joint Replacement held in 1982, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, together with the Office of Medical Applications of Research of the NIH, convened a second CDC on Total Hip Replacement on September 1214, 1994. The conference was cosponsored by the National Institute on Aging, the National Institute of Child Health and Human Development, and the Office of Research on Women's Health. After 1-1/2 days of presentations by experts in the relevant fields and discussion by a knowledgeable audience, an independent, non-Federal consensus panel composed of specialists from the fields of orthopedic surgery, epidemiology, rehabilitation and physical medicine, biomechanics and biomaterials,


geriatrics, rheumatology, as well as a public representative, weighed the scientific evidence and formulated a consensus statement in response to the following six previously stated questions: ·

What are the current indications for total hip replacement?

·

What are the design and surgical considerations relating to a replacement prosthesis?

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What are the responses of the biological environment?

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What are the expected outcomes?

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What are the accepted approaches and outcomes for revision of a total hip replacement?

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What are the most productive directions for future research?

This consensus statement reflects a synthesis of generally accepted observations and recommendations derived from the scientific presentations as well as a general review of current literature by the consensus panel. This panel also identified areas of limited information where further research would be most productive.

What Are the Current Indications for Total Hip Replacement? Primary total hip replacement (THR) is most commonly used for hip joint failure caused by osteoarthritis; other indications include, but are not limited to, rheumatoid arthritis, avascular necrosis, traumatic arthritis, certain hip fractures, benign and malignant bone tumors, the arthritis associated with Paget's disease, ankylosing spondylitis, and juvenile rheumatoid arthritis. The aims of THR are relief of pain and improvement in function. Candidates for elective THR should have radiographic evidence of joint damage and moderate to severe persistent pain or disability, or both, that is not substantially relieved by an extended course of nonsurgical management. These measures usually include trials of analgesic and nonsteroidal antiinflammatory drugs (NSAIDs), physical therapy, the use of walking aids, and reduction in physical activities that provoke discomfort. In certain conditions such as rheumatoid arthritis and Paget's disease, additional disease-specific therapies may be appropriate. The patient's goals and expectations should be ascertained prior to THR to determine whether they are realistic and attainable by the recommended therapeutic approach. Any discrepancies between the patient's expectations and the likely outcome should be discussed in detail with the patient and family members before surgery.


In the past, patients between 60 and 75 years of age were considered to be among the best candidates for THR. Over the last decade, however, the age range has been broadened to include more elderly patients, many of whom have a higher level of comorbidities, as well as younger patients, whose implants may be exposed to greater mechanical stresses over an extended time course. In patients less than 55 years of age, alternative surgical procedures such as fusion and osteotomy deserve consideration. However, there are no data showing that the outcomes of these procedures are as good or better than those from THR when performed for similar indications. Advanced age alone is not a contraindication for THR; poor outcomes appear to be related to comorbidities rather than to age. There are few contraindications to THR other than active local or systemic infection and other medical conditions that substantially increase the risk of serious perioperative complications or death. Obesity has been considered a relative contraindication because of a reported higher mechanical failure rate in heavier patients; however, the prospect of substantial long-term reduction in pain and disability for heavier patients appears to be similar to that for the population in general. Thus, although the clinical conditions and circumstances leading to THR are broadly defined, several issues regarding indications remained unresolved. For example, data are insufficient on the associations between potential risk factors (e.g., age, weight, smoking, medications) and outcomes to guide treatment of the individual patient. Moreover, indications are not clear for use of the various surgical approaches and types of prostheses in individual patients. Finally, standardized instruments to measure levels of pain, physical disability, and quality of life as perceived by the patient need to be used to guide clinical decision making and choice of surgery.

What Are the Considerations Relating to a Prosthesis? At the NIH CDC on Total Hip Joint Replacement held in 1982, aseptic loosening was identified as a major problem with THR. It was especially prevalent in young, active patients and after revision surgery. Because it appeared with increasing frequency over time, it was feared that a much larger problem would emerge. Newer fixation (cement and cementless) techniques had been introduced, but their long-term efficacy was unknown. Cobalt-, titanium-, and iron-based alloys, higher molecular weight polyethylene, and autocuring polymethylmethacrylate (PMMA) bone cement were the materials used in most implants. Chemical modifications


and altered processing of the alloys had been introduced to deal with the problem of fractured stems. As of 1994, state of the art pertaining to THR has changed substantially. For example, changes have been made in fixation (cement and cementless), device designs, and some materials. Concerns remain about the in vivo durability of femoral and acetabular components of the implants, but the procedure has a more predictable outcome. The newer cementing techniques have proven to be more successful than the original ones on the femoral side. Improved techniques include the use of a medullary plug, a cement gun, lavage of the canal, pressurization, centralization of the stem, and reduction in porosity in the cement. However, the optimum cement-metal interface has yet to be identified. These newer procedures minimize defects and localized stress concentrations in the cement. Their current success indicates that previously observed aseptic loosening within the first 10 years following implantation was primarily a mechanical process and that steps to reduce stresses in the materials and improve strength of the interfaces are reasonable to reduce loosening. Further optimization of the bone implant interface constitutes an important opportunity for future research. Another important change in fixation has been the introduction and widespread use of noncemented components that rely on bone growth into porous or onto roughened surfaces for fixation. In the femur, selected cementless components have exhibited clinical success, although with shorter follow-up, similar to that of cemented components installed with the newer cementing techniques. There is evidence that bone changes (osteolysis or bone resorption) can occur as well with some of the cementless components. Numerous reports document resorption, and although it has not usually become symptomatic during early stages of follow-up, concerns nevertheless exist about progressive osteolysis and consequent aseptic loosening or fracture. On the acetabular side, the cementless components have demonstrated less aseptic loosening compared with the cemented components over the short term, although long-term results are not yet available. The prospective and retrospective studies conducted have been specific to device design and technique, and any general comparison of cemented and noncemented systems should be viewed with caution. The implants themselves have undergone multiple changes. As a result of improved alloys and designs, fracture of femoral stems is no longer a significant problem. Stem cross-sections have been rounded to avoid high stresses in the cement. There is still controversy over the appropriate length


of uncemented stems and the extent and location of porous or roughened regions. Metal backing of cemented acetabular components has not been associated with a high degree of success and is now used infrequently. Metal-backed acetabular components with porous coatings have demonstrated good to excellent results in regard to loosening noted at 5- to 7-year follow-up and continue to be followed. Modular components have been introduced and are widely used, but it is recognized that in vivo disassembly, fretting and corrosion, and wear between components can be a source of debris and may contribute to osteolysis and isolated implant fractures. Given the potential problems, routine use of modular components needs to be evaluated specific to particular applications. There appears to be little justification for modularity or customization of femoral stems below the head-neck junction in primary THR, although the modular stem components for revisions may be useful. Revision rates for cemented femoral components, using modern techniques, have been reported to be less than 5 percent at 10-year follow-up; revision rates for uncemented acetabular components are approximately 2 percent at 5-year follow-up. To be deemed efficacious, new design features should be shown to have a mechanical failure rate equal to or lower than these figures. As in 1982, the primary implant materials are cobalt- and titanium-based alloys, PMMA bone cement, and ultrahigh molecular weight polyethylene. These continue to demonstrate biocompatibility in bulk, but particles of these materials, particularly the polyethylene, are suspected to have a role in bone resorption and potential implant loosening. Osteolysis that can occur with both cemented and cementless components on both the femoral and acetabular sides is thought to be due to an inflammatory process brought on by particulate matter. The articulating surfaces between the femoral and acetabular components are now recognized as a major source of debris, which has been shown to be important in this pathologic tissue response. Most components for femoral heads have polished cobalt alloy, which articulates with polyethylene sockets. Longitudinal research continues on smoothness and ion implantation of the articulating surfaces, ceramicpolymer, ceramic-ceramic, and alloy-alloy components, although the in vivo data remain limited at this time. Efforts to alter or replace the polyethylene are underway, but no new materials with reduced clinical wear rates are routinely available. Several factors have been suggested to minimize the production of wear debris. Polyethylene acetabular cups with minimum wall thickness of 6 mm and femoral heads with diameters of 28 mm are important design considerations associated with reduced wear. Where metallic shells are used


to contain the polyethylene cup, the interior of the shell should be smooth with a minimum number of openings for screws, and the polyethylene liner should be highly conforming and mechanically stable. Polyethylene of the highest quality is strongly advised for the manufacture of the components. Femoral heads with highly polished cobalt alloy, or polished ceramics as some data suggest, maybe advantageous to minimize effects of wear on the polyethylene surface. Studies also continue on surface modifications of implants to provide direct attachment to bone. For example, several types of calcium phosphate ceramics (CPC) (often called hydroxylapatite) have been added as coatings to THR surfaces to enhance fixation of noningrowth implants to bone. Concerns have been expressed about the longer term in vivo fatigue strengths of the substrate to coating interfaces, biodegradation, and the potential for generating ceramic particulates, although so far data addressing implant performance are comparable to those from other device designs at the same follow-up times. Research and development on the enhancement of bone growth into porous biomaterials using CPC has also shown promise, although longitudinal data are incomplete at this time. Long-term data are needed on the benefit-to-risk ratio of clinical outcomes for these types of surface modifications. Although there are in vitro tests for evaluating implant design features and material characteristics, as well as animal testing regimens, the relevance of these tests to in vivo human performance are often unknown and additional approaches are necessary. Long-term clinical studies are the only accepted method for evaluating the efficacy of the design and materials in human use, particularly with regard to patient-defined outcome measures. Since these take many years and are very expensive, few implant design features are supported by well-designed studies. Adaptive bone remodeling around the prosthesis continues to be a concern, but there is little evidence that it is a significant clinical problem during the first 10 years of follow-up. Joint forces are known with better confidence than in 1982, but it is still unknown which elements of force, magnitude, and time are relevant to implant failures. Detailed analysis of stress distribution is still limited by imprecise data on joint forces, viscoelastic properties, and failure modes of the materials and tissues. In 1994, the main problems of concern related to implant design are longterm fixation of the acetabular component, osteolysis due to particulate materials, biologic response to particles of implant materials, and the less favorable results of revision surgery.


