ANNEXURE 1 :
 ANNEXURE 2 :
 ANNEXURE 3 :
 ANNEXURE 4 :
 ANNEXURE 5 :
 ANNEXURE 6 :
 ANNEXURE 7 :
 ANNEXURE 8 :
 ANNEXURE 9 :

ANNEXURE 1 : GRADES OF RECOMMENDATION FOR LIFESTYLE INTERVENTION

He is the best physician who is the most ingenious inspirer of hope.                                                                                 -  Samule Taylor Coleridge

Grades of recommendation  :

 Grades of recommendations for lifestyle intervention  :

ANNEXURE 2                                                                                         GO-TOP

Life is not merely living but living in health.                                                                  - Martial

Priority aims and suggested actions for healthcare.

 Institutions  :

1. In patients presenting with a history of low impact fracture, diagnostic and therapeutic follow-up can be improved by taking following steps  :

·      Stastical analysis and recording of those patients who have had bone densitometry.

·        Stastical data collection and analysis of those patients identified as having low BMD values.

·        Percentage of patients with low impact fracture offered discussion and counseling of osteoporosis risk.  Documentation of steps taken by provider to provide health counseling.

·        Percentage of these patients offered osteoporosis treatment.

2.      Increase follow-up testing on patients on osteoporosis treatment with clinical
 evaluation and BMD measurements.

3.      Encourage adults in middle and late age groups presenting for health checkups for
 evaluation for osteoporosis risk factors.

·        Document percentage of patients presenting for a preventive check-up after
 documentation of risk factors for osteoporosis.

·        Percentage of patients at risk for fracture who have BMD testing done.

4.      Awareness regarding lifestyle factors affecting bone health should be encouraged
 amongst the institutional employees.

Annexure 3 : Abbreviations                                                     GO-TOP

When we ask advice, we are usually looking for an accomplice.                                       -  Marquis De Lagrange.

 
                                                                                                                                   GO-TOP

ANNEXURE 4 : RECOMMENDED BOOKS FOR FURTHER READINGS 

 Books are for nothing but to inspire.
- Ralph Waldo Emerson, The American Scholar

