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Paolo Bossi,1 Andrea Antonuzzo,2 Grazia Armento,3 Francesca Consoli,1 Jacopo Giuliani,4 Raffaele Giusti,5 Maurizio Lucchesi,6 Aurora Mirabile,7 Loredana Palermo,8 Sarah Scagliarini9 1Department of Medical Oncology, ASST-Spedali Civili, Brescia, Italy; 2Medical Oncology Unit 1 SSN, Oncology Center, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; 3Department of Medical Oncology, Campus Bio-Medico University Hospital, Rome, Italy; 4Unit Department Medical Oncology, Mater Salutis, Hospital, Legnago, Italy; 5Unit Department Medical Oncology, Sant ‘Andrea University Hospital, Rome, Italy; 6Pneumology Unit - Thoracic Oncology Service, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; 7Department of Oncology, San Raffaele University Hospital, Milan, Italy; 8Unit Department Medical Oncology, IRCCS Giovanni Paolo, Bari, Italy; 9Unit Department Medical Oncology, AORN Cardarelli, Napoli, ItalyCorrespondence: Paolo BossiDepartment of Medical Oncology, ASST-Spedali Civili, Brescia, 1, Brescia, 25123, ItalyTel +39 0303998969Fax +39 0303995072Email paolo.bossi@unibs.itBackground: Despite the prevalence of pain among patients with cancer and the availability of pertinent guidelines, the clinical management of oncological pain is decisively insufficient. To address this issue, we evaluated current trends in clinical practice and subsequently generated a list of ten corrective actions—five things to do and five things not to do—for the diagnosis, management, and monitoring of cancer pain.Methods: The survey included 18 questions about clinical practice surrounding background pain and breakthrough cancer pain (BTcP). Survey questions were developed by a scientific board of 10 physician experts and communicated via email to an expanded panel of physicians in Italy. Responses were tabulated descriptively for analysis.Results: Of 51 invited physicians, 32 (63%) provided complete survey responses. The responses revealed several incongruencies with current guideline recommendations: physicians did not always diagnose or monitor pain using diagnostically validated or disease-specific instruments; frequently based clinical decision-making on time availability or convenience; and pharmacological therapy was often inappropriate (eg, prescribing NSAIDs or corticosteroids for BTcP). The list of corrective actions generated by the scientific board favored a guideline-oriented approach that systematically characterizes oncological pain and implements treatment based on pain characteristics (eg, fast-acting transmucosal opioids for BTcP) and evidence-based recommendations.Conclusion: Oncologists require better education and training about the diagnosis, treatment, and monitoring of oncological pain. Physicians should be aware of current guideline recommendations as well as available pharmacological tools for BTcP.Keywords: cancer pain, pain management, precision medicine, digital medicine

The prevalence of radiographically ascertained vertebral fractures in a random sample of 413 in Mexican men is 9.7% (95% CI 6.85–12.55). Increase of vertebral fracture rises with age from 2.0% in the youngest group (50–59 years) to 21.4% in the oldest group (80 years and over).This is the first population-based study of vertebral fractures in Mexican men using a standardized methodology reported in other studies.The presence of radiographic vertebral fractures increases with age. This same pattern was found in Mexican women with steady age increments, but the higher prevalence of fractures in women starts at age 70, whereas in men, the higher prevalence starts a decade later (80 years and over).The standardized prevalence per 1,000 men 50 years and over in the Mexican population for the year 2005 is 65.8 (95% CI 29.9–105.5), and it is 68.6 (95% CI 32.2–108.7) in the US population for the year 2000.

Vertebral fractures in older women signal an increased risk of additional osteoporotic fractures. To identify risk factors for first vertebral fractures, we studied 5822 women greater than or equal to65 years of age who had no fracture on baseline radiographs of the spine. Several modifiable risk factors increased an older woman's risk of developing a first vertebral fracture, and women with multiple risk factors and low BMD had the highest risk. Risk factors and low BMD should be useful to help focus efforts to prevent these fractures. Introduction: Vertebral fractures are a common cause of back pain and disability and signal an increased risk of additional osteoporotic fractures in older women. Little is known about the risk factors for the first occurrence of a vertebral fracture. Materials and Methods: To identify risk factors for a first vertebral fracture, we studied 5822 women greater than or equal to65 years of age from the Study of Osteoporotic Fractures who had no fracture on baseline radiographs of the spine. We measured potential risk factors and BMD of the wrist and calcaneus at baseline and BMD of the spine and hip halfway through follow-up. Fractures were assessed by standard methods from spine radiographs obtained at baseline and follow-up an average of 3.7 years later. Results and Conclusions: In multivariable analyses, older age, previous nonspine fracture, low BMD at all sites, a low body mass index (BMI), current smoking, low milk consumption during pregnancy, low levels of daily physical activity, having a fall, and regular use of aluminum-containing antacids independently increased the risk of a first vertebral fracture. Women using estrogen and those who engaged in recreational physical activity had a decreased risk. The effects of low BMI, smoking, use of estrogen and antacids, and previous fracture were partially mediated by BMD. Women in the lower third of wrist BMD with five or more risk factors had a 12-fold greater risk than women in the highest third of BMD who had zero to three risk factors. The 27% of women at highest risk suffered 60% of the incident fractures. In conclusion, several modifiable risk factors and BMD independently increase an older woman's risk of developing a first vertebral fracture. The combination of risk factors and BMD should be useful for focusing efforts to prevent vertebral fractures.