What Are the Responses of the Biological Environment? Since the NIH CDC on Total Hip Joint Replacement held in 1982, bone resorption, or osteolysis, has emerged as the major concern with regard to the long-term survival of total hip arthroplasty. Significant resorption and massive osteolysis as well as more limited areas of bone destruction had been associated with cemented components and attributed to cement debris. Subsequent findings confirm that similar problems can be associated with cementless prosthetic implants, and some degree of osteolysis may be present in up to 30-40 percent of cases within 10 years of surgery. Both acetabular and femoral components may be affected. Components may remain well fixed in the presence of significant bone loss, but indications are that once osteolysis appears it tends to progress and may ultimately lead to implant failure. This bone loss is now considered to be a reaction to particulate matter derived from the implanted prosthetic components as well as the cement when used. Because osteolysis is an important contributor to failure of hip arthroplasties and may occur in the absence of clinical symptoms, it is important that patients with implants be followed and evaluated at regular intervals throughout life to ensure timely operative intervention, if necessary. Quantitatively, the material causing the most tissue reaction appears to be particulate polyethylene. These particles have been recovered in significant quantities from periprosthetic tissues, including sites remote from the source. Particle size varies, but the majority recovered are approximately 0.5 micron, with 90 percent less than 1.0 micron. It has been estimated that the average rate of wear for cobalt alloy-to-polyethylene interface is 0.1-0.2 mm/year. The volume of wear debris may increase with larger femoral head size. Metallic debris has also been identified in significant quantities. The source may be related to stem-bone fretting, particularly in loose prostheses and in more distal portions of proximally fixed prostheses where significant motion between stem and bone may persist. With the use of modular prostheses, corrosion and/or fretting have been identified in up to 35 percent of some retrieved specimens, and these connections could serve as a source of metallic particles. Fretting and corrosion are not limited to the interface between dissimilar alloys. Interactions have also been identified with cobaltcobalt and titanium-titanium as well as titanium-cobalt alloy junctions. Reactions at the head-neck junctions have been studied in depth. Corrosion and wear debris products can also form at the interfaces between screws and acetabular shells and at modular collars for adapting proximal femoral stems. Some of the metallic particles generated may be larger than the


polyethylene debris. The major effect of these larger metallic debris may relate to promoting third body wear of the polyethylene, with the derivative polyethylene particles of submicron size triggering the cellular response. However, smaller metal particles and ions have been demonstrated to be active in direct stimulation of biologic processes. The leading hypothesis to explain the development of massive osteolysisis that particulate matter derived from prosthetic components and cement stimulates an inflammatory response. Phagocytosis of the particles by macrophage and foreign-body giant cells (arising from the macrophage) appears to be the initial biologic response to particulate matter. The presence of intracellular particles is associated with the release of cytokines and other mediators of inflammation. These factors initiate a focal bone resorptive process largely mediated by osteoclasts. These osteoclasts do not contain debris particles. Thus, the long-term threat to component failure from a biologic standpoint appears to be wear-debris-associated periprosthetic osteolysis as a result of osteoclastic activity. This is stimulated by cytokines such as tumor necrosis factor, interleukins, and prostaglandins released by macrophages and possibly other cells including fibroblasts. The critical initiating sequence involves the interaction between small particulate materials and responding cells. The process is affected by the number, size, distribution, and type of particulate material, as well as responsiveness of the ingesting cells. The debris may be distributed beyond the hip joint. Material has been identified in distant lymph nodes, but no systemic consequences are documented up to this time. Since it is now recognized that both cobalt- and titanium-based alloys release soluble products in patients, long-term surveillance to assess possible systemic and remote side effects after THR is advisable. Adaptive bone remodeling occurs in the proximal femur in response to an altered mechanical environment following hip replacement. This process is commonly referred to as “stress shielding” or stress transfer. Stem rigidity or elasticity plays a major role. Bone resorption in unstressed areas is a common observation, but it has not been shown to be related to loosening. Nevertheless, it presents an important concern in terms of long-term stability and effect on revision surgery. Factors influencing adaptive bone remodeling have been considered in determining the location and extent of porous coating on uncemented stems. Finite element analysis suggests that proximally coated porous stems are


associated with less cortical bone stress shielding than fully coated stems, but the extent of coating on most currently used prosthetic stems is still greater than that calculated necessary to significantly reduce the stressshielding effect on the proximal femur. Decreasing porous coating to reduce stress shielding must be weighed against providing sufficient coating to ensure fixation. Efforts to reduce stem stiffness have been shown to lessen proximal cortical atrophy under experimental conditions.

What Are the Expected Outcomes? The success of THR in most patients is strongly supported by nearly 30 years of follow-up data. There appears to be immediate and substantial improvement in the patient's pain, functional status, and overall healthrelated quality of life. Promising data suggest that these immediate improvements persist in the long term. Over the last two decades, complications associated with THR have declined significantly. Prophylactic antibiotic therapy has helped to prevent infection. Use of anticoagulants in the perioperative period has reduced deep venous thrombosis and pulmonary emboli. The incidence of mechanical loosening has decreased with the introduction of improved fixation techniques. More than 90 percent of all artificial joints are never revised. Rates of revision are decreasing with improved surgical techniques. The important questions of today are not whether THR is effective compared with no treatment but rather which technology and methodology used for THR are best for a particular patient. For example, the various total hip designs, fixation methods, and surgical techniques need to be rigorously compared with one another. Surgeon's experience and hospital environment should be investigated for possible independent effects. Various rehabilitation interventions, including long-term therapeutic exercise, should be evaluated for effectiveness. Similarly, little is known about patient-level predictors of outcome, e.g., patient expectations, quality of the individual patient's bone stock, demographic characteristics, comorbidities, obesity, and activity level. Since length of acute hospital stay has become progressively shorter, more emphasis must be given to determining the role of preadmission educational programs, appropriate physical therapy, and rehabilitation during the acute stay and following discharge. Home health programs when indicated may be more effective than prolonged hospitalization. The benefits of a long-term therapeutic exercise program for patients who have undergone THR have


not been clearly demonstrated to improve mobility or hip stability. There appears to be insufficient appreciation for the role of exercise in THR rehabilitation; however, there is evidence that hip weakness persists up to 2 years after surgery in the presence of a normal gait. Multiple studies have demonstrated that weakness in the lower extremities is a major risk factor for falls in the geriatric age group. Thus, further studies are needed to assess the relationship between muscle function following THR, mobility, and risk for falls, as well as the role of therapeutic exercise in improving muscle function with enhancement of mobility and stability. Outcome assessment in THR has been limited by the lack of standardized terminology and by the use of various scales that have traditionally relied on the surgeon's assessment of the patient's pain, range of motion, muscle strength, and mobility. Most of these measures have not been adequately characterized in terms of validity, reliability, and responsiveness to change. The traditional assessments have not included patient-oriented evaluation of function or satisfaction. There is no consensus on the standard definitions of endpoints with respect to prosthesis failure. The American Academy of Orthopaedic Surgeons has developed recommendations for data to be collected, and this approach should be endorsed for use in clinical practice. The patient's functional status should be further assessed in follow-up by standardized, patient-reported, disease-specific measures and by at least one global outcome measure. Finally, the radiographic and clinical criteria for prosthesis failure should be defined. Long-term follow-up is essential to determining outcomes and pathological processes (e.g., failures related to osteolysis and particulate debris). These complications were not emphasized in the 1982 CDC on Total Hip Joint Replacement. The problems have been identified only by long-term followup of patients. Methodological issues that have limited THR outcomes assessment include lack of randomized trials and other well-controlled studies, lack of wellcharacterized patient cohorts for prospective observational studies, and insufficient sample sizes followed for prolonged periods of time. THR is performed more than 120,000 times per year in the United States. This represents a 64-percent increase in the number of THR procedures per year in the United States since the 1982 CDC. Analysis of Medicare claims data demonstrates significant variations in the rates of performance of THR with respect to geography, age, gender, and race. The highest rates of THR are in the Midwest and Northwest and the lowest rates in the South and East. A fourfold difference exists between the State with the highest rate of


THR (Utah) and the State with the lowest rate (Wyoming). A previous study demonstrated a 50-percent higher rate of THR in Boston, Massachusetts, compared with New Haven, Connecticut. Other procedures such as hip fracture repair have very low variation from one geographical area to another. In today's era of cost-containment and outcomes research, it is important to understand the factors contributing to these wide area variations as well as which rate of THR is most appropriate. Sixty-two percent of all THR procedures in the United States are performed in women. Furthermore, women have significantly worse preoperative functional status than do men and are 35 percent more likely to report the use of a walking aid at the time of surgery. These differences persist even after adjustment for other demographic and clinical characteristics. These data suggest that, compared with men, women are being operated on at a more advanced stage of the disease. Two-thirds of all THR procedures are performed in individuals who are older than 65 years of age. The rate of THR increases for 3patients up to 75 years of age and then declines. The highest age-specific incidence rates of THR are between 65 and 74 years of age for men and 75 and 84 years of age for women. Recent comparisons of rates of THR reveal that more are being done in the young and in the oldest patients. Among the older patients, there has been an increase in THR in patients with more comorbidities. Most THR procedures are performed in whites. The prevalence rate of hip implants (fixation devices and artificial joints) was 4.2 per 1,000 in whites compared with 1.7 per 1,000 in African-Americans. The disparity by race increases markedly with age. These findings were confirmed by an analysis of Medicare claims data that focused solely on THR. Observed differences in the rate of THR by race may reflect a disparity in access or referral for care for African-Americans. Additionally, individuals with higher income were 22 percent more likely to undergo THR than were individuals with low income. Health care providers and patients must be cognizant of the variations in the THR rate. It is important to carefully consider the potential influence of access to care, treatment selection biases, and patient knowledge and preferences on these variations in rates. In this era of cost-containment and managed care, the ultimate selection of a THR system should be based on individualized patient needs, safety, and efficacy. There is consensus that the THR patient requires periodic follow-up including appropriate x-ray examination throughout life. Periodic follow-up, perhaps at 5-year intervals after the first 5 years, could allow identification of osteolysis and other indicators of impending failure in their earliest forms and permits institution of treatment before catastrophic failure.