1. Osteoporosis - Edition 1 by Ralston, Stuart H. / Kleerekoper,  Michael MOSBY-YEAR BOOK INC
2. Osteoporosis Compendium - Edition 1 by Arden, Nigel CURRENT MEDICAL LITERATURE
3. The Johns Hopkins White Papers: Low Back Pain and Osteoporosis, 2002 - Edition 1 by Margolis, Simeon / Kostuik, John P. REBUS, INC
4. Clinician's Manual on Male Osteoporosis - Edition 1 by Orwoll                         SCIENCE PRESS INC.
5. Clinician's Manual on Prevention and Management of Osteoporosis - Edition 1 by Ralston SCIENCE PRESS INC.
6. Nutritional Aspects of Osteoporosis - Edition 1 by Burckhardt, Peter / Dawson-Hughes, / Heaney, Robert P.  ACADEMIC PRESS INC
7. Osteoporosis Sourcebook - Edition 1 by Cook, Allan R. OMNIGRAPHICS Bibliography
8. Osteoporosis (2-Volume Set) - Edition 2 by Marcus, Robert / Feldman, David / Kelsey, Jennifer ACADEMIC PRESS INC
9. The Osteoporosis Remedy: Designing a Personal Prevention Program - Edition 1 by Schettini, Stephen AVERY PUBLISHING GROUP
10. The Silent Thief: Osteoporosis, Exercises and Strategies for Prevention and Treatment - Edition 1 by Bohme, Karine / Budden, Frances FIREFLY BOOKS
11. An Atlas of Osteoporosis - Edition 2 by Stevenson, John C. / Marsh, Michael PARTHENON PUBLISHING
12. Contemporary Diagnosis and Management of Osteoporosis - Edition 1 by Baran HANDBOOKS IN HEALTH CARE COMPANY
13. Ernst Schering Research Foundation Workshop, 4: Hormone Replacement Therapy and Osteoporosis supplement 4 - Edition 1 by Kato, J. / Minaguchi, H. / Nichono, Y  SPRINGER VERLAG INC
14. Everything You Need to Know About Osteoporosis - Edition 1 82by Patrick, Judy Lyn PRIMA HEALTH PUBLISHING
15. Home Medical Guide to Osteoporosis - Edition 1 by American College of Physicians DK PUBLISHING
16. Osteoporosis - Edition 1 by Marcus, Robert BLACKWELL PUBLISHERS
17. Osteoporosis Management - Edition 1 by Reid, I.R. LIPPINCOTT WILLIAMS & WILKINS
18. Osteoporosis - Edition 1 by Marcus, Robert BLACKWELL PUBLISHERS clearance 04/02
19. Preventing and Managing Osteoporosis - Edition 1 by Gueldner, Sarah Hall / Burke, M. Susan / Smiciklas-Wright, Helen SPRINGER PUB CO INC
20. Preventing Osteoporosis with Ipriflavone: the Proven, Safe Alternative to Estrogen Replacement Therapy - Edition 1 by Girman, Andrea M. / Poole, Carol PRIMA HEALTH PUBLISHING
21. Preventing and Managing Osteoporosis - Edition 1 by Hall-Gueldner, Sarah / Burke, Susan / Smiciklas-Wright, Helen PROMETHEUS BOOKS
22. Strong Women, Strong Bones: Everything You Need to Know to Prevent, Treat, and Beat Osteoporosis - Edition 1 by Nelson, Miriam E. / Wernick, Sarah PENGUIN PUTNAM INC
23. The Athletic Woman's Survival Guide: How to Win the Battle Against Eating Disorders, Amenorrhea, Osteoporosis - Edition 1 by Otis, Carol L. / Goldingay, Roger HUMAN KINETICS PUBLISHERS
24. The Genetics of Osteoporosis and Metabolic Bone Disease - Edition 1 by Econs, Michael J.HUMANA PRESS
25. The Osteoporosis Primer - Edition 1 by Henderson, Janet E. / Goltzman, David CAMBRIDGE UNIVERSITY PRESS
26. Tumor Bone Diseases and Osteoporosis in Cancer Patients: Pathophysiology, Diagnosis, and Therapy - Edition 1 by Body, Jean-Jacques MARCEL DEKKER INC
27. Osteoporosis in Men: the Effects of Gender on Skeletal Health - Edition 1                               by Orwoll, Eric S. PRESS INC
28. Osteoporosis: Genetics, Prevention and Treatment - Edition 1                               by Adams, John S. / Lukert, Barbara P. ACADEMIC PUBLISHERS
29. Osteoporosis: Prevention, Diagnosis and Management - Edition 3                               by Notelovitz, Morris PROFESSIONAL COMMUNICATIONS INC                               new edition pending 03/03
30. Primer on Corticosteroid-Induced Osteoporosis - Edition 1 by Adachi, Jonathan D. WILLIAMS & WILKINS
31. Quantitative Ultrasound: Assessment of Osteoporosis and Bone Status - Edition 1 by Njeh, Christopher F. / Hans, Didier / Fuerst, Thomas                                 MARTIN DUNITZ LTD
32. Soy Smart Health: Discover the Super Food That Fights Breast Cancer, Heart Disease, Osteoporosis, Discomforts, and Estrogen - Edition 1 by Solomon, Neil / Passwater, Richard A. Elkins, Rita WOODLAND PUBLISHING CO
33. Super Calcium Counter: The Essential Guide to Preventing Osteoporosis and Building Strong Bones - Edition 1 by McIlwain, Harris / Bruce, Debra                               Fulghum KENSINGTON PUBLISHING CORP
34. Super Calcium Counter: The Essential Guide to Preventing Osteoporosis and Building Strong Bones - Edition 1 by McIlwain, Harris / Bruce, Debra                               Fulghum KENSINGTON PUBLISHING CORP
35. The Evaluation of Osteoporosis: Dual Energy X-Ray Absorptionmetry and Ultrasound in Clinical Practice - Edition 2 by Blake, Glen M. / Wahner, Heinz W. / Fogelman, Ignac MARTIN DUNITZ LTD
36. The Osteoporosis Book: A Guide for Patients and Their Families - Edition 1                               by Lane, Nancy E. UNIVERSITY PRESS
37. Walk Tall! An Exercise Program for the Prevention and Treatment of Osteoporosis - Edition 1 by Meeks, Sara TRIAD PUBLISHING COMPANY INC
38. Anabolic Treatments for Osteoporosis - Edition 1 by Whitfield, James F. CRC PRESS INC
39. Clinicians Manual Osteoporosis - Edition 1 by Avioli ©1998 n/a                               SAUNDERS W B CO not yet published, date indef  Orthopedics & Orthopedic Surgery
40. Novel Approaches to Treatment of Osteoporosis - Edition 1                               by Russell, R.G.G. / Skerry, T.M. / Kollenkirchen, U.                              SPRINGER VERLAG INC
41. Nutritional Aspects of Osteoporosis - Edition 1 by Burckhardt, Peter / Dawson-Hughes, / Heaney, Robert P. VERLAG INC
42. Osteoporosis: A Clinical Guide - Edition 2 by Woolf, Anthony D. / Dixon, Allan St. MARTIN DUNITZ LTD
43. Osteoporosis - Edition 1 by Stevenson, John C. / Lindsay, Robert                                 OXFORD UNIVERSITY PRESS
44. Osteoporosis in Clinical Practice: A Practical Guide for Diagnosis and Treatment - Edition 1 by Geusens, P. SPRINGER VERLAG INC
45. Shared Care for Osteoporosis - Edition 1 by Harrison                               MARTIN DUNITZ LTD
46. Stand Tall! Every Woman's Guide to Preventing and Treating Osteoporosis - Edition 2 by Notelovitz, Morris / Ware, Marsha / Tonnessen, Diana                                 TRIAD PUBLISHING COMPANY INC
47. The Parathyroid Hormone: An Unexpected Bone Builder for Treating Osteoporosis - Edition 1 by Whitfield, James F. / Morley, Paul / Willick, Gordon E. LANDES BIOSCIENCE PUBLISHERS
48. Bone Densitometry & Osteoporosis - Edition 1 by Genant                               SPRINGER VERLAG INC
49. Osteoporosis '96 - Edition 1 by Papapoulos, S.E. SCIENCE.
50. The Basics of arthritis – Edition 1 2003 by Dr Manoj R Kandoi, National Book Depot India.
51. Living with arthritis – Edition 1 2003 by Dr Manoj R Kandoi, Institute of Arthritis Care and Prevention, India.

