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February 17, 1989, Vol 261, No. 7 >
ARTICLE | February 17, 1989

`Senile' Osteoporosis Reconsidered FREE

Neil M. Resnick, MD; Susan L. Greenspan, MD
[+] Author Affiliations

Reprint requests to Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Resnick).


JAMA. 1989;261(7):1025-1029. doi:10.1001/jama.1989.03420070075034
Text Size: A A A
Published online
Article
References

Osteoporosis is a devastating, morbid, and costly condition whose ravages are felt most profoundly by women over age 70 years. Yet most research on its prevention and treatment has focused on perimenopausal women, although there are significant differences between perimenopausal and older women in factors related to bone mineral metabolism, rates of bone loss, the structural integrity of remaining bone, risk factors for fractures, and the types of fractures sustained. Currently recommended therapies, which slow bone loss in perimenopausal women, may be of less benefit for older women whose loss of bone has already slowed or ceased and whose remaining bone may be of inadequate quantity and quality to prevent fracture. Thus, the application of currently available modalities is unlikely to mitigate significantly the consequences of osteoporosis in this population. Further research is urgently needed, and some directions for future investigation are suggested.

(JAMA 1989;261:1025-1029)

REFERENCES

1 +
Riggs BL, Melton LJ III:  Involutional osteoporosis . N Engl J Med 1986;;314:1676-1686.
2 +
Cummings SR, Kelsey JL, Nevitt MC, et al:  Epidemiology of osteoporosis and osteoporotic fractures . Epidemiol Rev 1985;;7:178-208.
3 +
Melton LJ III, Riggs BL:  Epidemiology of age-related fractures , in Avioli LV (ed): The Osteoporotic Syndrome . New York, Grune & Stratton, 1983;, pp 45-72.
4 +
Cummings SR, Black D:  Should perimenopausal women be screened for osteoporosis? Ann Intern Med 1986;;104:817-23.
5 +
Dans PE, Kerr MR:  Gerontology and geriatrics in medical education . N Engl J Med 1979;;300:228-232.
6 +
Heaney RP, Gallagher JC, Johnston CC, et al:  Calcium nutrition and bone health in the elderly . Am J Clin Nutr 1982;;36:986-1013.
7 +
Ireland P, Fordtran JS:  Effect of dietary calcium and age on jejunal calcium absorption in humans studied by intestinal perfusion . J Clin Invest 1973;;52:2672-2681.
8 +
Gallagher JC, Riggs BL, Eisman J, et al:  Intestinal calcium absorption and serum vitamin D metabolites in normal subjects and osteoporotic patients: Effect of age and dietary calcium . J Clin Invest 1979;;64:729-736.
9 +
Slovik DM:  The vitamin D endocrine system, calcium metabolism, and osteoporosis . Special Top Endocrinol Metab 1983;;5:83-148.
10 +
Heaney RP, Recker RR, Saville PD:  Menopausal changes in calcium balance performance . J Lab Clin Med 1978;;92:953-963.
11 +
Jensen J, Riis BJ, Hummer L, et al:  The effects of age and body composition on circulating serum estrogens and androstenedione after the menopause . Br J Obstet Gynecol 1985;;92:260-265.
12 +
Tiegs RD, Body JJ, Barta JM, et al:  Secretion and metabolism of monomeric human calcitonin: Effects of age, sex, and thyroid damage . J Bone Min Metab 1986;;1:339-349.
13 +
Deftos LJ, Weisman MH, Williams GW, et al:  Influence of age and sex on plasma calcitonin in human beings . N Engl J Med 1980;;302:1351-1353.
14 +
Young G, Marcus R, Minkoff JR, et al:  Age-related rise in parathyroid hormone in man: The use of intact and midmolecule antisera to distinguish hormone secretion from retention . J Bone Min Res 1987;;2:367-374.
15 +
Tsai K, Heath H III, Kumar R, et al:  Impaired vitamin D metabolism with aging in women . J Clin Invest 1984;;73:1668-1672.
16 +
Forero MS, Klein RF, Nissenson RA, et al:  Effect of age on circulating immunoreactive and bioactive parathyroid hormone levels in women . J Bone Min Res 1987;;2:363-366.