What Are the Approaches for a Total Hip Replacement? As more primary THRs occur on a cumulative basis, as indications extend to more conditions and to older and younger individuals, and as the population ages, the absolute number of revision hip replacements will increase, even if the frequency of failures in primary procedures continues to decrease. Revision surgery is highly complex and costly and requires considerable scientific and technical expertise, an array of expensive technological options, a supportive health care environment, and a skilled health care team. Consequently, issues such as the surgeon's experience, the hospital characteristics, the related health care costs, and appropriateness of current hospital reimbursements associated with revision should be carefully examined. Currently, the results of revision THR are inferior to those of primary procedures. It remains important to refine the indications for revision and to do so on the basis of the best available outcome data. Not all “failed” primary THRs require revision. The decision to revise, as is true of decisions regarding primary procedures, must consider such circumstances as the presence of disabling pain, stiffness, and functional impairment unrelieved by appropriate medical management and lifestyle changes. In addition, radiographic evidence of bone loss or loosening of one or both components should be present. Indeed, evidence of progressive bone loss alone provides sufficient reason to consider revision in advance of catastrophic failure. Fracture, dislocation, malposition of components, and infection involving the implant are other reasons to consider revision. A number of options must be considered in planning a revision operation. The selection of specific technology is currently a judgment of the surgeon and depends on the amount and quality of the bone stock, the age and functional demands of the patient, and the reason for failure of the primary procedure. The weight of clinical experience suggests that a loose acetabular component, either cemented or porous coated, can be reliably replaced by a porous-coated component in the presence of adequate bone stock. In one study using this approach, 91 percent of implants were radiographically stable and 9 percent required re-revision (for dislocation and infection rather than aseptic loosening) between 8 and 11 years after revision. In elderly patients with lower functional demands and those with osteogenic bone, cemented implants have also provided satisfactory results. To achieve prosthetic stability in the absence of sufficient bone stock, deficits can be filled with morselized or structural bone grafts (either autografts or


allografts obtained from accredited tissue banks), customized metal components, or, under some circumstances, bone cement. The approach to revision of the femoral component must be based on the nature of the remaining bone stock in the proximal femur, and clinical judgment usually takes into account the age and functional demands of the patient. Under many circumstances, revision of the femoral component with a cemented stem is possible using modern cementing techniques. The rerevision rate for this approach is between 10 and 18 percent at 10- to 11-year follow-up. An acceptable alternative approach to revision of femoral components when there is substantial residual bone stock has been the use of noncemented implants, particularly the extensively coated components. This approach has resulted in 90-percent stem survivorship at a 9-year follow-up. Morselized bone graft can be used successfully to fill defects in the femoral canal with or without the use of bone cement, and cortical bone can be augmented with only grafts as necessary. Under exceptional circumstances, it may be necessary to use large structural allografts when the proximal femoral bone stock deficiency is substantial. If this is done, the implant should be cemented into the graft. Both the diagnosis and the treatment of infected implants remain challenging. The infection rates of the past have been dramatically reduced. Current infection rates of less than 1 percent at 1 year after primary THR are now being reported. Nonetheless, infection remains a devastating complication, and treatment alternatives remain controversial. Recovery of the infecting organism is essential to the selection of appropriate antibiotics and the planning of surgical approaches. For organisms highly susceptible to multiple antibiotics, one-stage surgical approaches that combine extensive debridement and an ensuing exchange of implants are associated with a 77to 94-percent success rate. Two-stage revisions that include at least 4 weeks of appropriate antibiotic treatment following implant removal and wound debridement and a variable period of time before reinsertion determined by the characteristics of the organism have resulted in a success rate greater than 80 percent. In young people, there may be value to a third, intermediate stage in which the bone stock is augmented in anticipation of later reimplantation.


What Are the Most Productive Directions for Future Research? THR is acknowledged as a highly successful procedure that has provided relief of pain, increased mobility, and improved tolerance for activity for thousands of people. Despite the advances made in the past decade, obvious deficiencies in knowledge remain regarding treatment alternatives, patient characteristics, and environmental issues. To address these concerns most effectively, it is important to identify those avenues of investigation that will lead to decreased morbidity and enhanced quality of life for the population at large affected by debilitating hip disease. Standardized instruments for assessing outcomes need to be developed, validated, and introduced into clinical use. These may also be useful in developing guidelines for surgery and in making physicians aware of their patients' physical capabilities and expectations. The issues of age, sex, weight, activity level, and comorbidities have been implicated for their effects on the outcome of THR and need to be studied in relation to the indications for surgery and timing of the procedure. Serious questions have been raised concerning the disparate rates for THR between racial groups and geographic locations that seem to have no direct relationship to incidence of disease. Indepth analysis of rate differential can lead to an identification of underlying reasons. In this way, the benefits of THR can be extended to an appropriate segment of the population that appears to have limited access. Materials currently used for the manufacture of THR implants have been improved with regard to design and finish. Wear debris, however, remains a factor that affects the durability of the implants and their fixation. Research is ongoing and support is needed to expand investigations of new materials and to create a better understanding of wear processes that can prolong the life of the implant and reduce the wear and wear products. One of the necessary approaches for evaluating implant failure modes is an organized, ongoing analysis of in situ prostheses retrieved from cadavers. Such a program should be national in scope and supported by grant monies. As part of this effort, it is anticipated that significant data could be obtained concerning wear processes involving the articular surfaces under circumstances where the implant did not fail. At the same time, this avenue of research would further clarify the device and tissue interactions that are characteristic of the cemented and noncemented types of devices.


Randomized clinical trials are needed to determine the efficacy of implant designs and surgical approaches, including the effect of coatings that encourage appositional or interpositional bone growth for fixation. The contribution of prehospital, inhospital, and posthospital education and rehabilitation programs to the eventual outcome of the surgical procedure deserves an organized, in-depth study to determine optimum regimen, duration of treatment, and expected outcomes. Clinical data suggest that potential capabilities of the patients are not being fully developed. The biologic interface between the implant and the host bone has been recognized as a source of potential failure. Basic research efforts into the mechanisms by which these changes occur are providing some clues, but much more needs to be known about specific cellular mechanisms associated with osteolysis, suggested immunologic or inflammatory responses, and the reactions to varying stresses encountered by the bone. In addition, further investigation should be encouraged into the ways by which the local inflammatory response to particulate matter could be modified by regional or systemic interventions. As the indications for THR are extended into the younger age group, patients with THR will be exposed to more rigorous environmental demands, both occupational and recreational. Investigations are needed into the environmental modifications, activity limitations, or types of physical effort that contribute to extended prosthesis survival. Physical conditioning activities--muscle development, improvement in coordination, and exercises that enhance bone integrity without affecting fixation--need to be studied as they relate to the anticipated lifestyle and occupational objectives of the patient. Outcomes of revision hip surgery are less reliable and satisfactory than those of primary procedures. Those biologic, biomechanical, and rehabilitation factors that influence these results need to be explored and solutions developed. Regional or national registries should be established to capture a minimum data set on all THR and revision procedures. The goals of this registry should be to better define the natural history and epidemiology of THR in the U.S. population as a whole and to identify risk factors for poor outcomes that relate to the implant, procedure, and patient characteristics.


Conclusions: ·

HR is an option for nearly all patients with diseases of the hip that cause chronic discomfort and significant functional impairment.

·

In the aggregate, THR is a highly successful treatment for pain and disability. Most patients have an excellent prognosis for long-term improvement in symptoms and physical function.

·

Perioperative complications such as infection and deep venous thrombosis have been significantly reduced because of use of prophylactic antibiotics and anticoagulants and early mobilization.

·

The predominant mode of long-term prosthetic failure appears to be related to generation of particulate matter, which in turn causes an inflammatory reaction and subsequent bone resorption around the prosthesis.

·

Revision of THR is indicated when mechanical failure occurs. The surgery is technically more difficult and the long-term prognosis is generally not as good as for primary THR. The optimal surgical techniques for THR revision vary considerably depending on the conditions encountered. Continued periodic follow-up is necessary to identify early evidence of impending failure so as to permit remedial actions before a catastrophic event.

·

Improved methods for evaluating existing technology should be developed and implemented, especially with respect to patient-defined outcomes.

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Future research should focus on refining indications for surgery; defining reasons for differences in procedure rates by age, race, gender, and geographic region; developing surgical techniques, materials, and designs that will be clearly superior to current practices; understanding the inflammatory response to particulate material and how to modify it; determining optimal short- and long-term rehabilitation strategies; and elucidating risk factors that may lead to accelerated prosthetic failure.

Vocabulary Builder Alloys: A mixture of metallic elements or compounds with other metallic or metalloid elements in varying proportions. [NIH] Analgesic: An agent that alleviates pain without causing loss of consciousness. [EU] Antibiotic: A chemical substance produced by a microorganism which has


the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Anticoagulants: Agents that prevent blood clotting. Naturally occurring agents in the blood are included only when they are used as drugs. [NIH] Biodegradation: The series of processes by which living systems render chemicals less noxious to the environment. [EU] Biomechanics: The study of the application of mechanical laws and the action of forces to living structures. [NIH] Cobalt: A trace element that is a component of vitamin B12. It has the atomic symbol Co, atomic number 27, and atomic weight 58.93. It is used in nuclear weapons, alloys, and pigments. Deficiency in animals leads to anemia; its excess in humans can lead to erythrocytosis. [NIH] Distal: Remote; farther from any point of reference; opposed to proximal. In dentistry, used to designate a position on the dental arch farther from the median line of the jaw. [EU] Elasticity: Resistance and recovery from distortion of shape. [NIH] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Gait: Manner or style of walking. [NIH] Implantation: The insertion or grafting into the body of biological, living, inert, or radioactive material. [EU] Interleukins: Soluble factors which stimulate growth-related activities of leukocytes as well as other cell types. They enhance cell proliferation and differentiation, DNA synthesis, secretion of other biologically active molecules and responses to immune and inflammatory stimuli. [NIH] Medullary: Pertaining to the marrow or to any medulla; resembling marrow. [EU] Mobilization: The process of making a fixed part or stored substance mobile, as by separating a part from surrounding structures to make it accessible for an operative procedure or by causing release into the circulation for body use of a substance stored in the body. [EU] Osteoclasts: A large multinuclear cell associated with the absorption and removal of bone. An odontoclast, also called cementoclast, is cytomorphologically the same as an osteoclast and is involved in cementum resorption. [NIH] Osteolysis: Dissolution of bone; applied especially to the removal or loss of