 Annexure 5  :  Recommended web sites                                                         GO-TOP

Thought is the first faculty of man; to express it is one of his first desires; to spread it, his dearest privilege.
-  Abbe Raynal

Annexure 6  Recommended guidelines for further readings                         GO-TOP

Reading is to the mind what exercise is to the body.
         - Richard Steele, The Tatler, no.147

ANNEXURE 7 : RECOMMENDED READINGS                                                        GO-TOP

People say that life is the thing, but I prefer reading.
                       -  Logan Pearsall Smith, Afterthoughts

 Epidemiology

1. Ensrud KE,Thompson DE,Cauley JA,et al (Fracture Intervention Trial Research Group). Prevalent vertebral deformities predict mortality and hospitalization in older women with low bone mass.J Am Geriatr Soc.2000; 48:241-249.
2. Grainge MJ,Coupland CA,Cliffe SJ,Chilvers CE, Hosking DJ (Nottingham EPIC Study Group). Cigarette smoking, alcohol and caffeine consumption, and bone mineral density in postmenopausal women.Osteoporos Int. 1998;8:355-363.
3. Kado DM,Browner WS,Palermo L,Nevitt MC, Genant HK,Cummings SR (Study of Osteoporotic Fractures Research Group). Vertebral fractures and mortality in older women:a prospective study. Arch Intern Med.1999;159:1215-1220.
4. Melton LJ III,Egan KS,O ’Fallon WM,Riggs BL . Influence of fracture criteria on the outcome of a randomized trial of therapy. Osteoporos Int.1998;8:184-191.
5. Ray NF,Chan JK,Thamer M,Melton LJ III. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995:report from the National Osteoporosis Foundation .J Bone Miner Res.1997;12:24-35.

 General Information

1. Jensen ME,Evans AJ,Mathis JM,Kallmes DF,Cloft HJ,Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures:technical aspects. Am J Neuroradiol.1997;18:1897-1904.
2. Kano K. Relationship between exercise and bone mineral density among over 5,000 women aged 40 years and above. J Epidemiol.1998;8:28-32.
3. McClung MR.Therapy for fracture prevention. JAMA.  1999;282:687-689.
4. Meunier PJ.Evidence-based medicine and osteoporosis:a comparison of fracture risk reduction data from osteoporosis randomised clinical trials. Int J Clin Pract.1999;53: 122-129.
5. Wolff I,van Croonenborg JJ,Kemper HC,Kostense PJ,Twisk JW.The effect of exercise training programs on bone mass:a meta-analysis of published controlled trials in pre-and postmenopausal women.Osteoporos Int.1999;9:1-12.

