WEEK FIVE

1- Review of concept maps and secondary questions: Tuberculosis.

2- Lecture: Falls.

3- Constructing a concept map and Preliminary questions: Falls.

Structure of the session

08:00 – 09:20 Group Work Review of concept maps tuberculosis and secondary
questions.

09:30- 10:10 Lecture title: Falls.

10:30- 12:30 Group Work Constructing a Concept map: Falls.

1- Group work: Review of concept map

Review and compare concept maps . Does your concept map enable you to
answer the following secondary questions? if not, consider how your concept
map could be developed to lead you to consider the following secondary
questions and other potential secondary questions.

 Isoniazid, or INH, is one of the most useful agents used in treating TB. Why
give vitamin B6 during treatment?

 Explain the most likely interpretation of hypercalcaemia in some patients

with tuberculosis.
 After a period of starting the treatment, your colleague find out yellowish
appearance of the patient's eyes. How can you explain this?

 ESR is very high in tuberculosis. Describe the mechanism of this

phenomenon.

 Why patient with pulmonary TB is likely coughing-up blood ?

 What is the medical term of coughing up blood?

 The prevalence of TB-associated anemia is approximately 30%.Mention

three causes of TB-associated anemia.

 What are the common site of human lung TB germ most likely reside?
Why?

 Is tuberculosis is a communicable disease? What I do if I have some of the

symptoms of TB or think I might have been exposed to TB?
  Could TB affect only the lungs? Enumerate other organs of human body
might be affected by TB.

 Your school friend inquire about the effects of TB on the lung mechanics.

 Suppose that there are 70 cases of TB had been diagnosed during the
previous year in Basrah city and there are 77 cases had been diagnosed
during 2012 ,if the population of Basrah city is 3000000 persons , find:
o incidence.
o prevalence
o What are the factors affecting the prevalence?

2- Lecture: Falls

Aim

The aim of this session is that you should use the example of falls to explore how
to build conceptual structures which will help you to diagnose and manage
complex multi-factorial conditions.

Learning outcomes

By the end of this cycle you will be able to:

 identify and map in the logical way the topics relevant to the
understanding, diagnosis and management of falls
 identify detailed information both from concurrent modules in the
semester and from previous study to populate your map
Lecture Synopsis:

Falls

Falls are a huge problem for the elderly in particular. This is in part because
elderly people are more likely to fall, but also because injuries from falls,
especially fractures, are much more likely. We will therefore consider first why
people might be more likely to fall and second, why fractures are more likely if
they do.

Everyone falls at some stage. It is impossible to avoid occasional trips even when
sober and in many sports falls are common. Individuals who are elderly or who
suffer disability may well fall when other people would not. Most falls in young fit
people do not, however lead to serious injury. Staying upright requires
considerable motor control informed by sensory input from a variety of sources.
Impairment of any part of this process leads to an unexpected fall. Falls may occur
if the sensory inputs are disrupted. Damage to sensory organs in the inner ear can
lead to dizziness and instability. Impaired sensation from the feet and legs may
compromise stability, as may impaired vision, as humans use a wide variety of
sensory inputs to stay upright and to detect trip hazards whilst walking.

Information from sensory organs must be centrally processed by the brain. Many
falls follow from poor central processing, either because of long term neurological
problems, or short term shortage of oxygen if blood flow to the brain is
compromised. Many falls in the elderly are attributable to cardiovascular
problems, which cause a transient fall in arterial blood pressure and therefore
blood flow to the brain in the upright position. The resulting transient loss of
consciousness leads to a fall. These are commonly attributable to disruption of
the normal pattern of the heart beat – arrhythmias, many of which can readily be
treated.

Even if sensory inputs are intact and central processing functioning, defects in
motor outputs can lead to stumbles and falls, such as happens in diseases like
Multiple Sclerosis.
Most falls in the elderly are multifactorial, but often simple intervention, such as
removing clutter to trip over can greatly reduce the incidence even with
underlying medical problems.

So long as the patient can get up unaided a fall per se is not too harmful, but
unfortunately in the elderly the risk of serious injury especially fractures is very
high, even in an apparently trivial fall. Most commonly this is because bones
weaken – a condition known as osteoporosis. Osteoporosis

Osteoporosis is a condition characterised by a reduction in bone mass associated

with characteristic changes in the micro-architecture of bone, making it much less
strong, and so prone to fracture. Osteoporosis is very common, and a significant
cause of ill health and disability leading to major demand on health service
resources. Osteoporosis is mostly manifest in older people, and is more common
in women than men.

Bone mass peaks around the age of 30, then declines slowly with age in everyone.
Women attain a lower peak, and after the menopause there is a period of more
rapid decline, so that, on average bone mass is lower in older women than older
men. Increased risk of fracture is strongly associated with reducing bone mass, so
that, for example, by the age of eighty 30% of women will have sustained a hip
fracture, which is painful, debilitating and can lead to significant lasting disability
and loss of independence.

