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https://learn.uea.ac.uk/bbcswebdav/pid-3419307-dt-content-rid-16437340_1/xid-16437340_1
this is professor Frazers older lecture on calcium homeostatsis

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https://www.youtube.com/watch?v=EEM0iRJNhU8&t=337s

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Endocrinology - Calcium and Phosphate Regulation

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https://teachmeorthopedics.info/pathologic-fracture/

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Ovid: 5-Minute Orthopaedic Consult

A pathologic fracture occurs through diseased bone rather than through normal bone.

The normal bone is replaced by abnormal bone or no bone at all.

Pathologic fractures in the geriatric patient are most likely secondary to bone metastases, multiple myeloma, and lymphoma.

Occasionally, a destructive lesion such as a chondrosarcoma or malignant fibrous histiocytoma is the cause of the fracture.

In children and adolescents, the most common benign cause of a pathologic fracture is a unicameral bone cyst or a NOF.

The 2 malignancies that may cause a pathologic fracture are osteosarcoma and Ewing sarcoma.

No preventative measures if the patient is unaware of the pathologic process

Many patients do have antecedent pain with activity.

The pain usually is directly referable to the involved bone.

Pathologic fractures usually are caused by well-recognized conditions in children, adolescents, and adults.

Bone strength is weakened substantially when >50% cortical bone destruction occurs.

Measure on AP and lateral radiographs.

CT scans are excellent for defining bone loss if it is not apparent on radiographs.

No specific genetic associations are known.

Any defect in the cortex of a long bone results in diminished capacity to withstand forces.

50% symmetric cortical involvement results in a 60% reduction in bending strength (1).

50% asymmetric cortical involvement results in 90% reduction in strength (1).

Long lytic defects (length longer than the diameter of the bone) result in up to 90% reductions in torsional strength (1).

Any condition that substantially weakens the bone by replacing normal bone tissue

Pain and bone tenderness are the 2 dominant findings

Bone pain: Before fracture, patients may note moderate or severe pain with ambulation.

Bone tenderness: Palpation often will cause severe pain.

Once complete fracture has occurred, patients will note severe pain that is excruciating with any motion or palpation.

Before pathologic fracture, physical examination findings may be few or nonexistent.

Palpate for bone tenderness.

Palpate for a soft-tissue mass that sometimes is present in malignancies.

Check ROM gently so as not to cause a pathologic fracture.

Imaging studies are the major modalities.

Serum tests are not helpful.

Once a pathologic fracture has occurred, plain radiographs are the major diagnostic modality.

AP/lateral plain radiographs are used to look for the cause.

Look for lytic bone destruction.

Look for host bone reaction: Sclerotic rim, thickening of cortex

Diagnostic Procedures/Surgery

The evaluation strategy is based on the assessment of the plain radiographs.

If the radiographs suggest a malignant process:

Chest radiograph, chest CT, and abdominal
CT to look for a carcinoma or metastases from the lesion causing the
pathologic fracture

Needle or open biopsy after the staging evaluation is complete

If the radiographs suggest a benign process:

If the plain radiographs are diagnostic
(unicameral bone cyst, NOF, fibrous dysplasia), treatment can be
planned and initiated without a biopsy.

If plain radiographs are not diagnostic, a biopsy is necessary.

Depend on the nature of the underlying lesion

The differential diagnosis varies based on the age of the patient and the plain radiographs.

Many patients have bone pain with activity, and it may occur weeks to months before pathologic fracture.

When activity-related pain exists with a
radiographically documented destructive lesion, an ambulatory support
to reduce loading should be recommended.

Reduce forces with walking aid or by placing patient at bed rest.

Pain medications used as necessary

Diphosphonates for metastatic bone disease and multiple myeloma

Pathologic fractures usually are treated with an internal fixation device such as an intramedullary nail.

Hip replacement is used for femoral neck fractures.

Patients with pathologic fractures
secondary to sarcomas, such as osteosarcoma, usually are treated with a
cast and then wide resection after several cycles of chemotherapy.

Patients are followed at 1-month intervals until the fracture heals.

Plain radiographs are used to assess healing.

Patients are referred to an orthopaedic oncologist for management.

1-month intervals until the fracture heals

1. Hipp JA, Springfield DS, Hayes WC. Predicting pathologic fracture risk in the management of metastatic bone defects. Clin Orthop Relat Res 1995;312:120-135.

2. McCarthy
EF, Frassica FJ. Plasma cell dyscrasia. In: Pathology of Bone and Joint
Disorders: With Clinical and Radiographic Correlation. Philadelphia: WB
Saunders, 1998:185-193.

3. McCarthy
EF, Frassica FJ. Primary bone tumors. In: Pathology of Bone and Joint
Disorders: With Clinical and Radiographic Correlation. Philadelphia: WB
Saunders, 1998:195-275.

4. Hornicek
FJ. Ewing's sarcoma. In: Menendez LR, ed. Orthopaedic Knowledge Update:
Musculoskeletal Tumors. Rosemont, IL: American Academy of Orthopaedic
Surgeons, 2002:195-202.

Miscellaneous

Patients are instructed on the nature of the underlying lesion.

Protected weightbearing until fracture union occurs

Prophylactic fixation often is recommended if the weakened bone state is detected before the fracture occurs.

Q: What is the most common cause of a pathologic fracture in the adult patient?

A: Bone metastases and myeloma are the most common causes.

Q: How long does it take for a pathologic fracture to heal?

A: In general, ~6-10 weeks, depending on the fracture pattern and the amount of bone loss.