 Bone Density Measurement

1. Cummings SR,Palermo L,Browner W,et al (Fracture Intervention Trial Research Group).Monitoring osteoporosis therapy with bone densitometry: misleading changes and regression to the mean.JAMA.2000;283:1318-1321.
2. Garton MJ,Cooper C,Reid D. Perimenopausal bone density screening will it help prevent osteoporosis? Maturitas.1997;26:35-43.
3. Orwoll ES,Bauer DC,Vogt TM,Fox KM (Osteoporotic Fractures Research Group).Axial bone mass in older women.Ann Intern Med.1996;124:187-196.
4. Wasnich RD,Miller PD. Antifracture efficacy of antiresorptive agents are related to changes in bone density.J Clin Endocrinol Metab.2000;85:231-236.
5. Watts NB. Understanding the bone mass measurement act. J Clin Densitom.1999;2:211-217.

 Biochemical Markers of Bone Turnover in Osteoporosis

1. Garnero P,Delmas PD. Biochemical markers of bone turnover:applications for osteoporosis.Endocrinol Metab Clin North Am.1998;27:303-323.
2. Hannon R,Blumsohn A,Naylor K,Eastell R. Response of biochemical markers of bone turnover to hormone replacement therapy:impact of biological variability. J Bone Miner Res.1998;13:1124-1133.
3. Looker AC,Bauer DC,Chesnut CH III,et al. Clinical use of biochemical markers of bone remodeling: current status and future directions. Osteoporos Int.2000;11:467-480.

Alendronate

1. Black DM,Cummings SR,Karpf DB,et al (Fracture Intervention Trial Research Group). Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures.Lancet.1996;348:1535-1541.
2. Black DM,Thompson DE,Bauer DC,et al (FIT Research Group). Fracture risk reduction with alendronate in women with osteoporosis:the Fracture Intervention Trial. J Clin Endocrinol Metab.2000;85:4118-4124.
3. Cummings SR,Black DM,Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial.JAMA.1998;280:2077-2082.
4. de Groen PC,Lubbe DF,Hirsch LJ, et al. Esophagitis associated with the use of alendronate.N Engl J Med. 1996;335:1016-1021.
5. Devogelaer JP,Broll H,Correa-Rotter R, et al. Oral alendronate induces progressive increases in bone mass of the spine, hip, and total body over 3 years in postmenopausal women with osteoporosis [erratum in Bone.  1996;19:78 ].Bone.1996;18:141-150.
6. Downs RW Jr,Bell NH,Ettinger MP, et al. Comparison of alendronate and intranasal calcitonin for treatment of osteoporosis in postmenopausal women. J Clin Endocrinol Metab.2000;85:1783-1788.
7. Ensrud KE,Black DM,Palermo L, et al. Treatment with alendronate prevents fractures in women at highest risk: results from the Fracture Intervention Trial.Arch Intern Med.1997;157:2617-2624.
8. Felsenberg D,Alenfeld F,Bock O,Hammermeister C, Gowan W (Fosamax International Trial [FOSIT ]Study Group). Placebo-controlled multicenter study of oral alendronate in postmenopausal osteoporotic women. Maturitas.1998;31:35-44.
9. Hosking D,Chilvers CE,Christiansen C,et al (Early Postmenopausal Intervention Cohort Study Group). Prevention of bone loss with alendronate in postmenopausal women under 60 years of age. N Engl J Med. 1998;338:485-492.
10. Karpf DB,Shapiro DR,Seeman E, et al (Alendronate Osteoporosis Treatment Study Groups). Prevention of nonvertebral fractures by alendronate:a meta-analysis. JAMA.1997;277:1159-1164.
11. Liberman UA,Weiss SR,Broll J, et al (Alendronate Phase III Osteoporosis Treatment Study Group). Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis.N Engl J Med.1995;333:1437-1443.
12. Lowe CE,Depew WT,Vanner SJ,Paterson WG, Meddings JB. Upper gastrointestinal toxicity of alendronate. Am J Gastroenterol.2000;95:634-640.
13. Pols HA,Felsenberg D,Hanley DA,et al (Fosamax International Trial Study Group). Multinational, placebo-controlled, randomized trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass: results of the FOSIT study. Osteoporos Int.1999;9:461-468.
14. Ravn P,Weiss SR,Rodriguez-Portales JA, et al (Alendronate Osteoporosis Prevention Study Group). Alendronate in early postmenopausal women:effects on bone mass during long-term treatment and after withdrawal. J Clin Endocrinol Metab.2000;85:1492-1497.
15. Ribeiro A,DeVault KR,Wolfe JT III,Stark ME. Alendronate-associated esophagitis:endoscopic and pathologic features. Gastrointest Endosc.1998;47:525-528.
16. Saag KG,Emkey R,Schnitzer TJ,et al (Glucocorticoid Induced Osteoporosis Intervention Study Group). Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis.N Engl J Med.1998;339:292-299.
17. Schnitzer T,Bone HG,Crepaldi G, et al (Alendronate Once-Weekly Study Group). Therapeutic equivalence of alendronate 70 mg once-weekly and alendronate 10 mg daily in the treatment of osteoporosis.Aging (Milano).2000;12:1-12.
18. Stock JL,Bell NH,Chesnut CH III, et al. Increments in bone mineral density of the lumbar spine and hip and suppression of bone turnover are maintained after discontinuation of alendronate in postmenopausal women. Am J Med. 1997;103:291-297.
19. Tonino RP,Meunier PJ,Emkey R,et al (Phase III Osteoporosis Treatment Study Group). Skeletal benefits of alendronate:7-year treatment of postmenopausal osteoporotic women. J Clin Endocrinol Metab.2000;85:3109-3115.
20. Watts N,Freedholm D,Daifotis A. The clinical tolerability profile of alendronate.Int J Clin Pract Suppl.1999; 101:51-61.