Bone is made up of calcium salts (mainly calcium hydroxy-apatite) in a

proteoglycan matrix. The main protein is type 1 collagen, whose alpha helical
structure confers strength. Mature bone is composed of osteons, which are
cylindrical units made up of concentric lamellae. Within individual bones some
parts are made of compact (dense) bone, usually the outer parts (cortex), and
some parts are spongy (cancellous or trabecular), where the bone is organised as
trabeculae with spaces in between. Osteoporosis tends to weaken spongy bone
more so those parts of bones with most spongy bone are the most likely to
fracture.
Bone is constantly remodelled throughout life. One group of cells, the
osteoblasts, form bone, another group the osteoclasts break it down. The
dynamic balance between the activity of these two groups of cells determines
bone mass. Osteoblasts form the extracellular matrix which is then mineralised.
Osteoclasts break down the matrix, releasing calcium salts into the circulation.

The calcium concentration in blood is critical. If it becomes too low, then

uncontrolled muscle contractions occur (‘tetany’) which can be fatal. If it is too
high, then nervous function is suppressed, and calcium salts tend to precipitate in
unfortunate places. Hormones from the parathyroid and thyroid glands control
blood calcium levels by drawing upon the reserves of calcium in bone through
control of the activity of osteoclasts. So long as sufficient calcium is absorbed
from the diet, then bone mass is maintained in youth at least. Calcium absorption
from food requires vitamin D, which must either be ingested from foods or made
in the skin by the action of sunlight.

The osteoclasts and osteoblasts are also affected by other hormones, especially
the gonadal steroids. Testosterone favours bone formation, which is why men
have a higher bone mass. In women oestrogen stimulates osteoblasts, and
inhibits osteoclasts, also favouring bone formation, but less powerfully. At the
menopause oestrogen secretion from the ovaries declines, and as a result the
difference between osteoblast and osteoclast activity changes, favouring bone
reabsorption over formation. Only a tiny changes will lead to significant bone loss
over time. If there is less oestrogen earlier, then bone loss will be greater.
Steroids from the cortex of the adrenal gland (‘gluco-corticoids’) tend to stimulate
osteoclasts, so reducing bone density. Steroid drugs used to reduce inflammation
in a variety of conditions are related to gluco-corticoids, and so will also reduce
bone density.

The bone mass later in life depends upon the maximum achieved in youth and the
rate of subsequent decline. Both are affected by ‘risk factors’ which lead to lower
bone mass in old age. Whilst there are some genetic factors, osteoporosis is not
primarily a genetic disease.
The main risk factors are:

 Gender - primarily because of the effects of declining oestrogen levels in

women after the menopause
 Ethnicity – Caucasian and south Asian people are more susceptible
 Changes in gonadal function – if there is hypo-gonadism for any other
reason in men or women bone mass will be lower later in life
 Long term treatment with steroid drugs - stimulate bone reabsorption
 Diets low in calcium and vitamin D – reduce initial bone mass, and favour
bone reabsorption
 Immobilisation – bones need stress to remodel effectively, and lose mass if
not subject to day to day stresses

Osteoporosis is often undetected until a fracture occurs. In some patients this

follows a fall, and may involve the distal radius (a ‘Colles’ fracture), or the neck of
the femur (a ‘hip’ fracture). In other patients, often at a later age, the vertebrae
may collapse, commonly during activities of daily life without obvious trauma.

It is however, possible to scan for bone density in individuals who might be at risk.
If a patient is found to be suffering from osteoporosis then the rate of reduction
of bone density may be reduced by drugs. Bisphosphonates are analogues of
normal bone pyrophosphate and bind to hydroxy- apatite, so inhibiting the action
of osteoclasts. Oestrogen replacement therapy, which is prescribed for other
effects of the menopause also helps to limit osteoporosis. Dietary calcium
supplements with vitamin D are also important.
Your concept map:
3- Group work: concept map: Fall.

By the end of this lecture you should be able to complete your concept map in the
space above. Spend the first part of the group work on this task.

Your next task is to consider the following list of questions . For each question:
First locate the question on your concept map. There are some phrases in italics
to help you. Which box does it fit into? Why? Second, write a brief answer to that
question. In some cases you may already know it, or it may come from the
lecture. In others you may have to seek out information from textbooks or other
sources.

“Low bone mineral density” is a description of a physiological state, not a disease.

 What conditions could “low bone mineral density” be describing?

 What differentiates the conditions described by “low bone mineral

density”?

 Protein synthesis often involves post-translational modification to enable

the protein to serve specialised functions.

 What is the major protein of bone?

  What are the SIX key features in the synthesis of this protein?

The maintenance of homeostasis is the key to maintenance of most functions in

the body. The derangement of homeostasis inevitably leads to pathological
processes and events.

 Where are calcium and phosphate stored in the body?

 How is the level of calcium in the blood controlled?

Anatomical and histological structure is linked to function. When function is not in

accord with the structure, breaks occur.

 Name the sites where fractures associated with osteoporosis most

commonly occur.

 Why are those sites susceptible to fractures with osteoporosis?