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Pathologic Fracture - TeachMe Orthopedics

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Ovid: 5-Minute Orthopaedic Consult A pathologic fracture occurs through diseased bone rather than through normal bone. The normal bone is replaced by abnormal bone or no bone at all. Pathologic fractures in the geriatric patient are most likely secondary to bone metastases, multiple myeloma, and lymphoma.

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https://www.gponline.com/bone-pain-red-flag-symptoms/musculoskeletal-disorders/musculoskeletal-disorders/article/1295575

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Red flag symptoms

History of malignancy

Weight loss

Night sweats

Reduction in appetite

Night pain

Pain that is progressive or persistent

Pain in children

Any history of recent trauma

Symmetrical joint swelling

Thoracic pain, specifically pain that wakes up the patient

History of fever

Presentation

Bone pain is not an uncommon presentation, particularly in an increasingly ageing population. Patients often refer to pain in their bones, but this is a non-specific symptom and there are a range of differential diagnoses to consider (see possible causes box below).

A detailed description of what the patient means by 'bone pain' is crucial. It is also important to establish why the patient has presented at this time and what their ideas, concerns and expectations are. This will help to guide your management plan.

Questions to ask the patient

Where do you feel the pain?

Can you localise it, or is it generalised?

What sort of pain is it?

Does the pain radiate?

Are there aggravating or relieving factors?

Is there any pattern of pain - for example, is it worse at night or in the morning?

Have you tried any analgesia and, if so, has it worked?

How long has the pain been present?

Has it developed suddenly or insidiously?

Is it continuous or intermittent?

Is there a history of trauma?

Is a specific joint affected? If so, is there any associated heat or swelling?

Is the arthralgia symmetrical?

Are there associated symptoms such as nausea, vomiting, fever, swelling of the affected area, weight loss or pain at night?

Do you take any regular or over-the-counter medication?

Have you experienced any mood disturbance?

How is the pain affecting your quality of life? Is it affecting work, school, university or hobbies?

History

Bone pain is generally described as a dull, deep-seated pain. Sharp, shooting pains, in contrast, should lead you to focus on a neuropathic aetiology. Widespread bone pain may be a physical manifestation of an underlying psychological problem, such as in a patient presenting with whole body pain.

A sexual history may be relevant if Reiter's syndrome is suspected. You should also ask about any history of malignancy or TB, particularly in patients from migrant populations.

The patient's smoking and alcohol history may be important, as may a family history of osteoporosis.

In addition to the questions listed on the previous page, it may be useful to find out what the patient thinks the problem could be and what have they done to try to alleviate it. Many patients will have researched their symptoms online and will have developed an idea of why they are experiencing these symptoms.

A systemic review may reveal important information if metastatic bone disease is suspected. Be alert to the malignancies that commonly metastasise to bone. These include breast, renal, lung and prostate. Do not forget melanomas and gynaecological malignancies.

Clinical examination: remote and face to face

The clinical examination will be guided by the history. Depending on information revealed in the history and systemic review, examination of a specific system may be required.

Examination can occur either remotely via telephone or video consultation, or by face-to-face examination.

Remote examination via telephone will be limited, but establish how much pain the patient is in, and ask if they can send a picture of an affected area, as well as describe any swelling.
When performing a remote video consultation, if a specific joint is involved can you visualise the joint?

Can you ask the patient to do any specific movements for you? Are you able to assess their mental state?

For face-to-face examinations, ensure you wear appropriate PPE. A focused neurological exam may be necessary if the spine is the main area causing problems.

Possible causes of bone pain

Fracture

Primary bone cancer, such as osteosarcoma

Metastatic bone disease

Vitamin D deficiency leading to osteomalacia

Multiple myeloma

Paget's disease

Osteoporosis

Osteoarthritis

Hypercalcaemia, for example, secondary to hyperparathyroidism

Inflammatory arthropathy - for example, rheumatoid arthritis (RA)

TB of the bone

Psychosomatic

Iatrogenic - for example, bisphosphonates can cause osteonecrosis of the jaw, or prednisolone can cause vertebral fractures

Osteomyelitis

Prolapsed intervertebral disc

Frailty can lead to generalised aches and pains

Investigations and referral

The decision about which investigations to perform will be largely determined by the history and examination.

FBC, U&Es, ESR, calcium, phosphate and LFTs

Vitamin D level

Prostate specific antigen (PSA) test, after appropriate counselling

Parathyroid hormone (PTH) level -this generally needs to be sent to the laboratory on ice within an hour

If raised alkaline phosphatase is detected, isoenzymes may be required to discover whether this is from a liver or a bone source

Myeloma screen, to include serum paraprotein and urinary Bence Jones protein

Anti-cyclic citrullinated peptide and rheumatoid factor may also be necessary if RA is suspected

A plain chest X-ray may be required if bronchogenic carcinoma is suspected

A FRAX score to evaluate bone fracture risk may be necessary if osteoporosis is suspected and, if appropriate, a DEXA (dual energy X-ray absorptiometry) scan to assess bone mineral density

Plain X-rays may be necessary if the pain is localised to a specific area, such as in the hands or wrists

Hospital Anxiety and Depression Scale score

Tumour markers can be done but are generally not recommended in primary care. If a malignancy is suspected, appropriate referral under the 2-week wait is mandatory. Referral pathways will differ across different localities.