Risedronate
 

1. Cohen S,Levy RM,Keller M, et al. Risedronate therapy prevents corticosteroid-induced bone loss: a twelve-month, multicenter, randomized, double-blind, placebo controlled, parallel-group study. Arthritis Rheum.1999;42:2309-2318.
2. Eastell R,Devogelaer JP,Peel NF, et al. Prevention of bone loss with risedronate in glucocorticoid-treated rheumatoid arthritis patients.Osteoporos Int.2000;11:331-337.
3. Harris ST,Watts NB,Genant HK, et al (Vertebral Efficacy With Risedronate Therapy [VERT ]Study Group). Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis:a randomized controlled trial.JAMA.1999;282:1344-1352.
4. McClung MR,Geusens P,Miller PD, et al (Hip Intervention Program Study Group).Effect of risedronate on the risk of hip fracture in elderly women.N Engl J Med.2001;344:333-340.
5. Reginster J,Minne HW,Sorensen OH, et al (Vertebral Efficacy with Risedronate Therapy [VERT ]Study Group). Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis.Osteoporos Int.2000;11:83-91.
6. Reid DM,Hughes RA,Laan RF, et al. Efficacy and safety of daily risedronate in the treatment of corticosteroid induced osteoporosis in men and women: a randomized trial;European Corticosteroid-Induced Osteoporosis Treatment Study.J Bone Miner Res.2000;15:1006-1013.
7. Watts N,Roux C,Genant H, et al. Risedronate reduces vertebral fracture risk after the first year of treatment in postmenopausal women with established osteoporosis.J Bone Miner Res.1999;14:S136.

Other Bisphosphonates

1. Heikkinen JE,Selander KS,Laitinen K,Arnala I, Vaananen HK. Short-term intravenous bisphosphonates in prevention of postmenopausal bone loss.J Bone Miner Res.1997;12:103-110.
2. Lees B,Garland SW,Walton C,Ross D,Whitehead MI, Stevenson JC. Role of oral pamidronate in preventing bone loss in postmenopausal women.Osteoporos Int. 1996;6:480-485.
3. Miller PD,Watts NB,Licata AA, et al. Cyclical etidronate in the treatment of postmenopausal osteoporosis: efficacy and safety after seven years of treatment [erratum in Am J Med.1998;104:608 ].Am J Med.1997;103: 468-476.
4. Orr-Walker B,Wattie DJ,Evans MC,Reid IR. Effects of prolonged bisphosphonate therapy and its discontinuation on bone mineral density in post-menopausal osteoporosis. Clin Endocrinol (Oxf).1997;46:87-92.
5. Peretz A,Body JJ,Dumon JC, et al. Cyclical pamidronate infusions in postmenopausal osteoporosis. Maturitas.1996;25:69-75.
6. Recker RR,Stakkestad JA,Felsenberg D, et al. A new treatment paradigm:quarterly injections of ibandronate reduce the risk of fractures in women with postmenopausal osteoporosis (PMO):results of a 3-year trial.Osteoporos Int.2000;11:S209.
7. Roux C,Oriente P,Laan R, et al (Ciblos Study Group). Randomized trial of effect of cyclical etidronate in the prevention of corticosteroid-induced bone loss.J Clin Endocrinol Metab.1998;83:1128-1133.
8. Watts NB. Treatment of osteoporosis with bisphosphonates. Endocrinol Metab Clin North Am.1998;27:419-439.