the calcium of bone. [EU] Phagocytosis: Endocytosis of particulate material, such as microorganisms or cell fragments. The material is taken into the cell in membrane-bound vesicles (phagosomes) that originate as pinched off invaginations of the plasma membrane. Phagosomes fuse with lysosomes, forming phagolysosomes in which the engulfed material is killed and digested. [EU] Polyethylene: A vinyl polymer made from ethylene. It can be branched or linear. Branched or low-density polyethylene is tough and pliable but not to the same degree as linear polyethylene. Linear or high-density polyethylene has a greater hardness and tensile strength. Polyethylene is used in a variety of products, including implants and prostheses. [NIH] Porosity: Condition of having pores or open spaces. This often refers to bones, bone implants, or bone cements, but can refer to the porous state of any solid substance. [NIH] Progressive: Advancing; going forward; going from bad to worse; increasing in scope or severity. [EU] Prostaglandins: A group of compounds derived from unsaturated 20carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase pathway. They are extremely potent mediators of a diverse group of physiological processes. [NIH] Prosthesis: An artificial substitute for a missing body part, such as an arm or leg, eye or tooth, used for functional or cosmetic reasons, or both. [EU] Pulmonary: Pertaining to the lungs. [EU] Registries: The systems and processes involved in the establishment, support, management, and operation of registers, e.g., disease registers. [NIH] Resorption: The loss of substance through physiologic or pathologic means, such as loss of dentin and cementum of a tooth, or of the alveolar process of the mandible or maxilla. [EU] Rigidity: Stiffness or inflexibility, chiefly that which is abnormal or morbid; rigor. [EU] Thrombosis: The formation, development, or presence of a thrombus. [EU]

Online Glossaries 161

ONLINE GLOSSARIES The Internet provides access to a number of free-to-use medical dictionaries and glossaries. The National Library of Medicine has compiled the following list of online dictionaries: ·

ADAM Medical Encyclopedia (A.D.A.M., Inc.), comprehensive medical reference: http://www.nlm.nih.gov/medlineplus/encyclopedia.html

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MedicineNet.com Medical Dictionary (MedicineNet, Inc.): http://www.medterms.com/Script/Main/hp.asp

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Merriam-Webster Medical Dictionary (Inteli-Health, Inc.): http://www.intelihealth.com/IH/

·

Multilingual Glossary of Technical and Popular Medical Terms in Eight European Languages (European Commission) - Danish, Dutch, English, French, German, Italian, Portuguese, and Spanish: http://allserv.rug.ac.be/~rvdstich/eugloss/welcome.html

·

On-line Medical Dictionary (CancerWEB): http://www.graylab.ac.uk/omd/

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Technology Glossary (National Library of Medicine) - Health Care Technology: http://www.nlm.nih.gov/nichsr/ta101/ta10108.htm

·

Terms and Definitions (Office of Rare Diseases): http://rarediseases.info.nih.gov/ord/glossary_a-e.html

Beyond these, MEDLINEplus contains a very user-friendly encyclopedia covering every aspect of medicine (licensed from A.D.A.M., Inc.). The ADAM Medical Encyclopedia Web site address is http://www.nlm.nih.gov/medlineplus/encyclopedia.html. ADAM is also available on commercial Web sites such as Web MD (http://my.webmd.com/adam/asset/adam_disease_articles/a_to_z/a) and drkoop.com (http://www.drkoop.com/). Topics of interest can be researched by using keywords before continuing elsewhere, as these basic definitions and concepts will be useful in more advanced areas of research. You may choose to print various pages specifically relating to avascular necrosis and keep them on file.


Online Dictionary Directories The following are additional online directories compiled by the National Library of Medicine, including a number of specialized medical dictionaries and glossaries: ·

Medical Dictionaries: Medical & Biological (World Health Organization): http://www.who.int/hlt/virtuallibrary/English/diction.htm#Medical

·

MEL-Michigan Electronic Library List of Online Health and Medical Dictionaries (Michigan Electronic Library): http://mel.lib.mi.us/health/health-dictionaries.html

·

Patient Education: Glossaries (DMOZ Open Directory Project): http://dmoz.org/Health/Education/Patient_Education/Glossaries/

·

Web of Online Dictionaries (Bucknell University): http://www.yourdictionary.com/diction5.html#medicine

Glossary 163

AVASCULAR NECROSIS GLOSSARY The following is a complete glossary of terms used in this sourcebook. The definitions are derived from official public sources including the National Institutes of Health [NIH] and the European Union [EU]. After this glossary, we list a number of additional hardbound and electronic glossaries and dictionaries that you may wish to consult. Abdomen: That portion of the body that lies between the thorax and the pelvis. [NIH] ACTH: Adrenocorticotropic hormone. [EU] Adolescence: The period of life beginning with the appearance of secondary sex characteristics and terminating with the cessation of somatic growth. The years usually referred to as adolescence lie between 13 and 18 years of age. [NIH]

Adrenergic: Activated by, characteristic of, or secreting epinephrine or substances with similar activity; the term is applied to those nerve fibres that liberate norepinephrine at a synapse when a nerve impulse passes, i.e., the sympathetic fibres. [EU] Allergen: A antigenic substance capable of producing immediate-type hypersensitivity (allergy). [EU] Alloys: A mixture of metallic elements or compounds with other metallic or metalloid elements in varying proportions. [NIH] Analgesic: An agent that alleviates pain without causing loss of consciousness. [EU] Anemia: A reduction in the number of circulating erythrocytes or in the quantity of hemoglobin. [NIH] Ankle: That part of the lower limb directly above the foot. [NIH] Anoxia: A total lack of oxygen; often used interchangeably with hypoxia to mean a reduced supply of oxygen to the tissues. [EU] Antibiotic: A chemical substance produced by a microorganism which has the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics that are sufficiently nontoxic to the host are used as chemotherapeutic agents in the treatment of infectious diseases of man, animals and plants. [EU] Antibody: An immunoglobulin molecule that has a specific amino acid sequence by virtue of which it interacts only with the antigen that induced its synthesis in cells of the lymphoid series (especially plasma cells), or with antigen closely related to it. Antibodies are classified according to their ode


of action as agglutinins, bacteriolysins, haemolysins, opsonins, precipitins, etc. [EU] Anticoagulants: Agents that prevent blood clotting. Naturally occurring agents in the blood are included only when they are used as drugs. [NIH] Antioxidant: One of many widely used synthetic or natural substances added to a product to prevent or delay its deterioration by action of oxygen in the air. Rubber, paints, vegetable oils, and prepared foods commonly contain antioxidants. [EU] Arthroplasty: Surgical reconstruction of a joint to relieve pain or restore motion. [NIH] Arthroscopy: Endoscopic examination, therapy and surgery of the joint. [NIH] Aseptic: Free from infection or septic material; sterile. [EU] Asparaginase: A hydrolase enzyme that converts L-asparagine and water to L-aspartate and NH3. EC 3.5.1.1. [NIH] Assay: Determination of the amount of a particular constituent of a mixture, or of the biological or pharmacological potency of a drug. [EU] Asymptomatic: Showing or causing no symptoms. [EU] Autoantigens: Endogenous tissue constituents that have the ability to interact with autoantibodies and cause an immune response. [NIH] Autoimmunity: Process whereby the immune system reacts against the body's own tissues. Autoimmunity may produce or be caused by autoimmune diseases. [NIH] Bacteria: Unicellular prokaryotic microorganisms which generally possess rigid cell walls, multiply by cell division, and exhibit three principal forms: round or coccal, rodlike or bacillary, and spiral or spirochetal. [NIH] Benign: Not malignant; not recurrent; favourable for recovery. [EU] Bile: An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts, cholesterol, and electrolytes. It aids digestion of fats in the duodenum. [NIH] Biochemical: Relating to biochemistry; characterized by, produced by, or involving chemical reactions in living organisms. [EU] Biodegradation: The series of processes by which living systems render chemicals less noxious to the environment. [EU] Biomechanics: The study of the application of mechanical laws and the action of forces to living structures. [NIH] Biopolymers: Polymers, such as proteins, DNA, RNA, or polysaccharides formed by any living organism. [NIH] Biopsy: The removal and examination, usually microscopic, of tissue from

Glossary 165

the living body, performed to establish precise diagnosis. [EU] Biosynthesis: The building up of a chemical compound in the physiologic processes of a living organism. [EU] Bradykinin: A nonapeptide messenger that is enzymatically produced from kallidin in the blood where it is a potent but short-lived agent of arteriolar dilation and increased capillary permeability. Bradykinin is also released from mast cells during asthma attacks, from gut walls as a gastrointestinal vasodilator, from damaged tissues as a pain signal, and may be a neurotransmitter. [NIH] Bronchial: Pertaining to one or more bronchi. [EU] Bursitis: Inflammation of a bursa, occasionally accompanied by a calcific deposit in the underlying supraspinatus tendon; the most common site is the subdeltoid bursa. [EU] Calibration: Determination, by measurement or comparison with a standard, of the correct value of each scale reading on a meter or other measuring instrument; or determination of the settings of a control device that correspond to particular values of voltage, current, frequency or other output. [NIH] Calpain: Cysteine proteinase found in many tissues. Hydrolyzes a variety of endogenous proteins including neuropeptides, cytoskeletal proteins, proteins from smooth muscle, cardiac muscle, liver, platelets and erythrocytes. Two subclasses having high and low calcium sensitivity are known. Removes Z-discs and M-lines from myofibrils. Activates phosphorylase kinase and cyclic nucleotide-independent protein kinase. [NIH] Capsules: Hard or soft soluble containers used for the oral administration of medicine. [NIH] Carbohydrate: An aldehyde or ketone derivative of a polyhydric alcohol, particularly of the pentahydric and hexahydric alcohols. They are so named because the hydrogen and oxygen are usually in the proportion to form water, (CH2O)n. The most important carbohydrates are the starches, sugars, celluloses, and gums. They are classified into mono-, di-, tri-, poly- and heterosaccharides. [EU] Carcinoma: A malignant new growth made up of epithelial cells tending to infiltrate the surrounding tissues and give rise to metastases. [EU] Cardiac: Pertaining to the heart. [EU] Cardiomyopathy: A general diagnostic term designating primary myocardial disease, often of obscure or unknown etiology. [EU] Cardiovascular: Pertaining to the heart and blood vessels. [EU] Caspases: A family of intracellular cysteine endopeptidases. They play a key


role in inflammation and mammalian apoptosis. They are specific for aspartic acid at the P1 position. They are divided into two classes based on the lengths of their N-terminal prodomains. Caspases-1,-2,-4,-5,-8, and -10 have long prodomains and -3,-6,-7,-9 have short prodomains. EC 3.4.22.-. [NIH]