Dr Pipin Singh is a GP in Northumberland. This article was reviewed and updated by Dr Singh in April 2021

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History of malignancy Weight loss Night sweats Reduction in appetite Night pain Pain that is progressive or persistent Pain in children Any history of recent trauma Symmetrical joint swelling Thoracic pain, specifically pain that wakes up the patient History of fever Bone pain is not an uncommon presentation, particularly in an increasingly ageing population.

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https://bnf.nice.org.uk/treatment-summary/analgesics.html

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

If you believe you are seeing this page in error please contact us.

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The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories. If you believe you are seeing this page in error please contact us.

# data[].attributes.body
https://clinicalkeymeded.elsevier.com/reader/books/9780702074462/epubcfi/6/106[%3Bvnd.vst.idref%3Did_chp00043]!/4/2/10/2[s0080]/18/2[s0185]/4[p0675]/3:253[ere%2C%20pa] there's a really good table that gives the info on each opioid

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I used the crash course rheumatology and orthopaedics book, so easy to get the info we need and concise.
I have the actual book but you can also find it on clinical key

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I think the pathology lecture went hand and hand with this one as they both covered the same topics but pathology went into it in more depth

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I used the crash course rheumatology and orthopaedics book, so easy to get the info we need and concise.
I have the actual book but you can also find it on clinical key

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I used the crash course rheumatology and orthopaedics book, so easy to get the info we need and concise.
I have the actual book but you can also find it on clinical key

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I thought the lectures before term on calcium homeostasis helped tie everything together

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https://pubmed.ncbi.nlm.nih.gov/8393817/

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Abstract

The retinoblastoma (RB) gene is the prototype tumor suppressor gene. It encodes a nuclear protein that acts as a cell cycle control checkpoint at the G1 phase. Deletion or inactivation of both RB alleles plays an essential, rate-limiting role in retinoblastoma and in the osteosarcomas that arise within families that carry a mutated RB gene. RB inactivation is also found in other sarcomas, small cell carcinoma of the lung, and in carcinoma of the breast, bladder, and prostate. Transforming proteins encoded by SV40, and the transforming or tumor-associated subtypes of adenoviruses and human papilloma viruses (HPV) can bind RB, thereby blocking its normal function. The EBNA-5 protein of Epstein-Barr virus (EBV) is also able to bind RB in vitro. In addition, RB can interact with several cellular proteins, including the transcription factor E2F. RB gene knock-out mice die in utero around day 14 of gestation. The embryos show disturbed neural and hematopoietic differentiation, indicating that RB is vitally important for these processes. This notion is further supported by studies demonstrating that RB expression in mouse embryo tissues is highest in cells undergoing differentiation, and that RB is required for MyoD-induced muscle differentiation.

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national center for biotechnology information

# data[].attributes.attachment_link.title
The retinoblastoma gene: role in cell cycle control and cell differentiation - PubMed

# data[].attributes.attachment_link.description
The retinoblastoma (RB) gene is the prototype tumor suppressor gene. It encodes a nuclear protein that acts as a cell cycle control checkpoint at the G1 phase. Deletion or inactivation of both RB alleles plays an essential, rate-limiting role in retinoblastoma and in the osteosarcomas that arise wit ...

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Philadelphia chromosome - mutation found in chronic myeloid leukemia

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Philadelphia chromosome - mutation found in chronic myeloid leukemia

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https://www.ncbi.nlm.nih.gov/books/NBK560689/

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Introduction

Philadelphia chromosome (Ph), named after the city where it was first described, was described for the first time by Nowell and Hungerford in 1960, in two patients who had lost the long arm of chromosome 22.[1][2][3] As the Giemsa staining improved over the decade, Rowley showed that this truncated chromosome was generated as a result of the translocation of the long arm of chromosomes 9 and 22.[2][3][4] The presence of the abnormal Ph chromosome in cells of myeloid, megakaryocytic, along with erythroid lineages pointed to the origination of the disorder in a pluripotential stem cell.[2] Philadelphia chromosome is the hallmark of chronic myeloid leukemia (CML) along with some other leukemias including acute lymphoblastic leukemia (ALL) (mostly B cell ALL, rarely T cell ALL), acute myeloid leukemia (AML), chronic neutrophilic leukemia (CNL), and mixed phenotype acute leukemia (MPAL).[4][5][6][7][8][9][10][11]

Development

The Philadelphia chromosome is generated when the proto-oncogene Abelson murine leukemia (ABL1) gene, located on the band q34 on chromosome 9, translocates to the band q11 on chromosome 22 where the breakpoint cluster gene (BCR) is.[8][12] The translocation t(9;22)(q34;q11) results in the formation of a fusion gene called BCR-ABL1.[4]

Biochemical

The domains from BCR include:

Ser/Thr kinase domain (contains a docking site Y177)

The domains from ABL1 include:

The CC domain and Y177 of BCR are essential for the activation of the ABL1 gene and have shown to be closely associated with sensitivity to tyrosine kinase inhibitor (TKI). The Rho/GEF kinase domain plays a vital role in activating differentiation in the protooncogene induced leukemogenesis.[4][13]

The SH domain of ABL1 controls the gene's activation and deactivation, and hence this domain is an important site for pharmacologic intervention.[4]

As a result of different breakpoints in the BCR gene, that occur over quite a short DNA stretch of 5 -6 kilobases in the middle of the gene, three different BCR/ABL1 proteins are formed namely P190, P210, P230 which are usually associated with ALL, CML and CNL respectively. The numeral value represents the kDa size of the hybrid protein. There have been some reports showing correlations of P190 with CML, P210 with ALL, and P190 or P210 with AML. P230is formed by the fusion of the ABL1 gene with almost the entire BCR gene leading to the production of a 230-kDa protein.[2] It is the molecular diagnostic marker for neutrophilic-chronic myeloid leukemia (CML-N).[4][9]