17 +
Endres DB, Morgan CH, Garry PJ, et al:  Age-related changes in serum immunoreactive parathyroid hormone and its biological action in healthy men and women . J Clin Endocrinol Metab 1987;; 65:724-731.
18 +
Falch JA, Gautvik KM:  A longitudinal study of pre- and postmenopausal changes in calcium metabolism . Bone 1988;;9:15-19.
19 +
Omdahl JL, Garry PJ, Hunsaker LA, et al:  Nutritional status in a healthy elderly population: Vitamin D . Am J Clin Nutr 1982;;36:1225-1233.
20 +
Parfitt AM, Gallagher JC, Heaney RP, et al:  Vitamin D and bone health in the elderly . Am J Clin Nutr 1982;;36:1014-1031.
21 +
Egsmose C, Lund B, McNair P, et al:  Low serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in institutionalized old people: Influence of solar exposure and vitamin D supplementation . Age Aging 1987;;16:35-40.
22 +
Toss G, Almqvist S, Larsson L, et al:  Vitamin D deficiency in welfare institutions for the aged . Acta Med Scand 1977;;202:87-89.
23 +
Doppelt SH, Neer RM, Daly M, et al:  Vitamin D deficiency and osteomalacia in patients with hip fractures: An unrecognized epidemic, abstracted . Orthop Trans 1983;;7:512-513.
24 +
Holick MF:  Vitamin D requirements for the elderly . Clin Nutr 1986;;5:121-129.
25 +
MacLaughlin J, Holick MF:  Aging decreases the capacity of human skin to produce vitamin D3 . J Clin Invest 1985;;76:1536-1538.
26 +
Slovik DM, Adams JS, Neer RM, et al:  Deficient production of 1,25-dihydroxyvitamin D in elderly osteoporotic patients . N Engl J Med 1981;; 305:372-374.
27 +
Baylink D, Maloney N, Morey E, et al:  Mild vitamin D deficiency: A cause of osteoporosis in the elderly, abstracted . Gerontologist 1977;;17:39.
28 +
Boland R:  Role of vitamin D in skeletal muscle function . Endocr Rev 1986;;7:434-448.
29 +
Nilas L, Christiansen C:  Bone mass and its relationship to age and the menopause . J Clin Endocrinol Metab 1987;;65:697-702.
30 +
Riggs BL, Wahner HW, Seeman E, et al:  Changes in bone mineral density of the proximal femur and spine with aging . J Clin Invest 1982;; 70:716-723.
31 +
Riggs BL, Wahner HW, Melton LJ III, et al:  Rates of bone loss in the appendicular and axial skeletons of women . J Clin Invest 1986;;77:1487-1491.
32 +
Quigley MET, Martin PL, Burnier AM, et al:  Estrogen therapy arrests bone loss in elderly women . Am J Obstet Gynecol 1987;;156:1516-1523.
33 +
Hui SL, Wiske PS, Norton JA, et al:  A prospective study of change in bone mass with age in postmenopausal women . J Chronic Dis 1982;;35:715-725.
34 +
Ruff CB, Hayes WC:  Subperiosteal expansion and cortical remodeling of the human femur and tibia with aging . Science 1982;;217:945-947.
35 +
Ruff CB, Hayes WC:  Sex differences in age-related remodeling of the femur and tibia . J Orthop Res 1988;;6:886-896.
36 +
Parfitt AM, Mathews CHE, Villaneuva AR, et al:  Relationships between surface, volume, and thickness of iliac trabecular bone in aging and in osteoporosis . J Clin Invest 1983;;72:1396-1409.
37 +
Parfitt AM:  Trabecular bone architecture in the pathogenesis and prevention of fracture . Am J Med 1987;;82( (suppl 1B) ):68-72.
38 +
Parfitt AM:  Bone remodeling: Relationship to the amount and structure of bone, and the pathogenesis and prevention of fractures , in Riggs BL, Melton LJ III (eds): Osteoporosis Etiology, Diagnosis, and Management . New York, Raven Press, 1988;, pp 45-94.
39 +
Paganini-Hill A, Ross RK, Gerkins VR, et al:  Menopausal estrogen therapy and hip fracture . Ann Intern Med 1981;;95:28-31.
