Third edition of the atlas discussing pathophysiology, epidemiology, diagnosis, prevention and treatment of postmenopausal osteoporosis, as well as the importance of bone quality and strength in fracture risk.

Fully illustrated with over 120 full colour images
Thoroughly revised and updated new edition
Written by a team of world-leading experts in bone health

Written by a world-renowned expert in rheumatology this book serves as a refresher for GPs and hospital doctors containing practical diagnostic and treatment advice.

Reviews clinical developments and guidelines, and places them into everyday clinical practice

Stresses the importance of early and aggressive treatment

Concise but comprehensive whilst being loaded with illustrations including imaging examples all presented in pocket sized format

Rheumatoid arthritis (RA) is the most common and serious inflammatory arthritis, resulting in joint destruction, functional impairment and increased mortality. The outcome of the disease, however, has improved considerably in recent years with the availability of effective therapies and the recognition that early intensive treatment strategies result in better outcomes.

This book has been designed to increase physician awareness of the importance of early and intensive treatment a key pharmaceutical strategy in rheumatoid arthritis.

Written by a world-recognised expert in the field of osteoporosis, who has published extensively, and is recognized as a key opinion leader.

Aimed at primary care physicians, rheumatologists, orthopaedic surgeons, geriatricians, endocrinologists, and nurse specialists who wish to keep up to date in the prevention and management of osteoporosis

High quality clinical photos and figures to enhance descriptions and aid diagnosis
Written by a well-known author

During the menopause, both the quantity and quality of bone decline rapidly, leading to a dramatic increase in the risk of fracture in postmenopausal women. Although many factors are known to be associated with osteoporotic fractures, measures to identify and treat women at risk are underused in clinical practice. Consequently, osteoporosis is frequently not detected until a fracture occurs. Identification of postmenopausal women at high risk of fracture therefore is a priority.

The "Handbook of Osteoporosis" reviews the risk factors, and lifestyle changes that can help prevent osteoporosis and evaluates the pharmacological treatments currently available.

Radiology, the youngest of the major medical sciences, has undergone an extraordinary technical evolution since the discovery of X-rays. It began with the development of the different types of tomography and the adoption of many contrast agents, then proceeded rapidly to serioscopy, subtraction of images, direct enlargement, echography, thermography, and xerography. Today, even before all these innovations have come into common use, another branch of radiologic technology has evolved: computerized (axial) tomography. More than just an innovation, its true dimensions are unfore seeable. Radiology has become in less than a century an indispensable adjunct to the practice of medicine. The development of radiology as a speciality followed its technical advances, which varied greatly from country to country. This rapid development led quickly to subspecialization, even the very early development of radiotherapy and radiodiagnostics as separate entities. However, the entry of radiology into the university has preserved it a single branch of medicine, avoiding the frequent tendency toward auto nomy of the branches of a speciality. Today the fourth generation of radiologists is faced with another deci sion: whether to become technologists subjugated to their machinery, to become sub specialists with a single skill, or to remain doctors. The vast majority of this fourth generation has rejected becoming an accessory to a master technique and rather has specialized according to the hippocratic concept of medicine."

Recent developments in basic science and clinical rheumatology make it appropriate at this time to create a volume devoted to the immunology of rheumatic diseases. The impact of molecular biology, gene cloning, and new technologies for establishing hybridomas and T-cell lines in the laboratory is now beginning to be felt in clinical medicine. There is a general air of excitement and a feeling that we stand on the threshold of a new era in molecular medicine and clinical science. It is this excitement that we have tried to capture in this book. This volume is divided into five sections entitled Basic Mechanisms, Autoimmunity, Classical Concepts of Rheumatic Diseases, Pathogenetic Mechanisms, and Therapy. This is not an arbitrary arrangement but represents our belief that from an understanding of basic mechanisms of disease pathogenesis will come new and more successful forms of treatment for the sufferers of rheumatic disorders. We have tried in the selection of authors to choose internationally recognized experts who have both a scientific and a clinical orientation to their subjects. We believe the marriage of clinical and basic disciplines represents the best hope for rapid knowledge transfer from the laboratory to the clinic, where such knowledge can be used to improve patient health.