In CML, the oncoprotein P210 forms by the fusion of exon 2 (b2) or exon 3 (b3) of the BCR gene with the exon 2 (a2) of the ABL1 gene leading to the formation of either b2a2 or b3a2 11345193. Both of the transcripts produce a hybrid P210.[4]

Function

The normal ABL Tyrosine Kinase (TK) is responsible for the activation of signal pathways that lead to increased proliferation, better viability, and changed migration as well as homing. Normally these pathways are under close regulation by different hematopoietic growth factors.[2] The ABL1 protein is a non-receptor tyrosine kinase, and it exists throughout the hematopoietic development, however myeloid maturation results in its declining levels.[4] The normal BCR gene is responsible for the oxidative burst in neutrophils.

Mechanism

The generation of BCR/ABL1 results in the constitutive activation of tyrosine kinase. It results in continued cell proliferation, inhibiting cell differentiation, and cell death. There are numerous pathways associated with the pathogenesis of BCR-ABL1 gene, including:

JAK2/STAT pathway: The activation of Janus Kinase (JAK) and Signal Transducers and Activation of Transcription (STAT) has been reported in P190 and P210positive leukemias. The JAK2/STAT activation in BCR/ABL1 leads to uncontrolled cell growth as well as cell survival.[14][15][16]

PI3K-AKT-mTOR pathway: The PI3K-AKT-mammalian target of the rapamycin (mTOR) pathway activates the c-kit positive hematopoietic stem cells; this leads to a proliferative state in CML.[17] This pathway controls cell survival, proliferation, cell cycle arrest, and has gained importance for pharmacological intervention over the past decade.[4]

MAPK/ERK (RAS/RAF/MEK/ERK) pathway: This pathway is involved in signal transmission from cell surface receptors to nuclear factors involved in transcription. Osteopontin (OPN), which overexpresses in BCR/ABL1, uses this pathway to maintain a leukemic microenvironment. It, in turn, promotes and maintains the proliferation and survival of leukemic cells as well as plays a role in cell differentiation and apoptosis.[4][18]

TRAIL-induced apoptosis: Tumor necrosis factor (TNF)- related apoptosis-inducing ligand- TNFSF10 (TRAIL) is a death receptor ligand that normally plays a role in apoptosis. BCR/ABL1 oncogene results in the downregulation of TRAIL, hence leading to decreased apoptosis.[19][20][21][20]

C/EBP-mediated differentiation: CCAAT/enhancer-binding proteins (C/EBPs) are a type of transcription factors that are involved in the regulation of normal maturation of common myeloid cells to granulocyte-monocyte progenitor cells. This pathway is suppressed by the BCR/ABL1 oncogene.[4][22]

CONCURRENT GENETIC ABNORMALITIES:

In addition to the leukemogenic effect, evidence suggests that BCR/ABL1 oncogene independently leads to genomic instability.[23] A recent study has shown that several genes that predominantly play a role in the proliferation and differentiation of hematopoietic stem cells are upregulated in BCR/ABL positive CML.[24]

Common genes that are reportedly deleted in Philadelphia positive leukemias include

Studies have shown that primary or acquired resistance to treatment as well as relapse, can be attributed to different mutations. Rearrangements in the BCR gene can help in the prediction of response to therapy.[4]

Testing

Philadelphia chromosome is detectable with cytogenetic testing, or a reverse transcriptase PCR test can demonstrate the BCR/ABL transcripts.[2] Along with a quantitative PCR for BCR/ABL1, flow cytometry is also necessary to determine the lineage. As mentioned before, the patients usually have a concurrent genetic abnormality, so it is reasonable to get a mutational analysis done.[30][31] In addition to the above testing, liver function tests, as well as renal function tests, should be performed.[30]

Pathophysiology

This oncogene leads to constitutive activation of tyrosine kinase, which is responsible for more proliferation and better viability of the myeloid lineage cells.[4] The translocation results in decreased requirements for growth factors and provides freedom from their regulatory control.[2] This oncogene also affects cellular differentiation and apoptosis.[4]

Clinical Significance

In addition to CML, Philadelphia chromosome has shown an association with different leukemias including

There have been reports of detection of the chromosomal abnormality rarely in normal healthy people.[2] Recently, a Philadelphia like ALL (Ph-like ALL) has been identified, which lacks the novel BCR-ABL1 translocation.[32]

CML: The Ph chromosome is the diagnostic feature of CML. CML has an incidence of 50 per million per year and accounts for approximately 7 to 15% of the leukemias in the adult population.[2][33]

ALL: Philadelphia chromosome has been detected in 11 to 29 % of patients with ALL, although it is rarer with a prevalence of 1 to 3% in childhood ALL.[34][35]

AML: In patients with AML, the chromosomal abnormality has a reported incidence of less than 1.5%.[36]

MPAL: Data collected from patients diagnosed with MPAL shows that the Ph chromosome is the most frequent aberrant cytogenetic abnormality, which has led to the recognition of Ph+MPAL as a distinct disease entity with a prevalence of less than 1% of all acute leukemias.[37]

THERAPEUTIC IMPLICATIONS:

For CML, at the moment, many (five FDA approved) tyrosine kinase inhibitors, belonging to different generations, (TKI) are being used for the treatment. TKIs belonging to different generations are currently available. Frist generation TKI includes imatinib, and second-generation TKI includes bosutinib, dasatinib, and nilotinib. Third generation TKIs include ponatinib. For the chronic phase, TKI first and second-generation TKIs are included in the frontline treatments recommended.[30][38][39][40][41]

In patients diagnosed with the chronic phase of CML, risk calculations are performed before initiation of therapy. For this purpose, two different scoring systems are used.[31] One is the Sokal risk calculation, which requires the age of the patient, platelet count, the percentage of myeloblasts found in the peripheral blood and size of the spleen, whereas the Hasford risk calculation utilizes the same variables as Sokal calculator except for the percentage of myeloblasts it uses the percentage of blasts, basophils, and eosinophils.[42][43][42] For patients that have an intermediate or higher risk score, the recommendation is to consider the second-generation TKIs as the first line.[30][40][41]

For patients with treatment failure or resistance to prior lines, the third generation TKI should be used.[44] For patients with a disease that is refractory to the TKI therapy, a chemotherapeutic agent omacetaxine is also a recommendation.[30][45] Studies have shown that primary or acquired resistance to treatment, as well as relapse, is attributable to different mutations. Rearrangements in the BCR gene can help in the prediction of response to therapy.

For patients with Ph+ive ALL, in addition to TKI, concurrent use of chemotherapeutic agents has shown remarkable results. For patients who are refractory to the TKI therapy and for patients with Ph+ive MPAL, a combination of alternative or advanced generation TKIs, and hematopoietic stem cell transplantation are recommendations.[4]

PROGNOSTIC SIGNIFICANCE:

The status of the Philadelphia chromosome is associated with substantially different prognoses in patients of different leukemic phenotypes. The presence of the Ph chromosome has also correlated with a higher risk of concurrent genomic abnormalities.[4]

In patients of CML, the location of the breakpoint in the BCR gene has shown an important association with prognosis. CML patients with a double Philadelphia chromosome are associated with a worse prognosis than those with a single Philadelphia chromosome.[46] The presence of concurrent genetic abnormalities is associated with a worse prognosis than in the blastic phase of CML.[2]

ALL patients, both adults, as well as children who are Ph+ive, have shown a poor prognosis in comparison to those who are Ph -ive.[8]

Patients with Ph+ive MPAL have shown a worse outcome in comparison to other leukemic phenotypes.[4]

References

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Philadelphia chromosome (Ph), named after the city where it was first described, was described for the first time by Nowell and Hungerford in 1960, in two patients who had lost the long arm of chromosome 22.[1][2][3] As the Giemsa staining improved over the decade, Rowley showed that this truncated chromosome

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I used the lecture/resources provided
I thought it was quite nice and covered the different parts of this LO

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this is an example of esophageal cancer (taken from the pathology lecture)

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in terms of grading and staging the grading was quite self explanatory (the higher the grade the less differentiated it is therefore the more aggressive its behaviour + rapid in growth and extent of spread etc.)
For staging the TNM system is used:
T- size of primary tumour/extent of invasion
N- lymph node metastases
M- distant metastases
(I've typed all this stuff up not because I don't think that you guys know it, but just for future reference:) )

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this image (was used in both the genetics and pathology lectures) and shows the genetic/pathological changes that the cancer cells have. I liked it because it also shows the drugs that can target all these changes in the cells.

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I thought the lecture was a bit long but the beginning did cover this LO.
This image goes over the hydroxylation of Vitamin D from it's inactive form as a prohormone to hormone form for it to be able to function

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https://theros.org.uk/information-and-support/osteoporosis/

Royal OPorosis society, seems superficial but can in fact access a lot of detail when click onto the various drug fact sheets for eg.

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Osteoporosis is a condition where your bones lose strength, making you more likely to break a bone than the average adult.

Living with osteoporosis means you are at higher risk of breaking a bone. But not everyone with osteoporosis goes on to break a bone. It's not inevitable, and we're here to help you live well with osteoporosis.

A broken bone and a fracture are the same thing. As bones lose strength, they can break after a minor bump or fall. You may hear or read these described as fragility fractures.

Become a member today to get all the latest information to help keep your and your family's bones healthy and strong.

Newly diagnosed?

Learn more and find answers to common questions in our video series.

Get support from a Specialist Nurse

Contact our free Helpline for tailored information about osteoporosis and bone health:
nurses@theros.org.uk

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Osteoporosis is a condition where your bones lose strength, making you more likely to break a bone than the average adult. Living with osteoporosis means you are at higher risk of breaking a bone. But not everyone with osteoporosis goes on to break a bone.

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i used the same video as the one linked for osteomalacia
i found it to be a very good resource

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I really liked Tarnyas video on this LO, I thought it pretty much covered it and I've linked it for us to have it here for future reference

https://learn-eu-central-1-prod-fleet01-xythos.content.blackboardcdn.com/5f47a5775541f/5587852?X-Blackboard-Expiration=1642118400000&X-Blackboard-Signature=eP1x%2BMN3mbccDtgyMRSbWMDlUPpRKlWGYwHq2O9j3y4%3D&X-Blackboard-Client-Id=131628&response-cache-control=private%2C%20max-age%3D21600&response-content-disposition=inline%3B%20filename%2A%3DUTF-8%27%27Tarnya%2520Marshall%2520-%2520Osteoporosis%2520and%2520Osteomalacia%252C%2520Collab%2520Recording.mp4&response-content-type=video%2Fmp4&X-Amz-Security-
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also sorry because its a huge link ://

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This is a comprehensive, easy-to-follow (but long) article, great for our background knowledge.
https://www.news-medical.net/health/Healthcare-Systems-Around-the-World.aspx#:~:text=The%20health%20system%20is%20financed,healthy%20competition%20between%20the%20two.