40 +
Melton LJ III, Wahner HW, Richelson LS, et al:  Osteoporosis and the risk of hip fracture . Am J Epidemiol 1986;;124:254-261.
41 +
Cummings SR:  Are patients with hip fractures more osteoporotic? Am J Med 1985;;78:487-494.
42 +
Khairi MRA, Cronin JH, Rabb JA, et al:  Femoral trabecular-pattern index and bone mineral content measurement by absorptiometry in senile osteoporosis . J Bone Joint Surg 1976;;58A:221-226.
43 +
Cooper C, Barker DJP, Morris J, et al:  Osteoporosis, falls, and age in fracture of the proximal femur . Br Med J 1987;;295:13-15.
44 +
Ashley MJ, Gryfe CI, Amies A:  A longitudinal study of falls in an elderly population: II. Some circumstances of falling . Age Ageing 1977;;6:211-220.
45 +
Bastow MD, Rawlings J, Allison SP:  Undernutrition, hypothermia, and surgery in elderly women with fractured femur: An injury response to altered metabolism? Lancet 1983;;1:143-146.
46 +
Ray WA, Griffin MR, Schaffner W, et al:  Psychotropic drug use and the risk of hip fracture . N Engl J Med 1987;;316:363-369.
47 +
Brocklehurst JC, Exton-Smith AN, Lempert Barber SM, et al:  Fracture of the femur in old age: A two-centre study of associated clinical factors and the cause of the fall . Age Ageing 1978;;7:2-15.
48 +
Wooton R, Brysin E, Elgasser U, et al:  Risk factors for fractured neck of femur in the elderly . Age Ageing 1982;;11:160-168.
49 +
Melton LJ III, Riggs BL:  Risk factors for injury after a fall . Clin Geriatr Med 1985;;1:525-538.
50 +
Iskrant AP, Smith RW Jr:  Osteoporosis in women 45 years and over related to subsequent fractures . Public Health Rep 1969;;84:33-38.
51 +
Kanis JA:  Treatment of osteoporotic fracture . Lancet 1984;;1:27-33.
52 +
 Osteoporosis . JAMA 1984;;252:799-802.
53 +
Riis B, Thomsen K, Christiansen C:  Does calcium supplementation prevent postmenopausal bone loss? N Engl J Med 1987;;316:173-177.
54 +
Riggs BL, Wahner HW, Melton LJ III, et al:  Dietary calcium intake and rates of bone loss in women . J Clin Invest 1987;;80:979-982.
55 +
Matkovic V, Kostial K, Simonovic I, et al:  Bone status and fracture rates in two regions of Yugoslavia . Am J Clin Nutr 1979;;32:540-549.
56 +
Jensen GF, Christiansen C, Transbol I:  Treatment of post menopausal osteoporosis: A controlled therapeutic trial comparing oestrogen/gestagen, 1,25-dihydroxy-vitamin D3 and calcium . Clin Endocr 1982;;16:515-524.
57 +
Smith EL Jr, Reddan W, Smith PE:  Physical activity and calcium modalities for bone mineral increase in aged women . Med Sci Sports Exerc 1981;;13:60-64.
58 +
Fowles DG: A Profile of Older Americans: 1986 . Washington, DC, American Association of Retired Persons, 1986;.
59 +
Aging America: Trends and Projections , US Senate Special Committee on Aging, 1984;.
60 +
 1987 annual reference for pharmacy practice . Drug Store News , (April) 1987;, p 8.
61 +
German PS, Klein LE, McPhee SJ, et al:  Knowledge of and compliance with drug regimens among the elderly . J Am Geriatr Soc 1982;;30:568-571.
62 +
Jensen GF, Meinecke B, Boesen J, et al:  Does 1,25(OH)2D3 accelerate spinal bone loss? Clin Orthop 1985;;192:215-221.
63 +
GallagherJC,Jerpbak CM,Ju WSS, et al:  1,25-Dihydroxyvitamin D3: Short- and long-term effects on bone and calcium metabolism in patients with postmenopausal osteoporosis . Proc Natl Acad Sci USA 1982;;79:3325-3329.