What medicine lacks in an increasingly specialised world is the medical polymath (or should it be medical bimath?) - the man who is an acknowledged expert in more than one field of medicine. Superpecialisation in the professional sense is an attempt to know more and more about less and less. It can be the microscopist's view of reality and such a microcosm can become also a refuge from realities. One reality difficult for the very specialised doctor to accept is that diseases don't exist. Only people with diseases exist and people do not always conform to convenient categories and compartments. It would be nice if they did but somehow they never do. A cherished medical tradition in Britain is that specialists are not hatched straight from medical schools. Indeed, young doctors are actively discouraged from taking too narrow an interest but are plunged for at least four years into the unspecific pool of general medicine until they have developed a broad awareness of the totality of human disease. Before this they are not allowed to narrow their sights on one particular target.

Neck and back pain are common symptoms which vary from the trivial to the incapacitating. Conventional medical textbooks concentrate disproportion ately on those causes which have clear-cut diagnostic patterns and pathological features demonstrable by investigations. Discussions of treatment often overemphasize the importance of the tiny minority of patients who proceed to surgery. Real life is very different. The majority of patients who consult their general practitioners do not suffer from readily categorized diseases, have no diagnostic investigational signs, and often respond to treatment in no other way than that expected from the passage of time. It is not surprising that such a situation has led to the emergence of a number of gurus, both orthodox and unorthodox, who provide diagnostic labels and treatment methods united by only one thing - certainty. I had expected two such prominent exponents of manipulative techniques as the authors of this book to be among those offering certainty and demanding blind acceptance but I was wrong. This book explores the scientific basis for treatment and evaluates a vru: iety of therapeutic options. It offers an approach to assessment and treatment which is overtly pragmatic but firmly based in conventional clinical medicine. It is a book which invites discussion, comment and criticism in an area where many texts offer little but dogmatism."

Since the rheumatic diseases are among the most prevalent of conditions, the anti-rheumatic drugs make up one of the largest groups of drugs prescribed. They vary from the non-steroidal anti-inflammatory drugs through to the complex imrnunomodulators. There are significant differences between these groups of drugs as regards their mechanism of action and within each spectrum of adverse reactions, yet there is also some overlap. class there are also subtle individual differences between the drugs despite a sharing of the basic mechanisms of action and range of side effects. It is this individual variation and, in particular, the individual reaction of the patient to the drug that we attempted to address at this symposium. The first symposium on Individual Variation in Response to Non Steroidal Anti-inflammatory Drugs was held at Leura, New South Wales, Australia as a satellite symposium to the XVI International Congress of Rheumatology in August, 1985. Following a successful meeting, proceedings of which were published in a supplement to Agents and Actions (Suppl. 17, 1986), it was decided to organise a second symposium as a satellite meeting of the International Congressof Pharmacology Meeting in Sydney, August, 1987. The meeting was held at the Manly Pacific and focused on variability in response to anti-rheumatic drugs in general rather than just concentrating on the non-steroidal drugs."

Bone and joint tuberculosis is common in developing countries, and surgeons in these countries are often faced with the dual problem of diagnosing and treating this disease. However, bone and joint tuberculosis has not yet completely disappeared from industrialized countries, either. Therefore, this book is also intended for orthopedic surgeons in industrialized countries, who, faced with the rare but characteristic problems posed by bone and joint tuberculosis, are searching for reliable solutions. The last comprehensive textbook on this subject appeared more than 20 years ago, and that was a third edition of a pre-war work. Advances in chemotherapy had made this edition out-of-date even before it was published. The need for a definite up-to-date textbook has therefore been acute. The present book has been written to fill that need, and is based not only upon 20 years' experience with 700 cases, but also upon the results of clinical, bacteriologic, pathologic, and therapeutic research.