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There are many philosophies shaping healthcare services around the world, and this article glances at some prominent examples. This may help understand why different countries experience healthcare differently.

Image Credit: pogonici/Shutterstock.com

Healthcare in the USA

The USA does not have a universal, free healthcare program, unlike most other developed countries. Instead, in line with the free-market-virtue mindset, most Americans are served by a mix of publicly and privately funded programs and healthcare systems.

Most hospitals and clinics are privately owned, with about 60% being non-profits, and another fifth being for-profit facilities. Coverage by federal and state programs is partial, and most insured Americans have employment-based private insurance.

Group plans funded by the employer cover about 150 million Americans.

Private insurance

These include health maintenance organizations (HMOs), which are networks of providers. Insured patients see a primary care physician (PCP), whose refers them to a specialist if necessary.

A more popular option is to use preferred provider organizations (PPOs), which allow patients to see external providers, choose their PCPs, and see a specialist without a PCP referral provided the former is willing.

These are now used by over 55% of insured employees, compared to 25% in HMOs or point-of-service (POS) plans.

With POS plans, patients must have a PCP in the provider network, but can go out of the network for a fee.

Federal insurance

The Indian Health Services and Veteran Health Administration provide care for Native Americans and military veterans, respectively. The Military Health System, operated by the Department of Defense, provides paid care to serving military personnel.

Publicly funded insurance

Public spending accounts for at least half of all healthcare expenditure, while third-party payers pay only 27%.

About a third of the population is covered by three publicly funded programs - Medicare, for people above 65 years and some disabled people, Medicaid, for those living in poverty. and the Children's Health Insurance programs, which cover children from families that are not eligible for Medicaid, at above 300 percent of the Federal Poverty Level (FPL).

The ACA act of 2010 ("Obamacare'), which was enacted in 2010, revamped health insurance. It created health insurance marketplaces, which cover about 17 million Americans. However, these plans are often small, exclusive, and restricted in provider choice.

At the same time, the expansion of Medicaid under the ACA act has possibly saved many lives at less than $900,000 per life saved, vs $7.6 million under other public insurance plans.

The good and the bad

Among 11 high-income countries, the US healthcare system is the most expensive, with 17% of the GDP being spent on healthcare in 2018. Many American health indicators far surpass world standards.

Its rate of specialized scans (computerized tomography - CT - and MRI) - are among the highest in the world, at double the OECD average. So is its utilization of hip replacements, influenza vaccines, and breast cancer screenings.

However, among developed countries, the American system is among the least accessible, efficient and equitable. The number of physicians, and rate of physician visits, is among the lowest. Ethnic and disadvantaged social groups suffer massive inequalities.

About 14% of Americans (over 27 million) were uninsured against illness at the end of 2018, causing an estimated 60,000 avoidable deaths. High medical costs have led to bankruptcy for a fourth of senior citizens, says an earlier study.

Preventable and lifestyle conditions such as obesity, hypertension and diabetes are rampant: this indicates poor access to primary care and primary prevention of disease, compared to its peers.

Meanwhile, US suicide rates are highest among all members of the Organization for Economic Co-operation and Development (OECD).

Overall, the US healthcare system allows providers to inflate prices and expensive services, but poorly compensates essential services such as primary care and behavioral advice. It also draws healthcare services away from rural and poor communities.

Nonetheless, the US leads in medical innovation, boasting many of the world's leading hospitals. For those who can pay, it provides high-quality care.

COVID-19 response

Even though the US healthcare system serves 4% of the world's population, a quarter of global COVID-19 cases and a fifth of global COVID-19 deaths occurred here. The reasons are not primarily related to the healthcare system, however.

Rather, they include a disjointed, reluctant and often contradictory public health response to the pandemic, driven by political apathy toward the virus threat.

There is no central command and control for healthcare in the country: this obstructs infection spread control.

Image Credit: Khongtham/Shutterstock.com

UK healthcare system

The UK healthcare system covers the whole population via the National Health System (NHS), which is 79% publicly financed from taxes, and operated by the Department of Health. About 20% is paid for by national insurance, and private patients and copayments make up the rest.

NHS England supervises and funds local Clinical Commissioning Groups. These provide comprehensive care, including preventive screening programs and vaccinations, inpatient and outpatient care in hospitals, maternity care, mental health care and palliative care.

Like the USA, the UK has public, private profit and nonprofit hospitals. The first type is operated as hospital trusts or foundation trusts, in three tiers: community hospitals, district hospitals, and regional-level hospitals. Dedicated hospitals offer specialized treatment.

General practitioners (GPs) offer primary care to locals through their practices. Many such practices are overtaxed: one alternative is registration-free walk-in centers. GPs refer patients as necessary for secondary care.

All residents of England, as well as anyone with a European Health Insurance Card, are entitled to NHS care: primary care is mostly free. Others receive emergency or infection-selective treatment.

Patients in the NHS can choose a hospital and specialist. Currently, 12% of the population also opts for private health insurance, mainly to avoid the waiting period for elective care, to have a choice of specialists, and better facilities.

Private hospitals typically offer specialized treatments, such as bariatric surgery, and do not offer trauma care, emergency services or intensive care.