64 +
Nordin BEC, Horsman A, Crilly RG, et al:  Treatment of spinal osteoporosis in postmenopausal women . Br Med J 1980;;280:451-454.
65 +
Hutchinson TA, Polansky SM, Feinstein AR:  Post-menopausal oestrogens protect against fractures of hip and distal radius . Lancet 1979;;1:705-709.
66 +
Weiss NS, Ure CL, Ballard JH, et al:  Decreased risk of fractures of the hip and lower forearm with postmenopausal use of estrogen . N Engl J Med 1980;;303:1195-1198.
67 +
Ettinger B, Genant HK, Cann LE:  Long-term estrogen replacement therapy prevents bone loss and fractures . Ann Intern Med 1985;;102:319-324.
68 +
Kiel DP, Felson DT, Anderson JJ, et al:  Hip fracture and the use of estrogens in postmenopausal women . N Engl J Med 1987;;317:1169-1174.
69 +
Wasnich R, Yano K, Vogel J:  Postmenopausal bone loss at multiple skeletal sites: relationship to estrogen use . J Chronic Dis 1983;;36:781-790.
70 +
Bush TL, Barrett-Connor E, Cowan LD, et al:  Cardiovascular mortality and noncontraceptive use of estrogen in women: Results from the Lipid Research Clinics Program Follow-up Study . Circulation 1987;;75:1102-1109.
71 +
Weinstein MC, Schiff I:  Cost-effectiveness of hormone replacement therapy in the menopause . Obstet Gynecol Surv 1983;;38:445-455.
72 +
Hillner BE, Hollenberg JP, Pauker SG:  Postmenopausal estrogens in prevention of osteoporosis . Am J Med 1986;;80:1115-1127.
73 +
Wilson PWF, Garrison RJ, Castelli WP:  Postmenopausal estrogen use, cigarette smoking, and cardiovascular morbidity in women over 50 . N Engl J Med 1985;;313:1038-1043.
74 +
Smith EL:  Exercise for prevention of osteoporosis: A review . Phys Sports Med 1982;;10:72-83.
75 +
Simkin A, Ayalon J, Leichter I:  Increased trabecular bone density due to bone-loading exercises in postmenopausal osteoporotic women . Calcif Tissue Int 1987;;40:59-63.
76 +
Larson EB, Bruce RA:  Exercise and aging . Ann Intern Med 1986;;105:783-785.
77 +
Paffenbarger RS Jr, Hyde RT, Wing AL, et al:  Physical activity, all-cause mortality, and longevity of college alumni . N Engl J Med 1986;;314:605-613.
78 +
Block JE, Smith R, Black D, et al:  Does exercise prevent osteoporosis? JAMA 1987;;257:3115-3117.

Figures

Tables

Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Riggs BL, Melton LJ III:  Involutional osteoporosis . N Engl J Med 1986;;314:1676-1686.
2 +
Cummings SR, Kelsey JL, Nevitt MC, et al:  Epidemiology of osteoporosis and osteoporotic fractures . Epidemiol Rev 1985;;7:178-208.
3 +
Melton LJ III, Riggs BL:  Epidemiology of age-related fractures , in Avioli LV (ed): The Osteoporotic Syndrome . New York, Grune & Stratton, 1983;, pp 45-72.
4 +
Cummings SR, Black D:  Should perimenopausal women be screened for osteoporosis? Ann Intern Med 1986;;104:817-23.
5 +
Dans PE, Kerr MR:  Gerontology and geriatrics in medical education . N Engl J Med 1979;;300:228-232.
6 +
Heaney RP, Gallagher JC, Johnston CC, et al:  Calcium nutrition and bone health in the elderly . Am J Clin Nutr 1982;;36:986-1013.
7 +
Ireland P, Fordtran JS:  Effect of dietary calcium and age on jejunal calcium absorption in humans studied by intestinal perfusion . J Clin Invest 1973;;52:2672-2681.
8 +
Gallagher JC, Riggs BL, Eisman J, et al:  Intestinal calcium absorption and serum vitamin D metabolites in normal subjects and osteoporotic patients: Effect of age and dietary calcium . J Clin Invest 1979;;64:729-736.