Calcitonin

1. Chesnut CH III,Silverman S,Andriano K, et al (PROOF Study Group). A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis:the Prevent Recurrence of Osteoporotic Fractures Study.Am J Med.2000;109:267-276.

 Estrogen and Hormone Replacement Therapy

1. WHI (Women’s Health Initiative) Writing Group for the Women’s Health Initiative Investigators.  Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-333.

2.      HERS (Heart and Estrogen/Progestin Replacement Study) Herrington DM, Vittinghoff E, Lin F, et al, for the HERS Study Group. Statin therapy, cardiovascular events, and total mortality in the Heart and Estrogen/Progestin Replacement Study (HERS). Circulation 2002; 105:2962-2967.

3. HERS II (Heart and Estrogen/Progestin Replacement Study) Grady D, Herrington D, Bittner V, et al, for the HERS Research Group. Cardiovascular disease out-comes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA 2002;288:49-57.
4. WEST (Women’s Estrogen for Stroke Trial) Viscoli CM, Brass LM, Kernan WN, Sarrel PM, Suissa S, Horwitz RI. A clinical trial of estrogen-replacement therapy after ischemic stroke. N Engl J Med 2001;345:1243-1249.
5. Nurses’ Health Study Grodstein F, Manson JE, Colditz GA, Willett WC, Speizer FE, Stampfer MJ. A prospective, observational study of postmenopausal hormone therapy and primary prevention of cardiovascular disease. Ann Intern Med 2000;133:933-941.
6. HOPE (Women’s Health, Osteoporosis, Progestin,Estrogen trial) Archer DF, Dorin M, Lewis V, Schneider DL, Pickar JH. Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on endometrial bleeding. Fertil Steril 2001;75:1080-1087.
7. ERA (Estrogen Replacement and Atherosclerosis trial) Herrington DM, Reboussin DM, Brosnihan KB, et al. Effects of estrogen replacement on the progression of coronary-artery atherosclerosis. N Engl J Med 2000; 343:522-529.
8. EPAT (Estrogen in the Prevention of Atherosclerosis Trial) Hodis HN, Mack WJ, Lobo RA, et al, for Estrogen in the Prevention of Atherosclerosis Trial Research Group. Estrogen in the prevention of atherosclerosis: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2001;135:939-953.
9. MORE (Multiple Outcomes of Raloxifene Evaluation) Barrett-Connor E, Grady D, Sashegyi A, et al, for the MORE Investigators (Multiple Outcomes of Raloxifene Evaluation). Raloxifene and cardiovascular events in osteoporotic postmenopausal women: four-year results from the MORE (Multiple Outcomes of Raloxifene Evaluation) randomized trial. JAMA 2002;287: 847-857.
10. PEPI (Postmenopausal Estrogen/Progestin Interventions study) Barrett-Connor E, Slone S, Greendale G, et al. The Postmenopausal Estrogen/Progestin Interventions Study: primary outcomes in adherent women. Maturitas 1997;27:261-274.
11. SWAN (Study of Women’s Health Across the Nation) Huang M-H, Schocken M, Block G, et al. Variation in nutrient intakes by ethnicity: results from the Study of Women’s Health Across the Nation (SWAN).Menopause 2002;9:309-319.
12. FIT (Fracture Intervention Trial) Black DM, Thompson DE, Bauer DC, et al, for the Fracture Intervention Trial. Fracture risk reduction with alendronate in women with osteoporosis: the Fracture Intervention Trial [erratum appears in J Clin Endocrinol Metab 2001;86:938]. J Clin Endocrinol Metab 2000;85:4118-4124.
13. VERT (Vertebral Efficacy With Risedronate Therapy study group) Harris ST, Watts NB, Genant HK, et al, for the Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. JAMA 1999;282:1344-1352.
14. HIP (Hip Intervention Program study group) McClung MR, Geusens P, Miller PD, et al. Effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med 2001;344:333-340.