Cataract: An opacity, partial or complete, of one or both eyes, on or in the lens or capsule, especially an opacity impairing vision or causing blindness. The many kinds of cataract are classified by their morphology (size, shape, location) or etiology (cause and time of occurrence). [EU] Chemotherapy: The treatment of disease by means of chemicals that have a specific toxic effect upon the disease - producing microorganisms or that selectively destroy cancerous tissue. [EU] Cholestasis: Impairment of biliary flow at any level from the hepatocyte to Vater's ampulla. [NIH] Cholesterol: The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. [NIH] Chronic: Persisting over a long period of time. [EU] Coagulation: 1. the process of clot formation. 2. in colloid chemistry, the solidification of a sol into a gelatinous mass; an alteration of a disperse phase or of a dissolved solid which causes the separation of the system into a liquid phase and an insoluble mass called the clot or curd. Coagulation is usually irreversible. 3. in surgery, the disruption of tissue by physical means to form an amorphous residuum, as in electrocoagulation and photocoagulation. [EU] Cobalt: A trace element that is a component of vitamin B12. It has the atomic symbol Co, atomic number 27, and atomic weight 58.93. It is used in nuclear weapons, alloys, and pigments. Deficiency in animals leads to anemia; its excess in humans can lead to erythrocytosis. [NIH] Collagen: The protein substance of the white fibres (collagenous fibres) of skin, tendon, bone, cartilage, and all other connective tissue; composed of molecules of tropocollagen (q.v.), it is converted into gelatin by boiling. collagenous pertaining to collagen; forming or producing collagen. [EU] Collapse: 1. a state of extreme prostration and depression, with failure of circulation. 2. abnormal falling in of the walls of any part of organ. [EU] Concomitant: Accompanying; accessory; joined with another. [EU] Contraception: The prevention of conception or impregnation. [EU] Cortical: Pertaining to or of the nature of a cortex or bark. [EU] Cysteine: A thiol-containing non-essential amino acid that is oxidized to form CYSTINE. [NIH] Cytokines: Non-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ

Glossary 167

from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner. [NIH] Cytoplasm: The protoplasm of a cell exclusive of that of the nucleus; it consists of a continuous aqueous solution (cytosol) and the organelles and inclusions suspended in it (phaneroplasm), and is the site of most of the chemical activities of the cell. [EU] Cytoskeleton: The network of filaments, tubules, and interconnecting filamentous bridges which give shape, structure, and organization to the cytoplasm. [NIH] Cytotoxins: Substances elaborated by microorganisms, plants or animals that are specifically toxic to individual cells; they may be involved in immunity or may be contained in venoms. [NIH] Degenerative: Undergoing degeneration : tending to degenerate; having the character of or involving degeneration; causing or tending to cause degeneration. [EU] Deprivation: Loss or absence of parts, organs, powers, or things that are needed. [EU] Diarrhea: Passage of excessively liquid or excessively frequent stools. [NIH] Diffusion: The process of becoming diffused, or widely spread; the spontaneous movement of molecules or other particles in solution, owing to their random thermal motion, to reach a uniform concentration throughout the solvent, a process requiring no addition of energy to the system. [EU] Dislocation: The displacement of any part, more especially of a bone. Called also luxation. [EU] Distal: Remote; farther from any point of reference; opposed to proximal. In dentistry, used to designate a position on the dental arch farther from the median line of the jaw. [EU] Dysplasia: Abnormality of development; in pathology, alteration in size, shape, and organization of adult cells. [EU] Elasticity: Resistance and recovery from distortion of shape. [NIH] Electromyography: Recording of the changes in electric potential of muscle by means of surface or needle electrodes. [NIH] Electroporation: A technique in which electric pulses of intensity in kilovolts per centimeter and of microsecond-to-millisecond duration cause a temporary loss of the semipermeability of cell membranes, thus leading to ion leakage, escape of metabolites, and increased uptake by cells of drugs, molecular probes, and DNA. Some applications of electroporation include introduction of plasmids or foreign DNA into living cells for transfection,


fusion of cells to prepare hybridomas, and insertion of proteins into cell membranes. [NIH] Endogenous: Developing or originating within the organisms or arising from causes within the organism. [EU] Enteritis: Inflammation of the intestine, applied chiefly to inflammation of the small intestine; see also enterocolitis. [EU] Enterocolitis: Inflammation involving both the small intestine and the colon; see also enteritis. [EU] Enzyme: A protein molecule that catalyses chemical reactions of other substances without itself being destroyed or altered upon completion of the reactions. Enzymes are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry. Each enzyme is assigned a recommended name and an Enzyme Commission (EC) number. They are divided into six main groups; oxidoreductases, transferases, hydrolases, lyases, isomerases, and ligases. [EU] Eosinophils: Granular leukocytes with a nucleus that usually has two lobes connected by a slender thread of chromatin, and cytoplasm containing coarse, round granules that are uniform in size and stainable by eosin. [NIH] Epiphyseal: Pertaining to or of the nature of an epiphysis. [EU] Epitopes: Sites on an antigen that interact with specific antibodies. [NIH] Fatigue: The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. [NIH] Femoral: Pertaining to the femur, or to the thigh. [EU] Femur: The longest and largest bone of the skeleton, it is situated between the hip and the knee. [NIH] Fibroblasts: Connective tissue cells which secrete an extracellular matrix rich in collagen and other macromolecules. [NIH] Fibula: The bone of the lower leg lateral to and smaller than the tibia. In proportion to its length, it is the most slender of the long bones. [NIH] Gait: Manner or style of walking. [NIH] Gastrointestinal: Pertaining to or communicating with the stomach and intestine, as a gastrointestinal fistula. [EU] Glomerular: Pertaining to or of the nature of a glomerulus, especially a renal glomerulus. [EU] Glucose: D-glucose, a monosaccharide (hexose), C6H12O6, also known as dextrose (q.v.), found in certain foodstuffs, especially fruits, and in the normal blood of all animals. It is the end product of carbohydrate metabolism and is the chief source of energy for living organisms, its

Glossary 169

utilization being controlled by insulin. Excess glucose is converted to glycogen and stored in the liver and muscles for use as needed and, beyond that, is converted to fat and stored as adipose tissue. Glucose appears in the urine in diabetes mellitus. [EU] Groin: The external junctural region between the lower part of the abdomen and the thigh. [NIH] Hematology: A subspecialty of internal medicine concerned with morphology, physiology, and pathology of the blood and blood-forming tissues. [NIH] Hepatic: Pertaining to the liver. [EU] Hepatocellular: Pertaining to or affecting liver cells. [EU] Hepatocytes: The main structural component of the liver. They are specialized epithelial cells that are organized into interconnected plates called lobules. [NIH] Hernia: (he protrusion of a loop or knuckle of an organ or tissue through an abnormal opening. [EU] Humeral: 1. of, relating to, or situated in the region of the humerus : brachial. 2. of or belonging to the shoulder. 3. of, relating to, or being any of several body parts that are analogous in structure, function, or location to the humerus or shoulder. [EU] Hydroxyurea: An antineoplastic agent that inhibits DNA synthesis through the inhibition of ribonucleoside diphosphate reductase. [NIH] Hyperbaric: Characterized by greater than normal pressure or weight; applied to gases under greater than atmospheric pressure, as hyperbaric oxygen, or to a solution of greater specific gravity than another taken as a standard of reference. [EU] Hypothyroidism: Deficiency of thyroid activity. In adults, it is most common in women and is characterized by decrease in basal metabolic rate, tiredness and lethargy, sensitivity to cold, and menstrual disturbances. If untreated, it progresses to full-blown myxoedema. In infants, severe hypothyroidism leads to cretinism. In juveniles, the manifestations are intermediate, with less severe mental and developmental retardation and only mild symptoms of the adult form. When due to pituitary deficiency of thyrotropin secretion it is called secondary hypothyroidism. [EU] Hypoxia: Reduction of oxygen supply to tissue below physiological levels despite adequate perfusion of the tissue by blood. [EU] Induction: The act or process of inducing or causing to occur, especially the production of a specific morphogenetic effect in the developing embryo through the influence of evocators or organizers, or the production of anaesthesia or unconsciousness by use of appropriate agents. [EU]


Inflammation: A pathological process characterized by injury or destruction of tissues caused by a variety of cytologic and chemical reactions. It is usually manifested by typical signs of pain, heat, redness, swelling, and loss of function. [NIH] Inotropic: Affecting the force or energy of muscular contractions. [EU] Insulin: A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulindependent diabetes mellitus. [NIH] Interleukins: Soluble factors which stimulate growth-related activities of leukocytes as well as other cell types. They enhance cell proliferation and differentiation, DNA synthesis, secretion of other biologically active molecules and responses to immune and inflammatory stimuli. [NIH] Intermittent: Occurring at separated intervals; having periods of cessation of activity. [EU] Intravenous: Within a vein or veins. [EU] Invasive: 1. having the quality of invasiveness. 2. involving puncture or incision of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. [EU] Iodine: A nonmetallic element of the halogen group that is represented by the atomic symbol I, atomic number 53, and atomic weight of 126.90. It is a nutritionally essential element, especially important in thyroid hormone synthesis. In solution, it has anti-infective properties and is used topically. [NIH]