9 +
Slovik DM:  The vitamin D endocrine system, calcium metabolism, and osteoporosis . Special Top Endocrinol Metab 1983;;5:83-148.
10 +
Heaney RP, Recker RR, Saville PD:  Menopausal changes in calcium balance performance . J Lab Clin Med 1978;;92:953-963.
11 +
Jensen J, Riis BJ, Hummer L, et al:  The effects of age and body composition on circulating serum estrogens and androstenedione after the menopause . Br J Obstet Gynecol 1985;;92:260-265.
12 +
Tiegs RD, Body JJ, Barta JM, et al:  Secretion and metabolism of monomeric human calcitonin: Effects of age, sex, and thyroid damage . J Bone Min Metab 1986;;1:339-349.
13 +
Deftos LJ, Weisman MH, Williams GW, et al:  Influence of age and sex on plasma calcitonin in human beings . N Engl J Med 1980;;302:1351-1353.
14 +
Young G, Marcus R, Minkoff JR, et al:  Age-related rise in parathyroid hormone in man: The use of intact and midmolecule antisera to distinguish hormone secretion from retention . J Bone Min Res 1987;;2:367-374.
15 +
Tsai K, Heath H III, Kumar R, et al:  Impaired vitamin D metabolism with aging in women . J Clin Invest 1984;;73:1668-1672.
16 +
Forero MS, Klein RF, Nissenson RA, et al:  Effect of age on circulating immunoreactive and bioactive parathyroid hormone levels in women . J Bone Min Res 1987;;2:363-366.
17 +
Endres DB, Morgan CH, Garry PJ, et al:  Age-related changes in serum immunoreactive parathyroid hormone and its biological action in healthy men and women . J Clin Endocrinol Metab 1987;; 65:724-731.
18 +
Falch JA, Gautvik KM:  A longitudinal study of pre- and postmenopausal changes in calcium metabolism . Bone 1988;;9:15-19.
19 +
Omdahl JL, Garry PJ, Hunsaker LA, et al:  Nutritional status in a healthy elderly population: Vitamin D . Am J Clin Nutr 1982;;36:1225-1233.
20 +
Parfitt AM, Gallagher JC, Heaney RP, et al:  Vitamin D and bone health in the elderly . Am J Clin Nutr 1982;;36:1014-1031.
21 +
Egsmose C, Lund B, McNair P, et al:  Low serum levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D in institutionalized old people: Influence of solar exposure and vitamin D supplementation . Age Aging 1987;;16:35-40.
22 +
Toss G, Almqvist S, Larsson L, et al:  Vitamin D deficiency in welfare institutions for the aged . Acta Med Scand 1977;;202:87-89.
23 +
Doppelt SH, Neer RM, Daly M, et al:  Vitamin D deficiency and osteomalacia in patients with hip fractures: An unrecognized epidemic, abstracted . Orthop Trans 1983;;7:512-513.
24 +
Holick MF:  Vitamin D requirements for the elderly . Clin Nutr 1986;;5:121-129.
25 +
MacLaughlin J, Holick MF:  Aging decreases the capacity of human skin to produce vitamin D3 . J Clin Invest 1985;;76:1536-1538.
26 +
Slovik DM, Adams JS, Neer RM, et al:  Deficient production of 1,25-dihydroxyvitamin D in elderly osteoporotic patients . N Engl J Med 1981;; 305:372-374.
27 +
Baylink D, Maloney N, Morey E, et al:  Mild vitamin D deficiency: A cause of osteoporosis in the elderly, abstracted . Gerontologist 1977;;17:39.
28 +
Boland R:  Role of vitamin D in skeletal muscle function . Endocr Rev 1986;;7:434-448.
29 +
Nilas L, Christiansen C:  Bone mass and its relationship to age and the menopause . J Clin Endocrinol Metab 1987;;65:697-702.
30 +
Riggs BL, Wahner HW, Seeman E, et al:  Changes in bone mineral density of the proximal femur and spine with aging . J Clin Invest 1982;; 70:716-723.
31 +
Riggs BL, Wahner HW, Melton LJ III, et al:  Rates of bone loss in the appendicular and axial skeletons of women . J Clin Invest 1986;;77:1487-1491.