Sonography is an ideal real-time imaging technique for the evaluation of muscles and tendons of the extremities, and this book is a useful reference for both the technique of examination and normal ultrasound anatomy. The first part considers technical aspects of the examination such as sonographic equipment, water-path systems, and dynamic maneuvers. The basic sonographic patterns of normal muscles, tendons, and other components of the extremities are then presented. Emphasis has been placed on pitfalls and artifacts. The other available imaging techniques for muscles and tendons are also discussed. The second part comprises an atlas of normal ultrasound scans of shoulder, arm, elbow, forearm, wrist, hand, thigh, knee, leg, ankle, and foot, with accompanying explanatory line drawings.

The importance of osteoporosis in the United Kingdom as a cause of death and disability is now well recognised. There are in excess of 200,000 osteoporotic-related fractures in the UK per annum asso ciated with an estimated cost of GBP942,000,000. Following hip fracture it is known that about 50% of patients are unable to live indepen dently and about 20% of such patients die within the first 6 months. These figures, compelling as they are, reflect poorly on current medical practices which manifestly have failed to identify patients with low bone density at risk of fracture. The hope is that the techni cal advances which have enabled bone mineral density, and other allied indices, to be measured with high precision and accuracy offers the chance of identifying patients at risk of fracture and guiding the clinician to make treatment decisions which may reduce the patients' risk of fracture. In the UK, services for identifying patients at risk of fracture are still in their infancy and are not uniformly available throughout the country. This situation is, however, likely to improve particularly fol lowing the publication of the Royal College of Physicians report "Osteoporosis -clinical guidelines for prevention and treatment" and the recognition in "Our Healthier Nation" that osteoporosis pre vention should be included as a target to achieve a reduction of 20% in accidents by 2010.

The relationship between infection and arthritis has occupied the attention of everybody throughout the history of investigative rheu matology, no less today than formerlyl. The present issue is a com pilation of essays reflecting some of the facets of this particular diamond and I am especially grateful to authors and publishers alike in the unusual and tragic circumstances which attended its preparation. We were all stunned and saddened by the untimely death of Pro fessor John Calabro which deprived us of a good friend and wise counsellor as well as a much esteemed professional colleague. Prof. Calabro's contribution to medicine was considerable, spanning highly individual, exemplary and caring clinical management, enthusiastic charismatic teaching at all levels and major contributions to research particularly in the field of juvenile arthritis. As with Robert Burns, whose works John knew, "when will we see his like again?." A personal sadness is that I was looking forward to welcoming John and his wife to "Geordieland." There is a strong tradition of the highest level of competitive ballroom dancing here and John was looking forward to visiting us and demonstrating the considerable skills which he and his wife displayed in this arena. To his wife and family we all extend our heartfelt condolences. W. CARSON DICK 1. Atkin, S., Walker, D., Mander, M., Malcolm, A. and Dick, W. Carson. (1988). Observation on the causes of rheumatoid arthritis. Br. J. Rheumatol., 27 (Suppl."

Calcium plays an enormous and varied role in living systems now widely appreciated by clinicians.
Calcium in Internal Medicine demonstrates the physiological significance of calcium in clinical medicine and discusses the abnormal calcium metabolism in disorders such as renal failure, hypertension, atherosclerosis and osteoporosis.
Hirotoshi Morii (Editor) linked the clinical use of vitamin D analogues in bone diseases, Yoshiki Nishizawa (Editor) researched the connection between calcium metabolism and atherosclerosis and Shaul G. Massry (Editor) was the first to systematize the importance of excess PTH in chronic renal failure. In addition to these areas, Calcium in Internal Medicine covers basic physiology, pathophysiology, nutritional requirements and the role of calcium in the development and treatment of other various diseases. The importance of calcium and its regulatory systems is brought together in one publication providing a useful reference tool for internists, rheumatologists and endocrinologists.