The UK spends about a tenth of its GDP on healthcare, with almost 80% being spent on the NHS.

Unlike the American healthcare system, the NHS's administrative spending is only 16% of healthcare costs.

The good and the bad

Universal free healthcare is widely considered to be good for the country, health-wise as well as economically.

The UK NHS provides free healthcare for all and higher life expectancy than in the USA, at half the cost. Patient satisfaction is relatively high, at 61%, compared to 29% in the US.

Taxes for healthcare may appear higher but are actually equivalent to the total medical expenses in the US. Moreover, drugs are cheaper, and there are no surprise medical costs.

Austerity cuts have led to a reluctance to recruit staff and to upgrade equipment, which may eventually affect the quality of care. Waiting times for consultations and surgeries are long.

A third issue is health tourism, where non-residents exploit the NHS to get high-quality medical care at a lower cost than is available where they live, but without a corresponding contribution through taxes.

Ethnic minorities and the poor face inequality in the healthcare system. Social care measures need to be implemented.

COVID-19 response

When the pandemic hit the UK, the government built seven temporary hospitals to cope with the sudden demand.

Case finding, contact tracing and isolation were woefully inadequate, allowing community spread to occur and forcing local authorities to take over.

Routine medical care was affected by the pandemic. Patients avoided the emergency department for fear of infection. At least 160,000 patients waited a year for diagnoses, vs the standard 18 weeks. Restoration of this standard may take years.

Mental health care, already pressured, is under massively increased stress, with an estimated 10 million new patients influenced by the pandemic.

Many staff were infected or exposed to infection: to compensate, others have been asked to forego or limit planned leave.

The new spike of cases in 2021 has caused more hospitalizations than at the peak in 2020. Additionally, the NHS is required to ensure vaccination of the whole country. Thirdly, it has to arrange long-term follow-up services for people with long COVID.

In order to restructure the NHS to meet all these needs, three areas must be prioritized - capacity, resources and public health.

Image Credit: Cinemanikor/Shutterstock.com

Healthcare in the European Union

Each country in the EU has its own healthcare system. However, EU members generally share the same goal as the UK model.

All healthcare systems in Europe automatically include all citizens irrespective of paying capacity. Secondly, all are mostly funded by taxes paid by the employer and by the public. Healthcare is free, except for some elective and specialist services.

Three models

There are fundamentally three models at work within the EU: single-payer, socialized, and privatized-regulated.

In a single-payer system, the government provides universal insurance or coverage, but the actual care is by private practices and hospitals.

Individuals may opt for additional private insurance to cover services that are not covered by public healthcare, but not for those already available. The payment for such providers may be fee-for-service, or capitation, based on the number of patients enrolled.

More recently, lump-sum payments have been adopted to cover all services per year per person enrolled. However, fee-for-service tends to encourage excessive use of manpower and capital resources.

Hospital funds are allocated as diagnosis-related groups (DRGs), per-diem, or as lump-sum payments for all services.

The socialized system is one where the government both provides insurance and runs the hospitals. It is thus the only health insurance provider. The NHS is a version of this model, which is also used in France, Italy, Norway and Sweden.

Patients may opt for supplemental private insurance, to get services not supplied within the public health service, or to see doctors not employed by this service.

France, cited by some as having among the best healthcare systems in the world, has a significant private healthcare system as well as statutory health insurance, offering a wide choice of coverage.

However, recent amendments to the law made it mandatory for employees to pay half of the insurance sponsored by their employers. This is especially so for dental and vision expenses, not covered by the state health insurance.

This system strongly resembles the American Medicare, Medicaid and Veteran Affairs schemes.

The privatized but regulated healthcare systems within the EU are exemplified by Germany. Here, though all citizens earning below a threshold must take health insurance, their unemployed spouses and dependents are also covered without any extra cost.

Above this threshold, employees may buy private insurance. However, other than self-employed and government servants, most people prefer not to.

In Switzerland and the Netherlands, health insurance is mandatory and provided exclusively by private providers. The government subsidizes the premiums through taxes, making it possible for even low-earning citizens to afford health insurance.

All insurers are legally required to accept any applicant. This costs the patient much less than it would in the US, the system is easier to navigate, and the coinsurance is capped at a reasonable ceiling.

Thus, European healthcare provides primary and some secondary medical care, with some places allowing private companies to sponsor more insurance for their employees.

Privatized programs allow for specialized care, cut down the waiting time for a procedure, or expand the patient's choices.

The EU average for healthcare expenditure is about 8% of the GDP, but Cyprus and Latvia are at 3.5%, with other East European nations at 5%. Public spending in this sector typically makes up about 15% of the total government budget.

The good and the bad

Most EU members enjoy the approval of the majority of their people for their healthcare systems, with less than 5% of people in four-fifths of European countries reporting unmet needs.

National health systems tend to control costs better. The introduction of internal markets may increase the healthcare economy and efficiency.

Nonetheless, funding pressures are likely to go up as patients expect more advanced treatments and as technology develops. The graying of Europe may impede fund flows to these programs, given that about 70% of the funding comes from the public sector in most countries.

At the same time, aging is associated with different patterns of disease, typically conditions that are both preventable and care-intensive. As age increases, however, social welfare tends to absorb more of the costs.

Audits of spending efficiency will be crucial to enhancing the spending power of each euro. "The OECD estimates that one fifth of health expenditure makes little or no contribution to improving people's health."

Inequalities in health status and inequity in healthcare finance and delivery continue to plague the system in many EU nations.

