Address correspondence and requests for reprints to: B. Lawrence Riggs, M.D., Mayo Clinic and Foundation, Department of Endocrinology/Metabolism and Internal Medicine, 200 First Street SW, Rochester, Minnesota 55905.
The Osteoporotic Syndrome: Detection, Prevention, and Treatment, L. V. Avioli, Editor; Academic Press, Publ., 2000, 205 pgs.
This is the fourth edition of this concise multiauthored book on osteoporosis that again is edited by Dr. Louis V. Avioli. The previous editions have been very successful, and this one will be also. During the 7 yr since the last edition was published, perhaps more progress has been made in the understanding of osteoporosis as a disease and on its diagnosis and treatment than had been made in the preceding 50 yr. Thus, in many ways, this is a new book, rather than a mere update. It is short (205 pages), compact in size, and light, and it will be carried in briefcases and purses by many professionals.
The book is divided into 13 chapters, each with a different author or authors, although Dr. Avioli has co-authored two chapters in addition to writing one. Six of the 13 chapters are authored by faculty members at Washington University School of Medicine in St. Louis, the editors home institution. This is appropriate because Washington University has been one of the premier centers for osteoporosis for many years. Authorities in the field of osteoporosis author the remaining chapters, so that the reader clearly receives a national perspective on osteoporosis management.
Of the 13 chapters, 3 are on epidemiology or pathophysiology, 3 are on diagnosis, and 7 are on management. Chapter 1 provides the necessary background on fracture incidence and cost that allows the reader to understand the importance of osteoporosis as a disease. Interestingly, however, it focuses mainly on the necessity of a managed care approach, and especially on the need for prevention. Chapter 2 covers pathogenesis and successfully integrates the multiple causes of osteoporosis into an overall model, including newer information on the regulation of osteoblast and osteoclast formation from precursors in bone marrow. Although estrogen deficiency is interwoven into pathophysiology along with nutritional factors, secondary hyperparathyroidism, and abnormalities in vitamin D metabolism, its overriding importance in causation in women deserved stronger emphasis. Also, a more in-depth discussion of causal factors in male osteoporosis would have been helpful. Chapter 3 gives a brief, but informative, introduction into the genetics of osteoporosis.
Of the three chapters on diagnosis, most readers will find chapter 4 on bone mass measurement to be the most valuable. The various available methods are well described, and their use and interpretation in clinical practice are covered clearly. Chapter 5 gives a good overview on the emerging usage of biochemical markers. Chapter 13 on the use of the bone biopsy in osteoporosis, although very well written, is almost an anachronism. With the advent of biochemical markers, there is rarely a need to perform it for clinical purposes, with the exception of the occasional patient in whom mild osteomalacia needs to be excluded.
The seven chapters on management are the heart of the book, as they should be. Chapters 69 cover the major standard therapies of calcium, estrogen and selective estrogen receptor modulators, bisphosphonates, and calcitonin and are written by leading authorities in the field. Although space did not permit incorporating great detail, these chapters were well written and informative. Chapter 10 reviews the nonstandard therapies of vitamin D metabolites, fluoride, thiazides, and isoflavones. Although space considerations again limited an in-depth discussion, I nonetheless feel these topics were covered too superficially. For example, the reader was not made adequately aware of why the FDA has not given approval to use these drugs. In particular, there was insufficient discussion on the large discrepancy between increases in bone density and changes in fracture occurrence in most controlled clinical trials evaluating sodium fluoride. The book was published too soon to include the new data from clinical trials with PTH. These show impressive increases in bone density and decreases in vertebral fracture rate. Indeed, PTH is likely to be the next drug approved by the FDA for the treatment of osteoporosis.
Chapter 11 on orthopedic management contains a large amount of overlap with previous chapters, and much of what is covered is unrelated to the role of the orthopedist. However, it does contain useful information on surgical correction of pain from spinal deformity by insertion of orthopedic hardware and the value of external hip protectors in the prevention of hip fracture in high-risk subjects. The chapter could have been improved by a more detailed discussion of pain relief from injection of methylmethacrylate into vertebral fractures that produce localized, but severe, pain; by information on orthopedic support and braces; and by general information about the role of physical therapy and rehabilitation.
Although the various causes of secondary osteoporosis are not specifically covered, chapter 12 provides considerable information of glucocorticoid-induced osteoporosis. If a single secondary disease is to be discussed, this certainly should be the one. Both the pathogenesis and management of this important problem are well covered.
All in all, this is a concise, but informative, book that can be read easily and relatively rapidly. It provides an overview on osteoporosis for those who have limited knowledge about it. Thus, it will be most valuable to medical students, residents, general physicians, and paramedical personnel. However, even physicians in those clinical specialties that care for osteoporotic patients will find much information of value.
It would be impossible to close without acknowledging the enormous and varied contributions made to the field of osteoporosis by the editor, Louis V. Avioli, M.D., who died shortly after the book was completed. Lou was one of the original pioneers whose contributions to osteoporosis began almost 40 yr ago and ended with the publication of this fine fourth edition of The Osteoporotic Syndrome.
Received March 13, 2001.
Accepted March 13, 2001.
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