Bone Metastases brings together the many recent developments that are gradually improving the prospects for patients with secondary involvement of the skeleton in a primary cancer elsewhere. The morbidity from bone metastases is extensive, and the palliative and supportive treatment that sufferers require for many months or even years constitutes a major health problem. A multidisciplinary approach is essential since a variety of specialists are involved: radiation and medical oncologists, general and orthopaedic surgeons, general physicians, radiologists and nuclear medicine physicians, symptom control and terminal care specialists. The book's editors, themselves authorities in the fields of oncology and bone disease respectively, have brought together experts from all these disciplines to provide comprehensive coverage of metastatic bone disease. They cover the biology and pathophysiology, hypercalcaemia, imaging, assessment of response to treatment, types of treatment (systemic, radiotherapy, surgery), and symptomatic and supportive care. Particularly new approaches included are magnetic resonance imaging, the assessment of skeletal response and isotope therapy.

The role of trace metals, especially copper and zinc, in the pathogenesis of rheumatic conditions has continued to receive much interest following the initial upsurge of research activity in the 1970s. Meantime also copper and zinc complexes receive continued attention for their potential anti-inflam matory actions. Since the previous major titles were published in this field some years ago (e. g. 1,2) it was considered timely to consider progress which has been made in the interceding period. Thus in this volume aspects are re viewed of the metabolism and biodisposition of copper and zinc, especially as they may be influenced by inflammatory processes, the mode of action of copper and zinc compounds in inflammatory states, and the actions of some newer copper complexes. While we still understand relatively little about how copper and zinc complexes work in inflammation, and indeed what the fate of the ligands and their complexed ions is in inflammation, it is hoped that this volume will be useful for giving a current view of the "state of art" in the field. Special thanks are given to the valued efforts of the contributors, Dr Peter Clarke (Publishing Director, Kluwer Academic Publishers) and Mrs Veronica Rainsford-Koechli for her help in proof-reading the manuscripts. K D Rainsford Hamilton, Ontario, Canada February 1989 References 1. Rainsford, K. D., Brune, K. and Whitehouse, M. W. (eds) (1981). Elements in the pathogenesis a treatment of inflammation."

Any physician travelling to other centres throughout the world must be struck by the similarity of the problems in diagnosis and management faced by fellow colleagues in rheumatology. Despite the international spread of journals and of standard textbooks, the same practical questions constantly appear - how do you manage the psychotic patient with cerebral lupus, or the patient with intractable polymyositis, or the rheumatoid patient who has failed on almost all known therapeutic agents. Is it worth differentiating various 'overlap' syndromes? How can one improve on the classification and treatment "i}f.vasculitis? Two questions - what is the patient telling us? and what can we do for the patient? are always central to the discussion. Although these high-minded ideals are often not fulfilled, frequently something new appears to come from individual case presentations. These cases, discussed at our weekly conferences, were contributed by a number of different staff members. Where possible, a standard format has been use in each case presentation and a comment added where indicated. A short list of relevant references has been included with each case. The aim of this book is to provide examples of these clinical problems and our own clinical approach to them - sometimes successfu~ sometimes not.

On May 24-27,1992 the European Society ofOsteoarthrology (ESOA) held its 19th sympo- sium in Noordwijkerhout, The Netherlands. The symposium was entitled "Joint destruction in arthritis and osteoarthritis" and sought to combine both clinical and experimental studies in this field. The present volume contains the proceedings of this meeting. The ESOA has organized most of its symposia in the eastern part of Europe, thanks to major input from Stanislav Havelka, who in recent years has been supported by Heikki Helminen. In appreciation of his efforts Stan Havelka was granted Honorary Presidentship of the ESOA at the meeting. In the era of European unification it seemed desirable to create a strong Uni- fied European Society, which would organize major meetings in both parts of Europe. Cartilage and bone research is expanding rapidly and the number of meetings in this field is continually growing. In line with these developments discussions took place with the recent- Iy founded "Eular Workshop on Bone and Cartilage Research" and the "Osteoarthritis Re- search Society (OARS)".