Combination Pharmacologic Therapy

1. Lindsay R,Cosman F,Lobo RA, et al. Addition of alendronate to ongoing hormone replacement therapy in the treatment of osteoporosis: a randomized, controlled clinical trial.J Clin Endocrinol Metab.1999;84:3076-3081.
2. Ravn P,Bidstrup M,Wasnich RD, et al. Alendronate and estrogen-progestin in the long-term prevention of bone loss: four-year results from the early postmenopausal intervention cohort study; a randomized, controlled trial. Ann Intern Med.1999;131:935-942.

 Unapproved Pharmacologic Agents

1. Feskanich D,Willett WC,Stampfer MJ,Colditz GA. A prospective study of thiazide use and fractures in women. Osteoporos Int.1997;7:79-84.
2. Finkelstein JS,Klibanski A,Arnold AL,Toth TL, Hornstein MD,Neer RM. Prevention of estrogen deficiency-related bone loss with human parathyroid hormone (1-34):a randomized controlled trial.JAMA.1998;280: 1067-1073.
3. Gambacciani M,Cappagli B,Piaggesi L,Ciaponi M, Genazzani AR. Ipriflavone prevents the loss of bone mass in pharmacological menopause induced by GnRH-agonists. Calcif Tissue Int.1997;61(Suppl 1):S15-S18.
4. Gambacciani M,Ciaponi M,Cappagli B,Piaggesi L, Genazzani AR. Effects of combined low dose of the isoflavone derivative ipriflavone and estrogen replacement on bone mineral density and metabolism in postmenopausal women.Maturitas.1997;28:75-81.
5. Gennari C,Agnusdei D,Crepaldi G, et al. Effect of ipriflavone a synthetic derivative of natural isoflavones on bone mass loss in the early years after menopause. Menopause.1998;5:9-15.
6. Hodsman AB,Fraher LJ,Watson PH, et al. A randomized controlled trial to compare the efficacy of cyclical parathyroid hormone versus cyclical parathyroid hormone and sequential calcitonin to improve bone mass in postmenopausal women with osteoporosis.J Clin Endocrinol Metab.1997;82:620-628.
7. Ishimi Y,Miyaura C,Ohmura M, et al. Selective effects of genistein,a soybean isoflavone,on B-lymphopoiesis and bone loss caused by estrogen deficiency.Endocrinology.1999;140:1893-1900.
8. Lindsay R,Nieves J,Formica C, et al. Randomised controlled study of effect of parathyroid hormone on vertebral bone mass and fracture incidence among postmenopausal women on oestrogen with osteoporosis.Lancet.1997;350: 550-555.
9. Lippuner K,Haenggi W,Birkhaeuser MH,Casez JP, Jaeger P. Prevention of postmenopausal bone loss using tibolone or conventional peroral or transdermal hormone replacement therapy with 17beta-estradiol and dydrogesterone.J Bone Miner Res.1997;12:806-812.
10. Meunier PJ,Sebert JL,Reginster JY, et al. Fluoride salts are no better at preventing new vertebral fractures than calcium-vitamin D in postmenopausal osteoporosis: the FAVO Study.Osteoporos Int.1998;8:4-12.
11. Pak CY,Zerwekh JE,Antich PP,Bell NH,Singer FR. Slow-release sodium fluoride in osteoporosis.J Bone Miner Res.1996;11:561-564.
12. Pavlov PW,Ginsburg J,Kicovic PM,van der Schaaf DB,Prelevic G,Bennink HJ. Double-blind, placebo-controlled study of the effects of tibolone on bone mineral density in postmenopausal osteoporotic women with and without previous fractures.Gynecol Endocrinol.1999;13:230-237.
13. Reginster JY,Meurmans L,Zegels B, et al. The effect of sodium monofluorophosphate plus calcium on vertebral fracture rate in postmenopausal women with moderate osteoporosis:a randomized,controlled trial. Ann Intern Med.1998;129:1-8.
14. Studd J,Arnala I,Kicovic PM,Zamblera D,Kroger H, Holland N.A randomized study of tibolone on bone mineral density in osteoporotic postmenopausal women with previous fractures.Obstet Gynecol.1998;92(4 Pt 1):574-579.