Ischemia: Deficiency of blood in a part, due to functional constriction or actual obstruction of a blood vessel. [EU] Laparoscopy: Examination, therapy or surgery of the abdomen's interior by means of a laparoscope. [NIH] Lesion: Any pathological or traumatic discontinuity of tissue or loss of function of a part. [EU] Lethal: Deadly, fatal. [EU] Lipid: Any of a heterogeneous group of flats and fatlike substances characterized by being water-insoluble and being extractable by nonpolar (or fat) solvents such as alcohol, ether, chloroform, benzene, etc. All contain as a major constituent aliphatic hydrocarbons. The lipids, which are easily stored in the body, serve as a source of fuel, are an important constituent of cell structure, and serve other biological functions. Lipids may be considered to include fatty acids, neutral fats, waxes, and steroids. Compound lipids comprise the glycolipids, lipoproteins, and phospholipids. [EU]

Glossary 171

Localization: 1. the determination of the site or place of any process or lesion. 2. restriction to a circumscribed or limited area. 3. prelocalization. [EU] Lupus: A form of cutaneous tuberculosis. It is seen predominantly in women and typically involves the nasal, buccal, and conjunctival mucosa. [NIH]

Lymphocytic: Pertaining to, characterized by, or of the nature of lymphocytes. [EU] Lymphoma: Any neoplastic disorder of the lymphoid tissue, the term lymphoma often is used alone to denote malignant lymphoma. [EU] Malignant: Tending to become progressively worse and to result in death. Having the properties of anaplasia, invasion, and metastasis; said of tumours. [EU] Mediator: An object or substance by which something is mediated, such as (1) a structure of the nervous system that transmits impulses eliciting a specific response; (2) a chemical substance (transmitter substance) that induces activity in an excitable tissue, such as nerve or muscle; or (3) a substance released from cells as the result of the interaction of antigen with antibody or by the action of antigen with a sensitized lymphocyte. [EU] Medullary: Pertaining to the marrow or to any medulla; resembling marrow. [EU] Membrane: A thin layer of tissue which covers a surface, lines a cavity or divides a space or organ. [EU] Metabolite: process. [EU]

Any substance produced by metabolism or by a metabolic

Methotrexate: An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of dihydrofolate reductase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. [NIH] Microscopy: The application of microscope magnification to the study of materials that cannot be properly seen by the unaided eye. [NIH] Mobility: Capability of movement, of being moved, or of flowing freely. [EU] Mobilization: The process of making a fixed part or stored substance mobile, as by separating a part from surrounding structures to make it accessible for an operative procedure or by causing release into the circulation for body use of a substance stored in the body. [EU] Molecular: Of, pertaining to, or composed of molecules : a very small mass of matter. [EU] Myocardium: The muscle tissue of the heart composed of striated, involuntary muscle known as cardiac muscle. [NIH]


Myositis: Inflammation of a voluntary muscle. [EU] Myxedema: A condition characterized by a dry, waxy type of swelling with abnormal deposits of mucin in the skin and other tissues. It is produced by a functional insufficiency of the thyroid gland, resulting in deficiency of thyroid hormone. The skin becomes puffy around the eyes and on the cheeks and the face is dull and expressionless with thickened nose and lips. The congenital form of the disease is cretinism. [NIH] Necrosis: The sum of the morphological changes indicative of cell death and caused by the progressive degradative action of enzymes; it may affect groups of cells or part of a structure or an organ. [EU] Neural: 1. pertaining to a nerve or to the nerves. 2. situated in the region of the spinal axis, as the neutral arch. [EU] Neurites: In tissue culture, hairlike projections of neurons stimulated by growth factors and other molecules. These projections may go on to form a branched tree of dendrites or a single axon or they may be reabsorbed at a later stage of development. "Neurite" may refer to any filamentous or pointed outgrowth of an embryonal or tissue-culture neural cell. [NIH] Neurologic: Pertaining to neurology or to the nervous system. [EU] Neuronal: Pertaining to a neuron or neurons (= conducting cells of the nervous system). [EU] Neurons: The basic cellular units of nervous tissue. Each neuron consists of a body, an axon, and dendrites. Their purpose is to receive, conduct, and transmit impulses in the nervous system. [NIH] Niacin: Water-soluble vitamin of the B complex occurring in various animal and plant tissues. Required by the body for the formation of coenzymes NAD and NADP. Has pellagra-curative, vasodilating, and antilipemic properties. [NIH] Nitrogen: An element with the atomic symbol N, atomic number 7, and atomic weight 14. Nitrogen exists as a diatomic gas and makes up about 78% of the earth's atmosphere by volume. It is a constituent of proteins and nucleic acids and found in all living cells. [NIH] Oophoritis: Inflammation of an ovary. [NIH] Oral: Pertaining to the mouth, taken through or applied in the mouth, as an oral medication or an oral thermometer. [EU] Orthopaedic: Pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopaedics. [EU] Orthopedics: A surgical specialty which utilizes medical, surgical, and physical methods to treat and correct deformities, diseases, and injuries to the skeletal system, its articulations, and associated structures. [NIH]

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Osteoarthritis: Noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane. It is accompanied by pain and stiffness, particularly after prolonged activity. [EU] Osteoclasts: A large multinuclear cell associated with the absorption and removal of bone. An odontoclast, also called cementoclast, is cytomorphologically the same as an osteoclast and is involved in cementum resorption. [NIH] Osteolysis: Dissolution of bone; applied especially to the removal or loss of the calcium of bone. [EU] Osteonecrosis: Death of a bone or part of a bone, either atraumatic or posttraumatic. [NIH] Osteoporosis: Reduction in the amount of bone mass, leading to fractures after minimal trauma. [EU] Osteotomy: The surgical cutting of a bone. [EU] Ovulation: The discharge of a secondary oocyte from a vesicular follicle of the ovary. [EU] Palpation: Application of fingers with light pressure to the surface of the body to determine consistence of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. [NIH] Pancreatitis: Acute or chronic inflammation of the pancreas, which may be asymptomatic or symptomatic, and which is due to autodigestion of a pancreatic tissue by its own enzymes. It is caused most often by alcoholism or biliary tract disease; less commonly it may be associated with hyperlipaemia, hyperparathyroidism, abdominal trauma (accidental or operative injury), vasculitis, or uraemia. [EU] Papillary: Pertaining to or resembling papilla, or nipple. [EU] Parenteral: Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc. [EU] Particle: A tiny mass of material. [EU] Pediatrics: A medical specialty concerned with maintaining health and providing medical care to children from birth to adolescence. [NIH] Pelvic: Pertaining to the pelvis. [EU] Perfusion: 1. the act of pouring over or through, especially the passage of a fluid through the vessels of a specific organ. 2. a liquid poured over or through an organ or tissue. [EU] Perioperative:

Pertaining to the period extending from the time of


hospitalization for surgery to the time of discharge. [EU] Phagocytosis: Endocytosis of particulate material, such as microorganisms or cell fragments. The material is taken into the cell in membrane-bound vesicles (phagosomes) that originate as pinched off invaginations of the plasma membrane. Phagosomes fuse with lysosomes, forming phagolysosomes in which the engulfed material is killed and digested. [EU] Phenotype: The outward appearance of the individual. It is the product of interactions between genes and between the genotype and the environment. This includes the killer phenotype, characteristic of yeasts. [NIH] Physiologic: Normal; not pathologic; characteristic of or conforming to the normal functioning or state of the body or a tissue or organ; physiological. [EU]

Polyarthritis: An inflammation of several joints together. [EU] Polyethylene: A vinyl polymer made from ethylene. It can be branched or linear. Branched or low-density polyethylene is tough and pliable but not to the same degree as linear polyethylene. Linear or high-density polyethylene has a greater hardness and tensile strength. Polyethylene is used in a variety of products, including implants and prostheses. [NIH] Polypeptide: A peptide which on hydrolysis yields more than two amino acids; called tripeptides, tetrapeptides, etc. according to the number of amino acids contained. [EU] Porosity: Condition of having pores or open spaces. This often refers to bones, bone implants, or bone cements, but can refer to the porous state of any solid substance. [NIH] Potassium: An element that is in the alkali group of metals. It has an atomic symbol K, atomic number 19, and atomic weight 39.10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte and it plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. [NIH] Prednisone: A synthetic anti-inflammatory glucocorticoid derived from cortisone. It is biologically inert and converted to prednisolone in the liver. [NIH]

Preoperative: Preceding an operation. [EU] Prevalence: The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. [NIH] Progesterone: Pregn-4-ene-3,20-dione. The principal progestational hormone of the body, secreted by the corpus luteum, adrenal cortex, and placenta. Its chief function is to prepare the uterus for the reception and development of the fertilized ovum. It acts as an antiovulatory agent when

Glossary 175

administered on days 5-25 of the menstrual cycle. [NIH] Progressive: Advancing; going forward; going from bad to worse; increasing in scope or severity. [EU] Prostaglandins: A group of compounds derived from unsaturated 20carbon fatty acids, primarily arachidonic acid, via the cyclooxygenase pathway. They are extremely potent mediators of a diverse group of physiological processes. [NIH] Prostate: A gland in males that surrounds the neck of the bladder and the urethra. It secretes a substance that liquifies coagulated semen. It is situated in the pelvic cavity behind the lower part of the pubic symphysis, above the deep layer of the triangular ligament, and rests upon the rectum. [NIH] Protease: Proteinase (= any enzyme that catalyses the splitting of interior peptide bonds in a protein). [EU] Proteins: Polymers of amino acids linked by peptide bonds. The specific sequence of amino acids determines the shape and function of the protein. [NIH]

Proteolytic: 1. pertaining to, characterized by, or promoting proteolysis. 2. an enzyme that promotes proteolysis (= the splitting of proteins by hydrolysis of the peptide bonds with formation of smaller polypeptides). [EU] Proximal: Nearest; closer to any point of reference; opposed to distal. [EU] Purpura: Purplish or brownish red discoloration, easily visible through the epidermis, caused by hemorrhage into the tissues. [NIH] Pyelonephritis: Inflammation of the kidney and its pelvis, beginning in the interstitium and rapidly extending to involve the tubules, glomeruli, and blood vessels; due to bacterial infection. [EU] Radiology: A specialty concerned with the use of x-ray and other forms of radiant energy in the diagnosis and treatment of disease. [NIH] Reagent: A substance employed to produce a chemical reaction so as to detect, measure, produce, etc., other substances. [EU] Receptor: 1. a molecular structure within a cell or on the surface characterized by (1) selective binding of a specific substance and (2) a specific physiologic effect that accompanies the binding, e.g., cell-surface receptors for peptide hormones, neurotransmitters, antigens, complement fragments, and immunoglobulins and cytoplasmic receptors for steroid hormones. 2. a sensory nerve terminal that responds to stimuli of various kinds. [EU] Reflective: Capable of throwing back light, images, sound waves : reflecting. [EU] Registries: The systems and processes involved in the establishment, support, management, and operation of registers, e.g., disease registers. [NIH]