These two volumes contain the proceedings of a 3 day international meeting held at the University of Cambidge and Queens' College Cambridge from 31st July to 2nd August 1985 on the Side-Effects of Anti-Inflammatory Analgesic Drugs. The first meeting was held in Verona, (Italy) in 1982 and the organisers feIt that, with a number of recent developments including the. withdrawal of a num- ber of new anti-inflammatory drugs, and concern being expressed in the lay and specialist medical press and other media about the safety of these drugs, that it was appl'Qpriate to have a second such meeting. The meeting was attended by some 300 delegates and the dis- cussion focussed most intently on the recent issues, . e. g. the value of adverse drug reaction reporting of the non-. steroidal anti- inflammatory (NSAI) drugs, certain side-effects associated with particular NSAI drugs, the predictive value of animal models etc. Organising a meeting de novo without outside help would not have been possible without the immensely valuable help given en- thusiastica1ly by people and financial assistance given most generously by those pharmaceutical companies listed below. These financial contributions were given despite current economic dif- ficulties and moves to restrict the proportion of profits towards educational actlvities.

These two volumes contain the proceedings of a 3 day international meeting held at the University of Cambidge and Queens' College Cambridge from 31st July to 2nd August 1985 on the Side-Effects of Anti-Inflammatory Analgesic Drugs. The first meeting was held in Verona, (Italy) in 1982 and the organisers felt that, with a number of recent developments including the withdrawal of a num ber of new anti-inflammatory drugs, and concern being expressed in the lay and specialist medical press and other media about the safety of these drugs, that it was appropriate to have a second such meeting. The meeting was attended by some 300 delegates and the dis cussion focussed most intently on the recent issues, e. g. the value of adverse drug reaction reporting of the non-steroidal anti inflammatory (NSAI) drugs, certain side-effects associated with particular NSAI drugs, the predictive value of animal models etc. Organising a meeting de novo without outside help would not have been possible without the immensely valuable help given en thusiastically by people and financial assistance given most generously by those pharmaceutical companies listed below. These financial contributions were given despite current economic dif ficulties and moves to restrict the proportion of profits towards educational activities."

Recent radiologic procedures in bone and joints, some of which eliminate the need for surgery are exposed, including: trephine biopsies of the thoracic and lumbar spine, sacro-iliac joints, peripheral bones synovial membrane and soft tissues, using either fluoroscopic echographic or CT guidance - chemonucleolysis - vascular embolization of skeletal tumors and management of vertebral hemangiomas - selective steroid injection in a broad spectrum of diseases including vertebral facet syndrom, cervicobrachial nerve root pain, rotator cuff calcium deposits, bone cysts. This unique volume supplies the reader with complete information regarding the performance of all these techniques.

Sine syndromes (SSs) represent atypical forms of inflammatory rheumatic diseases, the courses of which are often severe. While the diagnosis of rheumatic diseases can be determined according to an established set of diagnostic criteria based on clinical characteristics and laboratory parameters, Sine Syndromes do not fulfill the standard criteria used to assist in the classification of patients with rheumatological disorders. This concise book gives an overview of atypical courses in common inflammatory rheumatic diseases such as Wegener's granulomatosis, systemic sclerosis, Sjoegren's syndrome, or systemic lupus erythematosus. Each chapter reviews similar cases reported in the literature and presents current data on treatment options. Drawing on their vast clinical experience, the editors provide a series of detailed case reports in order to illustrate the different types of disease. The book is intended to facilitate early diagnosis and effective therapy in patients where a schematic approach may not prove sufficient. Sine Syndromes in Rheumatology will serve as a useful and easily accessible reference for specialists in rheumatology as well as for practitioners in the fields of internal medicine, pediatrics, and orthopedics.