32 +
Quigley MET, Martin PL, Burnier AM, et al:  Estrogen therapy arrests bone loss in elderly women . Am J Obstet Gynecol 1987;;156:1516-1523.
33 +
Hui SL, Wiske PS, Norton JA, et al:  A prospective study of change in bone mass with age in postmenopausal women . J Chronic Dis 1982;;35:715-725.
34 +
Ruff CB, Hayes WC:  Subperiosteal expansion and cortical remodeling of the human femur and tibia with aging . Science 1982;;217:945-947.
35 +
Ruff CB, Hayes WC:  Sex differences in age-related remodeling of the femur and tibia . J Orthop Res 1988;;6:886-896.
36 +
Parfitt AM, Mathews CHE, Villaneuva AR, et al:  Relationships between surface, volume, and thickness of iliac trabecular bone in aging and in osteoporosis . J Clin Invest 1983;;72:1396-1409.
37 +
Parfitt AM:  Trabecular bone architecture in the pathogenesis and prevention of fracture . Am J Med 1987;;82( (suppl 1B) ):68-72.
38 +
Parfitt AM:  Bone remodeling: Relationship to the amount and structure of bone, and the pathogenesis and prevention of fractures , in Riggs BL, Melton LJ III (eds): Osteoporosis Etiology, Diagnosis, and Management . New York, Raven Press, 1988;, pp 45-94.
39 +
Paganini-Hill A, Ross RK, Gerkins VR, et al:  Menopausal estrogen therapy and hip fracture . Ann Intern Med 1981;;95:28-31.
40 +
Melton LJ III, Wahner HW, Richelson LS, et al:  Osteoporosis and the risk of hip fracture . Am J Epidemiol 1986;;124:254-261.
41 +
Cummings SR:  Are patients with hip fractures more osteoporotic? Am J Med 1985;;78:487-494.
42 +
Khairi MRA, Cronin JH, Rabb JA, et al:  Femoral trabecular-pattern index and bone mineral content measurement by absorptiometry in senile osteoporosis . J Bone Joint Surg 1976;;58A:221-226.
43 +
Cooper C, Barker DJP, Morris J, et al:  Osteoporosis, falls, and age in fracture of the proximal femur . Br Med J 1987;;295:13-15.
44 +
Ashley MJ, Gryfe CI, Amies A:  A longitudinal study of falls in an elderly population: II. Some circumstances of falling . Age Ageing 1977;;6:211-220.
45 +
Bastow MD, Rawlings J, Allison SP:  Undernutrition, hypothermia, and surgery in elderly women with fractured femur: An injury response to altered metabolism? Lancet 1983;;1:143-146.
46 +
Ray WA, Griffin MR, Schaffner W, et al:  Psychotropic drug use and the risk of hip fracture . N Engl J Med 1987;;316:363-369.
47 +
Brocklehurst JC, Exton-Smith AN, Lempert Barber SM, et al:  Fracture of the femur in old age: A two-centre study of associated clinical factors and the cause of the fall . Age Ageing 1978;;7:2-15.
48 +
Wooton R, Brysin E, Elgasser U, et al:  Risk factors for fractured neck of femur in the elderly . Age Ageing 1982;;11:160-168.
49 +
Melton LJ III, Riggs BL:  Risk factors for injury after a fall . Clin Geriatr Med 1985;;1:525-538.
50 +
Iskrant AP, Smith RW Jr:  Osteoporosis in women 45 years and over related to subsequent fractures . Public Health Rep 1969;;84:33-38.
51 +
Kanis JA:  Treatment of osteoporotic fracture . Lancet 1984;;1:27-33.
52 +
 Osteoporosis . JAMA 1984;;252:799-802.
53 +
Riis B, Thomsen K, Christiansen C:  Does calcium supplementation prevent postmenopausal bone loss? N Engl J Med 1987;;316:173-177.
54 +
Riggs BL, Wahner HW, Melton LJ III, et al:  Dietary calcium intake and rates of bone loss in women . J Clin Invest 1987;;80:979-982.
55 +
Matkovic V, Kostial K, Simonovic I, et al:  Bone status and fracture rates in two regions of Yugoslavia . Am J Clin Nutr 1979;;32:540-549.