ANNEXTURE 8 : DIRECTIONS FOR FURTHER RESEARCH                                            GO-TOP

There is only one corner of the universe you can be certain of improving, and that’s your own self.
- Aldous Huxley

 The following issues need to be addressed:

1. To identify genetic factors leading to osteoporosis.
2. To develop pharmacogenetic approaches for targeting the predisposing genetic factors.
3. To develop strategies to maximize peak bone mass in girls and boys.
4. More research regarding the impact of various risk factors on bone mass.
5. To determine mechanism, extent of impact of steroid induced osteoporosis.  To develop steroid with least adverse effects on skeletal system.  To develop new pharmacological approaches to stimulate bone formation in this condition.
6. Further research on the use of biphosphonates or other drugs in secondary osteoporosis.
7. Trials of dietary supplements.
8. Improved detection methods and reporting of BMD and fracture risk.
9. To determine long term effects of fractures on individuals and society.
10. To determine the effects of micronutrients on bone health and conduct trials of dietary supplement containing these micronutrients.
11. To develop most effective tool for community screening of osteoporosis which is cost-effective.
12. Development  and assessment of agents stimulating bone formation.
13. To develop health education program for community and health professionals.
14. To study consequences of osteoporosis related fractures on non-skeletal body systems.
15. To determine the causes of disease in perimenopausal women.
16. Development of a combination therapy using antiresorptive and anabolic (bone forming) medications.
17. Identification of patients for diagnosis and treatment.  To determine which asymptomatic patient should have BMD screening.
18. To assure accessibility to treatment for people specially in developing countries.
19. To determine diagnosis and management paradigm for osteoporotic fractures.
20. Randomized clinical trials of combination therapies comprising of pharmacological, dietary supplement and lifestyle interventions.
21. To determine optimum duration of pharmacological therapies.
22. To determine cost effectiveness of recommended strategies on fall preventions.
23. To determine the effect of restraint removal, coupled with other interventions on falls related injuries.
24. To determine effective elements of exercise programs and cardiovascular programs for fall prevention.
25. To determine the effectiveness of assistive devices med alone as a method for preventing falls. 

ANNEXTURE 9 : RESOURCES                                                                                   GO-TOP

The foundation of every state is the education of its youth.
                                                                                               -  Diogenes.

 The following are major sources of health education, information on patient groups, self-help aids and equipment.

1. National Osteoporosis Foundation : 1150 17^th street, NW Suite 500, Washington, DC 20036.
2. US Arthritis Foundation : 1314 Spring St. New Atlanta, 6A 30309, USA.
3. Institute Of Arthritis Care And Prevention : Ashirwad Hospital, Almas Mension, SVP Road, New Colony, Ambernath (W), Dist : Thane State : Maharashtra.
4. Indian Rheumatism Association : Headquarters, PD Hinduja Hospital and Medical Research centre, Mumbai Maharashtra.
5. Rehabilitation International USA : 1123, Broadway, New York, NY 10010 USA.
6. American Occupational Therapy Association : 6000 Executive Bldg. Rockville, MD 20852 USA.
7. Arthritis Society : 920 Yonge St., Stc. 420, Toronto, Ontario M5E, 1E6 Canada.
8. National Association Of The Physically Handicapped, Inc. : 76 Elm. St. London, Ohio 43140 USA.
9. National Information Center For The Handicapped : PO Box 1492, Washington DC 20013 USA.
10. National Safety Council Dept. : H.P.O. Box 11171, Chicago, IL 60611 USA.
11. Public Affairs Committee, Inc. (pamphlet publishers) : 381 Park Avenue South New York, NY 10016 USA.
12. British Rheumatism And Arthritis Association : 6, Grosvenor Square, London SW1.
13. The Arthritis And Rheumatism Council : Fouaday House, 8/10 Charing Cross Road, London WC 2.
14. Clearinghouse On The Handicapped : Office of special education and rehabilitative services, Room 3106, Switzer Bldg., 330 C St SW, Washington, DC 20202.
15. Disabled USA : The president’s committee on employment of the handicapped, Washington, DC 20210.
16. Encore National Library : Service for the blind and physically handicapped, Library of congress, Washington, DC 20540 Bi-monthly recording for talking books, readers of selections for publications for the disabled.
17. National Rehabilitation Information Center : 4407, Eight Street, NW, Catholic University of America, Washington, DC 20017.    

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