The second common meeting of the European Section and the Cervical Spine Research Society took place in Marseille (France) from June 12 to 15, 1988 and was organized by Rene Louis. More than 130 specialists from every part of Europe, from America and Asia participated, representing, among others, the fields of Orthopedics, Neurosurgery, Traumatology, Neurology, Anatomy, Rheumatology and Radiology. This meeting again was convincing proof of the growing interest which exists in Europe in research into injuries and diseases of the cervical spine. The main topics of this meeting were the subluxation of the lower cervical spine (chapter 1) and the infectious diseases of the cervical spine (chapter 2). Chapters 3 and 4 of this volume deal with degenerative lesions and the upper cervical spine. In chapter 5 experimental reports are presented, so that a good synopsis is provided of our present state of knowledge of diseases of the cervical spine. The European Section of the Cervical Spine Research Society was founded by Mario Boni in 1984, who unfortunately died in 1986 and was proclaimed Honory President of the European Section. There is a European meeting every summer and one every three years with our colleagues from the United States of America, Canada and Japan organized in Europe. The first combined meeting was organized by Pierre Kehr in Strasbourg (France) in 1985 and the presented papers were published in Cervical Spine I (Springer, Wien-New York, 1987).

During the past decade there has been a burgeoning of interest in arthritis and related rheumatic diseases. The spe ciality of rheumatology, once regarded as a "Cinderella" speciality, is now one of the leading specialties in internal medicine. Indeed, just as infant mortality is a good index of the general health of a community, so a University Med ical School can be similarly judged by the quality of its Department of Rheumatology. Perhaps no other specialty has helped to advance knowledge in medicine as has rheu matology One might have thought that little could be added to the clinical and radiologic description of one of the most studied diseases in rheumatology rheumatoid arthritis. There are several excellent large radiology textbooks on bones and joints, and it is surprising that yet another book has been published. However, the reader will soon appreciate on reading this superb radiologic text on rheumatoid arthritis that here is something new and quite different from what has been published in the past. The combination of clinician and radiologist has produced a textbook which will become a standard reference on the subject. The authors are both well known in their respective fields and they have concentrated on the early changes in the disease-not only those in the articular surfaces but also those in the soft tissues. In 1948 the late Dr Philip Ellman coined the term "rheumatoid disease," to indicate the systemic nature of rheumatoid arthritis."

Back in September of 1974, I acquired much valuable information while attending the International Conference on Total Knee Replacement in London, which was organized by The Medical Engineering Working Party and the Tribology Group of the Institution of Mechanical Engineers, and the British Orthopaedic Association. I was greatly inspired by the conference, and it formed the beginning of my studies on total knee replacement. The co-editors of this proceedings, Prof. J. Paul and Dr. S. Yamamoto, are both acquaintances made originally at that conference. The International Symposium on Total Knee Replacement held in Nagoya, Japan, on 18-19 May 1987 was attended by many participants, including Prof. Walker, who had presented his studies earlier in London. During the past decade and a half, remarkable technical progress has been made in total knee prostheses. In this symposium, cemented total knee replacement (TKR), noncemented TKR, design considerations of total knee prostheses, problems concerning the patello femoral joint, and the newly developed total knee prosthesis were the main topics discussed. I believe that much new information, including that about the challenges which still remain, along with a fresh view towards continuing studies, are presented here for the reader. I would like to express my sincere gratitude to the support of the Knee Joint Research Society in Japan and to the participants in the symposium for their great help in publishing this book."

Percutaneous lumbar discectomy is a new surgical method for treating lumbar disc diseases. The goal of the procedure is decompression of the spinal nerve root by percutaneous removal of the nucleus pulposus under local anesthesia. Probably 20 % of all patients requiring lumbar disc surgery can be successfully treated by this method. During the past two years, percutaneous discectomy has spread rapidly, and it is now performed in most clinical departments engaged in spinal surgery. The first International Symposium on Percutaneous Lumbar Discectomy, held in Berlin in August 1988, covered all current procedures known as "percutaneous discectomy" and the entire range of percutaneous techniques, both clinical and experimental. Its publication is important because of the recency of this new surgical procedure, the outstanding experience of the speakers - including the Japanese, American, and European "pioneers" of the technique - and last but not least the gaps in the knowledge of physicians concerning this topic. This procedure opens up new perspectives in the surgical treatment of degenerative diseases of the lumbar spine.