56 +
Jensen GF, Christiansen C, Transbol I:  Treatment of post menopausal osteoporosis: A controlled therapeutic trial comparing oestrogen/gestagen, 1,25-dihydroxy-vitamin D3 and calcium . Clin Endocr 1982;;16:515-524.
57 +
Smith EL Jr, Reddan W, Smith PE:  Physical activity and calcium modalities for bone mineral increase in aged women . Med Sci Sports Exerc 1981;;13:60-64.
58 +
Fowles DG: A Profile of Older Americans: 1986 . Washington, DC, American Association of Retired Persons, 1986;.
59 +
Aging America: Trends and Projections , US Senate Special Committee on Aging, 1984;.
60 +
 1987 annual reference for pharmacy practice . Drug Store News , (April) 1987;, p 8.
61 +
German PS, Klein LE, McPhee SJ, et al:  Knowledge of and compliance with drug regimens among the elderly . J Am Geriatr Soc 1982;;30:568-571.
62 +
Jensen GF, Meinecke B, Boesen J, et al:  Does 1,25(OH)2D3 accelerate spinal bone loss? Clin Orthop 1985;;192:215-221.
63 +
GallagherJC,Jerpbak CM,Ju WSS, et al:  1,25-Dihydroxyvitamin D3: Short- and long-term effects on bone and calcium metabolism in patients with postmenopausal osteoporosis . Proc Natl Acad Sci USA 1982;;79:3325-3329.
64 +
Nordin BEC, Horsman A, Crilly RG, et al:  Treatment of spinal osteoporosis in postmenopausal women . Br Med J 1980;;280:451-454.
65 +
Hutchinson TA, Polansky SM, Feinstein AR:  Post-menopausal oestrogens protect against fractures of hip and distal radius . Lancet 1979;;1:705-709.
66 +
Weiss NS, Ure CL, Ballard JH, et al:  Decreased risk of fractures of the hip and lower forearm with postmenopausal use of estrogen . N Engl J Med 1980;;303:1195-1198.
67 +
Ettinger B, Genant HK, Cann LE:  Long-term estrogen replacement therapy prevents bone loss and fractures . Ann Intern Med 1985;;102:319-324.
68 +
Kiel DP, Felson DT, Anderson JJ, et al:  Hip fracture and the use of estrogens in postmenopausal women . N Engl J Med 1987;;317:1169-1174.
69 +
Wasnich R, Yano K, Vogel J:  Postmenopausal bone loss at multiple skeletal sites: relationship to estrogen use . J Chronic Dis 1983;;36:781-790.
70 +
Bush TL, Barrett-Connor E, Cowan LD, et al:  Cardiovascular mortality and noncontraceptive use of estrogen in women: Results from the Lipid Research Clinics Program Follow-up Study . Circulation 1987;;75:1102-1109.
71 +
Weinstein MC, Schiff I:  Cost-effectiveness of hormone replacement therapy in the menopause . Obstet Gynecol Surv 1983;;38:445-455.
72 +
Hillner BE, Hollenberg JP, Pauker SG:  Postmenopausal estrogens in prevention of osteoporosis . Am J Med 1986;;80:1115-1127.
73 +
Wilson PWF, Garrison RJ, Castelli WP:  Postmenopausal estrogen use, cigarette smoking, and cardiovascular morbidity in women over 50 . N Engl J Med 1985;;313:1038-1043.
74 +
Smith EL:  Exercise for prevention of osteoporosis: A review . Phys Sports Med 1982;;10:72-83.
75 +
Simkin A, Ayalon J, Leichter I:  Increased trabecular bone density due to bone-loading exercises in postmenopausal osteoporotic women . Calcif Tissue Int 1987;;40:59-63.
76 +
Larson EB, Bruce RA:  Exercise and aging . Ann Intern Med 1986;;105:783-785.
77 +
Paffenbarger RS Jr, Hyde RT, Wing AL, et al:  Physical activity, all-cause mortality, and longevity of college alumni . N Engl J Med 1986;;314:605-613.
78 +
Block JE, Smith R, Black D, et al:  Does exercise prevent osteoporosis? JAMA 1987;;257:3115-3117.

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To understand the clinical management of acute heart failure syndromes.
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The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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