Remission: A diminution or abatement of the symptoms of a disease; also the period during which such diminution occurs. [EU] Reperfusion: Restoration of blood supply to tissue which is ischemic due to decrease in normal blood supply. The decrease may result from any source including atherosclerotic obstruction, narrowing of the artery, or surgical clamping. It is primarily a procedure for treating infarction or other ischemia, by enabling viable ischemic tissue to recover, thus limiting further necrosis. However, it is thought that reperfusion can itself further damage the ischemic tissue, causing reperfusion injury. [NIH] Resorption: The loss of substance through physiologic or pathologic means, such as loss of dentin and cementum of a tooth, or of the alveolar process of the mandible or maxilla. [EU] Rheumatoid: Resembling rheumatism. [EU] Rheumatology: A subspecialty of internal medicine concerned with the study of inflammatory or degenerative processes and metabolic derangement of connective tissue structures which pertain to a variety of musculoskeletal disorders, such as arthritis. [NIH] Riboflavin: Nutritional factor found in milk, eggs, malted barley, liver, kidney, heart, and leafy vegetables. The richest natural source is yeast. It occurs in the free form only in the retina of the eye, in whey, and in urine; its principal forms in tissues and cells are as FMN and FAD. [NIH] Rigidity: Stiffness or inflexibility, chiefly that which is abnormal or morbid; rigor. [EU] Secretion: 1. the process of elaborating a specific product as a result of the activity of a gland; this activity may range from separating a specific substance of the blood to the elaboration of a new chemical substance. 2. any substance produced by secretion. [EU] Selenium: An element with the atomic symbol Se, atomic number 34, and atomic weight 78.96. It is an essential micronutrient for mammals and other animals but is toxic in large amounts. Selenium protects intracellular structures against oxidative damage. It is an essential component of glutathione peroxidase. [NIH] Serum: The clear portion of any body fluid; the clear fluid moistening serous membranes. 2. blood serum; the clear liquid that separates from blood on clotting. 3. immune serum; blood serum from an immunized animal used for passive immunization; an antiserum; antitoxin, or antivenin. [EU] Species: A taxonomic category subordinate to a genus (or subgenus) and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are

Glossary 177

designated by the genus name followed by a Latin or Latinized adjective or noun. [EU] Spectrum: A charted band of wavelengths of electromagnetic vibrations obtained by refraction and diffraction. By extension, a measurable range of activity, such as the range of bacteria affected by an antibiotic (antibacterial s.) or the complete range of manifestations of a disease. [EU] Spondylitis: Inflammation of the vertebrae. [EU] Steroid: A group name for lipids that contain a hydrogenated cyclopentanoperhydrophenanthrene ring system. Some of the substances included in this group are progesterone, adrenocortical hormones, the gonadal hormones, cardiac aglycones, bile acids, sterols (such as cholesterol), toad poisons, saponins, and some of the carcinogenic hydrocarbons. [EU] Substrate: A substance upon which an enzyme acts. [EU] Surgical: Of, pertaining to, or correctable by surgery. [EU] Synaptic: Pertaining to or affecting a synapse (= site of functional apposition between neurons, at which an impulse is transmitted from one neuron to another by electrical or chemical means); pertaining to synapsis (= pairing off in point-for-point association of homologous chromosomes from the male and female pronuclei during the early prophase of meiosis). [EU] Synovial: Of pertaining to, or secreting synovia. [EU] Talus: The second largest of the tarsal bones and occupies the middle and upper part of the tarsus. [NIH] Tendinitis: Inflammation of tendons and of tendon-muscle attachments. [EU] Testicular: Pertaining to a testis. [EU] Thalassemia: A group of hereditary hemolytic anemias in which there is decreased synthesis of one or more hemoglobin polypeptide chains. There are several genetic types with clinical pictures ranging from barely detectable hematologic abnormality to severe and fatal anemia. [NIH] Thermoregulation: Heat regulation. [EU] Thrombophilia: A disorder of hemostasis in which there is a tendency for the occurrence of thrombosis. [NIH] Thrombosis: The formation, development, or presence of a thrombus. [EU] Thyrotoxicosis: The condition resulting from presentation to the tissues of excessive quantities of the thyroid hormones, whether the excess results from overproduction by the thyroid gland (as in Graves' disease), originated outside the thyroid, or is due to loss of storage function and leakage from the gland. [EU] Thyroxine: An amino acid of the thyroid gland which exerts a stimulating effect on thyroid metabolism. [NIH]


Tomography: The recording of internal body images at a predetermined plane by means of the tomograph; called also body section roentgenography. [EU]

Toxic: Pertaining to, due to, or of the nature of a poison or toxin; manifesting the symptoms of severe infection. [EU] Toxin: A poison; frequently used to refer specifically to a protein produced by some higher plants, certain animals, and pathogenic bacteria, which is highly toxic for other living organisms. Such substances are differentiated from the simple chemical poisons and the vegetable alkaloids by their high molecular weight and antigenicity. [EU] Transaminase: Aminotransferase (= a subclass of enzymes of the transferase class that catalyse the transfer of an amino group from a donor (generally an amino acid) to an acceptor (generally 2-keto acid). Most of these enzymes are pyridoxal-phosphate-proteins. [EU] Transfusion: The introduction of whole blood or blood component directly into the blood stream. [EU] Transplantation: The grafting of tissues taken from the patient's own body or from another. [EU] Traumatology: The branch of surgery which deals with wounds and disability from injuries. [NIH] Tumour: 1. swelling, one of the cardinal signs of inflammations; morbid enlargement. 2. a new growth of tissue in which the multiplication of cells is uncontrolled and progressive; called also neoplasm. [EU] Tyrosine: A non-essential amino acid. In animals it is synthesized from phenylalanine. It is also the precursor of epinephrine, thyroid hormones, and melanin. [NIH] Ulcer: A local defect, or excavation, of the surface of an organ or tissue; which is produced by the sloughing of inflammatory necrotic tissue. [EU] Vasculitis: Inflammation of a vessel, angiitis. [EU] Veins: The vessels carrying blood toward the heart. [NIH] Venules: The minute vessels that collect blood from the capillary plexuses and join together to form veins. [NIH]

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General Dictionaries and Glossaries While the above glossary is essentially complete, the dictionaries listed here cover virtually all aspects of medicine, from basic words and phrases to more advanced terms (sorted alphabetically by title; hyperlinks provide rankings, information and reviews at Amazon.com): ·

Dictionary of Medical Acronymns & Abbreviations by Stanley Jablonski (Editor), Paperback, 4th edition (2001), Lippincott Williams & Wilkins Publishers, ISBN: 1560534605, http://www.amazon.com/exec/obidos/ASIN/1560534605/icongroupinterna

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Dictionary of Medical Terms : For the Nonmedical Person (Dictionary of Medical Terms for the Nonmedical Person, Ed 4) by Mikel A. Rothenberg, M.D, et al, Paperback - 544 pages, 4th edition (2000), Barrons Educational Series, ISBN: 0764112015, http://www.amazon.com/exec/obidos/ASIN/0764112015/icongroupinterna

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A Dictionary of the History of Medicine by A. Sebastian, CD-Rom edition (2001), CRC Press-Parthenon Publishers, ISBN: 185070368X, http://www.amazon.com/exec/obidos/ASIN/185070368X/icongroupinterna

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Dorland's Illustrated Medical Dictionary (Standard Version) by Dorland, et al, Hardcover - 2088 pages, 29th edition (2000), W B Saunders Co, ISBN: 0721662544, http://www.amazon.com/exec/obidos/ASIN/0721662544/icongroupinterna

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Dorland's Electronic Medical Dictionary by Dorland, et al, Software, 29th Book & CD-Rom edition (2000), Harcourt Health Sciences, ISBN: 0721694934, http://www.amazon.com/exec/obidos/ASIN/0721694934/icongroupinterna

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Dorland's Pocket Medical Dictionary (Dorland's Pocket Medical Dictionary, 26th Ed) Hardcover - 912 pages, 26th edition (2001), W B Saunders Co, ISBN: 0721682812, http://www.amazon.com/exec/obidos/ASIN/0721682812/icongroupinterna /103-4193558-7304618

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Melloni's Illustrated Medical Dictionary (Melloni's Illustrated Medical Dictionary, 4th Ed) by Melloni, Hardcover, 4th edition (2001), CRC PressParthenon Publishers, ISBN: 85070094X, http://www.amazon.com/exec/obidos/ASIN/85070094X/icongroupinterna

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Stedman's Electronic Medical Dictionary Version 5.0 (CD-ROM for Windows and Macintosh, Individual) by Stedmans, CD-ROM edition (2000), Lippincott Williams & Wilkins Publishers, ISBN: 0781726328, http://www.amazon.com/exec/obidos/ASIN/0781726328/icongroupinterna


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Stedman's Medical Dictionary by Thomas Lathrop Stedman, Hardcover 2098 pages, 27th edition (2000), Lippincott, Williams & Wilkins, ISBN: 068340007X, http://www.amazon.com/exec/obidos/ASIN/068340007X/icongroupinterna

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Tabers Cyclopedic Medical Dictionary (Thumb Index) by Donald Venes (Editor), et al, Hardcover - 2439 pages, 19th edition (2001), F A Davis Co, ISBN: 0803606540, http://www.amazon.com/exec/obidos/ASIN/0803606540/icongroupinterna