ContextAlendronate sodium reduces fracture risk in postmenopausal women who have vertebral fractures, but its effects on fracture risk have not been studied for women without vertebral fractures.ObjectiveTo test the hypothesis that 4 years of alendronate would decrease the risk of clinical and vertebral fractures in women who have low bone mineral density (BMD) but no vertebral fractures.DesignRandomized, blinded, placebo-controlled trial.SettingEleven community-based clinical research centers.SubjectsWomen aged 54 to 81 years with a femoral neck BMD of 0.68 g/cm2 or less (Hologic Inc, Waltham, Mass) but no vertebral fracture; 4432 were randomized to alendronate or placebo and 4272 (96%) completed outcome measurements at the final visit (an average of 4.2 years later).InterventionAll participants reporting calcium intakes of 1000 mg/d or less received a supplement containing 500 mg of calcium and 250 IU of cholecalciferol. Subjects were randomly assigned to either placebo or 5 mg/d of alendronate sodium for 2 years followed by 10 mg/d for the remainder of the trial.Main outcome measuresClinical fractures confirmed by x-ray reports, new vertebral deformities detected by morphometric measurements on radiographs, and BMD measured by dual x-ray absorptiometry.ResultsAlendronate increased BMD at all sites studied (P2.5 SDs below the normal young adult mean; RH, 0.64; 95% CI, 0.50-0.82; treatment-control difference, 6.5%; number needed to treat [NNT], 15), but there was no significant reduction among those with higher BMD (RH, 1.08; 95% CI, 0.87-1.35). Alendronate decreased the risk of radiographic vertebral fractures by 44% overall (relative risk, 0.56; 95% CI, 0.39-0.80; treatment-control difference, 1.7%; NNT, 60). Alendronate did not increase the risk of gastrointestinal or other adverse effects.ConclusionsIn women with low BMD but without vertebral fractures, 4 years of alendronate safely increased BMD and decreased the risk of first vertebral deformity. Alendronate significantly reduced the risk of clinical fractures among women with osteoporosis but not among women with higher BMD.

We present the case of F.G., a healthy, normally developed 22-year-old male subject affected by a pervasive disorder in environmental orientation and navigation who presents no history of neurological or psychiatric disease. A neuro-radiological examination showed no evidence of anatomical or structural alterations to the brain. We submitted the subject for a comprehensive neuropsychological assessment of the different cognitive processes involved in topographical orientation to evaluate his ability to navigate the spatial environment. The results confirmed a severe developmental topographical disorder and deficits in a number of specific cognitive processes directly or indirectly involved in navigation. The results are discussed with reference to the sole previously described case of developmental topographical disorientation (Pt1; Iaria et al., 2009). F.G. differs from the former case due to the following: the greater severity of his disorder, his complete lack of navigational skills, the failure to develop compensatory strategies, and the presence of a specific deficit in processing the spatial relationships between the parts of a whole. The present case not only confirms the existence of developmental topographical-skill disorders, but also sheds light on the architecture of topographical processes and their development in human beings. (Contains 3 tables and 4 figures.)

Byline: D. C. Bauer (1), D. C. Bauer (2), L. Palermo (2), D. Black (2) Keywords: Key words:Bone mineral density -- Mortality -- Prospective cohort -- Quantitative ultrasound Abstract: Previous studies suggest that low bone mineral density (BMD) is associated with increased mortality, but the relationship between quantitative ultrasound (QUS) and mortality is unknown. We studied 5816 women over age 70 years enrolled in the Study of Osteoporotic Fractures. QUS of the calcaneus, and BMD of the calcaneus and hip, were measured at baseline, and women were contacted every 4 months to determine vital status. All reported deaths were confirmed by review of the death certificate or hospital records, and classified by ICD-9 code. During 5.0 years of follow-up, 677 women died. Women in the lowest quintile of QUS had the highest mortality during follow-up. After adjustment for age, grip strength, weight, height, health status, estrogen use, smoking, physical activity, and history of hypertension, diabetes, cardiovascular disease, cancer and stroke, each 1 SD reduction in broadband ultrasonic attenuation (BUA) was associated with a 16% increase in mortality (RH = 1.16 95% CI: 1.07, 1.26). Mortality from cardiovascular disease, cancer and other causes were all increased among women with low QUS, but the association with cancer deaths was not statistically significant after multiple adjustments (RH = 1.09 CI: 0.93, 1.27). Low BMD was also associated with an increased risk of total and cause-specific mortality, but we found little evidence that BUA and BMD were independent predictors of mortality. Results were similar among women who did not fracture during follow-up. In this large population-based study of older women, low QUS is associated with both total and cause-specific mortality. This relationship was independent of other factors associated with mortality, such as age and health status, and suggests QUS and BMD may reflect some aspect of aging not captured by these traditional factors. Author Affiliation: (1) Division of General Internal Medicine, US (2) Department of Epidemiology and Biostatistics, University of California, San Francisco , US (3) Department of Epidemiology, University of Pittsburgh, USA, US Article note: Received: 16 March 2001 / Accepted: 19 February 2002