Index 181

INDEX A Abdomen .........................42, 83, 169, 170 Abdominal......................................23, 173 Adolescence ....................58, 83, 163, 173 Adverse .........................................36, 112 Alloys ...145, 146, 147, 149, 150, 159, 166 Analgesic .............................................144 Anemia ..........................43, 159, 166, 177 Ankle......................................................67 Antibiotic ......................132, 151, 155, 177 Antibody...55, 58, 74, 75, 76, 77, 166, 171 Anticoagulants .............................151, 158 Arterial ...................................................67 Arteritis ..................................................80 Arthropathy ............................................80 Arthroplasty ...................................48, 149 Arthroscopy ...........................................18 Aseptic ..4, 10, 53, 66, 115, 127, 145, 146, 154 Asparaginase...............................113, 127 Asymptomatic ..........................23, 78, 173 B Bacteria .................60, 122, 132, 177, 178 Benign ...........................................70, 144 Bile.................................................24, 177 Biodegradation ....................................148 Biomechanics ..............................142, 143 Biopsy....................................................14 Bronchial..............................................128 Bursitis ...................................................81 C Capsules..............................................125 Carbohydrate.........................56, 124, 168 Carcinoma .....................................50, 129 Cardiac ..............24, 54, 58, 165, 171, 177 Cataract .........................................22, 166 Chemotherapy ......12, 112, 113, 114, 116, 127, 129 Cholesterol ..............24, 49, 122, 124, 177 Chronic ....................23, 50, 143, 158, 173 Coagulation ...........................................11 Cobalt ..........................147, 148, 149, 150 Collagen ....................51, 55, 56, 166, 168 Collapse.........................10, 13, 16, 48, 67 Concomitant ..........................................50 Cortical ........................................151, 155 Cytokines .......................................65, 150 Cytoplasm........................55, 56, 167, 168 Cytotoxins ..............................................65 D Degenerative ...........23, 51, 123, 173, 176

Diarrhea .............................................. 122 Diffusion ................................................ 51 Dislocation .................. 11, 61, 62, 67, 154 E Elasticity.............................................. 150 Electroporation.............................. 56, 167 Endogenous.................................. 54, 165 Enteritis ................................... 56, 64, 168 Enterocolitis .................................. 68, 168 Enzyme ..... 56, 59, 60, 164, 168, 175, 177 Epiphyseal ............................................ 51 F Fatigue ................................................ 148 Femoral.. 4, 48, 49, 51, 52, 53, 61, 62, 64, 65, 70, 72, 114, 115, 116, 117, 127, 128, 129, 130, 143, 146, 147, 149, 155 Femur .... 11, 56, 115, 127, 146, 150, 151, 155, 168 Fibroblasts .......................................... 150 Fibula .................................................... 70 G Gait ..................................................... 152 Gastrointestinal ............... 54, 83, 165, 168 Glomerular ............................................ 71 Glucose........................... 56, 57, 168, 170 Groin ..................................................... 81 H Hernia ................................................... 81 Humeral .......................... 49, 53, 115, 129 Hyperbaric....................... 53, 57, 116, 169 Hypothyroidism ....................... 80, 83, 169 Hypoxia ......................................... 53, 163 I Implantation ................................ 146, 147 Induction ............................................. 112 Infarction ....................................... 60, 176 Insulin.............................. 56, 57, 169, 170 Interleukins.......................................... 150 Intermittent ............................................ 66 Intravenous ............................. 12, 58, 173 Invasive........................................... 16, 51 Iodine .................................................... 80 Ischemia............................ 51, 60, 66, 176 L Lesion ................................... 57, 116, 171 Lipid .............................................. 57, 170 Lupus .................. 12, 67, 75, 80, 128, 129 Lymphocytic ................................ 113, 127 Lymphoma ...... 53, 57, 114, 115, 116, 171


M Malignant ..54, 57, 72, 114, 144, 164, 165, 171 Medullary .............................................146 Membrane .....................23, 160, 173, 174 Metabolite ............................................125 Methotrexate................................113, 127 Mobility ..........................36, 143, 152, 156 Mobilization..........................................158 Molecular ..56, 59, 60, 65, 86, 89, 91, 145, 147, 167, 175, 178 Myxedema .............................................81 N Neural ....................................58, 123, 172 Niacin...................................................123 Nitrogen .................................................49 O Ocular ....................................................63 Oral ..................................12, 23, 165, 172 Osteoarthritis .....................13, 20, 51, 144 Osteoclasts..........................................150 Osteolysis ...146, 147, 148, 149, 150, 152, 153, 157 Osteonecrosis.......20, 49, 64, 67, 72, 127, 128, 129, 130 Osteoporosis .........................................80 Osteotomy .........................16, 48, 64, 145 Overdose .............................................123 P Palpation........................................68, 173 Pancreatitis............................................12 Papillary.................................................64 Parenteral ..............................................50 Pelvic ...........................................116, 175 Perfusion .................................51, 57, 169 Perioperative .........................36, 145, 151 Phenotype .....................................59, 174 Physiologic ......54, 59, 160, 165, 175, 176 Polyarthritis..........................................114 Polyethylene .......145, 147, 148, 149, 150, 160, 174 Polypeptide....................................43, 177 Porosity................................................146 Potassium............................................124 Prednisone ....................................12, 116 Preoperative ........................................153 Prevalence.....................49, 116, 128, 153 Prostaglandins.....................................150 Prostate .................................................74

Prosthesis ........... 144, 148, 152, 157, 158 Proteins.... 43, 54, 55, 56, 58, 59, 74, 122, 124, 164, 165, 166, 168, 172, 175, 178 Proximal ...... 149, 150, 151, 155, 159, 167 Pulmonary........................................... 151 Pyelonephritis ....................................... 71 R Radiology .............................................. 71 Receptor ................................... 74, 75, 81 Refractory ........................................... 129 Registries ............................................ 157 Reperfusion................................... 60, 176 Resorption.. 146, 147, 149, 150, 158, 159, 173 Rheumatoid................. 12, 20, 75, 80, 144 Rheumatology....................... 29, 142, 144 Riboflavin ............................................ 122 Rigidity ................................................ 150 S Secretion......... 60, 83, 159, 169, 170, 176 Selenium ............................................. 124 Serum ........................................... 43, 176 Species ................................. 60, 128, 176 Spectrum............................................. 128 Spondylitis..................................... 50, 144 Steroid................. 12, 20, 49, 59, 129, 175 Substrate............................................. 148 Surgical .... 14, 16, 19, 36, 59, 66, 70, 131, 143, 144, 145, 151, 155, 157, 158, 172, 173, 176 Synovial ........................................ 23, 173 T Talus ......................................... 4, 67, 127 Testicular .................................... 113, 116 Thermoregulation................................ 122 Thrombophilia ..................................... 127 Thrombosis ................................. 151, 158 Thyrotoxicosis ....................................... 80 Thyroxine ............................................ 124 Tolerance ............................................ 156 Tomography.................................... 14, 20 Toxic 22, 60, 68, 123, 132, 166, 167, 176, 178 Toxin ................................................... 178 Transplantation ..................................... 48 Tumour...................................... 74, 75, 76 V Vasculitis................................. 12, 23, 173 Veins ............................... 16, 60, 170, 178

Index 183


Index 185


The Official Patient's Sourcebook on Avascular Necrosis

The Official Patient's Sourcebook on Tooth Decay

The Official Patient's Sourcebook on Bell's Palsy

The Official Patient's Sourcebook on Infantile Apnea

The Official Patient's Sourcebook on Hypertrophic Cardiomyopathy

The Official Patient's Sourcebook on Chondromalacia

The Official Patient's Sourcebook on Vitiligo

The 2002 Official Patient's Sourcebook on Diabetes

The Official Patient's Sourcebook on Hematuria

The 2002 Official Patient's Sourcebook on Angina

The Official Patient's Sourcebook on Hemochromatosis

The Official Patient's Sourcebook on Crohn's Disease

The Official Patient's Sourcebook on Sinusitis

The 2002 Official Patient's Sourcebook on Obesity

The Official Patient's Sourcebook on Conjunctivitis

The Official Patient's Sourcebook on Chlamydia

The Official Patient's Sourcebook on Hemochromatosis

The Official Patient's Sourcebook on Arenaviruses

The Official Parent's Sourcebook on Primary Immunodeficiency

The Official Patient's Sourcebook on Hepatitis A

The Official Patient's Sourcebook on Crohn's Disease

The Official Patient's Sourcebook on Spinal Stenosis

The 2002 Official Patient's Sourcebook on Hemophilia

The Official Patient's Sourcebook on Typhoid Fever

The Official Patient's Sourcebook on Narcolepsy

The Official Patient's Sourcebook on Transplantation

The Official Patient's Sourcebook on Macular Holes

The 2002 Official Patient's Sourcebook on Alcoholism

The Official Patient's Sourcebook on Typhoid Fever

The 2002 Official Patient's Sourcebook on Asthma

The Official Patient's Sourcebook on Binswanger's Disease

The Official Patient's Sourcebook on Avascular Necrosis

The Official Patient's Sourcebook on Tooth Decay

The Official Patient's Sourcebook on Bell's Palsy

The Official Patient's Sourcebook on Infantile Apnea

The Official Patient's Sourcebook on Hypertrophic Cardiomyopathy

The Official Patient's Sourcebook on Chondromalacia

The Official Patient's Sourcebook on Vitiligo

The 2002 Official Patient's Sourcebook on Diabetes

The Official Patient's Sourcebook on Hematuria

The 2002 Official Patient's Sourcebook on Angina

The Official Patient's Sourcebook on Hemochromatosis

The Official Patient's Sourcebook on Crohn's Disease

The Official Patient's Sourcebook on Sinusitis

The 2002 Official Patient's Sourcebook on Obesity

The Official Patient's Sourcebook on Conjunctivitis

The Official Patient's Sourcebook on Chlamydia

The Official Patient's Sourcebook on Hemochromatosis

The Official Patient's Sourcebook on Arenaviruses

The Official Parent's Sourcebook on Primary Immunodeficiency

The Official Patient's Sourcebook on Hepatitis A

The Official Patient's Sourcebook on Crohn's Disease

The Official Patient's Sourcebook on Spinal Stenosis

The 2002 Official Patient's Sourcebook on Hemophilia

The Official Patient's Sourcebook on Typhoid Fever

The Official Patient's Sourcebook on Narcolepsy

The Official Patient's Sourcebook on Transplantation

The Official Patient's Sourcebook on Macular Holes

The 2002 Official Patient's Sourcebook on Alcoholism

The Official Patient's Sourcebook on Typhoid Fever

The 2002 Official Patient's Sourcebook on Asthma

The Official Patient's Sourcebook on Binswanger's Disease

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