COVID-19 response

While many countries set up smoothly functioning mechanisms to deal with the emerging pandemic, the EU was, generally, unprepared. The stockpiles of equipment, medicines and ventilators were inadequate in many places.

This hampered these countries from buying testing kits and setting up contact tracing, for example, early in the pandemic, which further slowed down virus containment efforts.

Crisis management plans fell short of reality, forcing healthcare staff to improvise and innovate, as well as overwork, to compensate. The need to share resources, and hospital capacity, internationally, could also be significant.

Thus, logistics, preparedness, coordination, and continuing with routine healthcare, are areas that need future improvement.

Image Credit: elenabsl/Shutterstock.com

Healthcare systems in Asia

Asian healthcare systems are a mélange of public and privately managed programs.

Singapore

Singapore uses the 3Ms system: a public statutory insurance system, MediShield Life for large hospital bills, and some high-end outpatient treatments as well, but not primary care, or specialist care at the outpatient level.

The premiums are subsidized to help even low-earning people to pay them, and working-age people pay more to allow older people to enjoy lower premiums.

A compulsory national health savings account called MediSave helps pay for hospital care and some outpatient treatments. MediFund is a social welfare program for poor citizens who cannot pay for out-of-pocket expenses even with MediSave.

Thus, the government, healthcare providers, and patients all share the responsibility for healthcare coverage - a multipayer financing system. While competition and market forces enhance the quality of healthcare, the government strictly regulates the costs when they begin to rise beyond affordable rates.

The Ministry of Health also plans for workforce strength, training and land allotment for healthcare facilities, along with preventive health interventions. The system's centralized nature keeps administrative costs low and simplifies procedures.

Singapore spends about 4.5% of its GDP on healthcare, about 40% by the government, with 30% being out-of-pocket expenses.

China

China has almost universal publicly funded medical insurance, with urban employees enrolled in employment-based programs. Others enroll voluntarily, for basic subsidized medical insurance. Comprehensive healthcare is covered, but deductibles and copayments apply. There is also a ceiling on reimbursement.

For-profit private insurance is also available for services not covered by public insurance. Patients share costs for physician visits, inpatient care and prescription drugs, which are uncapped.

China spends about 6.6% of its GDP on healthcare, with 28% being funded by central and local governments, 28% out-of-pocket, and 44% by public or private insurance, and social health donations. These form part of a medical assistance program for the poor.

Wide inequalities in public health services have been reported. Most residents feel that their insurance is as helpful, at least, as the basic public health services.

India

India provides universal free outpatient and inpatient care at government clinics and hospitals. States are in charge of organizing their healthcare services.

However, government facilities are notoriously understaffed and ill-equipped, so that most people pay out-of-pocket for private healthcare. The National Health Protection Scheme (Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana, or PM-JAY) was recently launched to attempt to address this: it supersedes the earlier under-performing National Health Insurance Program (Rashtriya Swasthya Bima Yojana, or RSBY).

The PM-JAY program is financed by taxes and enables free secondary and tertiary care at private hospitals. PM-JAY envisages grassroots Health and Wellness Centers while providing cashless hospital care for the 40% of people (approximately 100 million) who live below the poverty line.

Government workers and most formal employees have their own health insurance schemes. A few private health insurance providers also exist, with limited uptake. Less than 40% of Indians are insured.

The situation is worsened by the poor quality of public healthcare services and the shortage of doctors and equipment. Corruption, as in many developing countries, along with accessibility issues, exacerbates these drawbacks.

India spends less than 4% of its GDP on healthcare, with a quarter being funded by the public sector. Out-of-pocket payments at private hospitals make up 75% of the total expenditure, in stark contrast to other poor countries.

COVID-19 response

The overall strategy in east Asia's advanced economies was to suppress the spread of the virus using conventional containment measures.

Careful case tracking, contact tracing, and quarantine helped contain the virus in Singapore, Hong Kong and South Korea, for instance.

Even in less economically advanced countries like India, the Philippines, and Vietnam, public health education and preexisting community values proved useful.

These commonly shared values allowed people to take more easily to non-pharmaceutical interventions (NPIs) such as masking up, staying at home, and social distancing.

In India, the lockdown was a key weapon against the spread of the virus. This was coupled with a ramping up of production of personal protective equipment, ventilators and testing kits.

Yet, extreme and widespread poverty, weak healthcare systems and the high population density make tracking and countering the pandemic a difficult task in India, as in other developing Asian countries.

Healthcare systems in Australia

Australia has a tax-funded universal free public health insurance program, called Medicare. All citizens get free care for public and many physician services and drugs at public hospitals.

About 50% of Australian citizens also take out private insurance to pay for private hospital care or dental care. This is encouraged by the government, and high-income families pay a tax penalty for not buying private insurance.

The total expenditure on healthcare is about 10% of GDP, with 67% being from the public sector. It is jointly run by federal, state and territorial governments, and is among the best in the world.

Pros and cons

While free universal care is an undoubted advantage, funding may be challenging as the population ages, reducing tax inflow. Meanwhile, medical technology costs go up, making it difficult to keep up.

There is a disparity in access and care quality between the non-indigenous and the aboriginal population. Research is not well-aligned with national priorities. Urbanization continues to pose an obstacle to healthy living.

COVID-19 response

The Australian response to the pandemic included building transparency between the government and citizens, to ensure public trust. This in turn resulted in a high level of compliance to lockdowns, masking up and quarantine, as well as rapid testing.

Secondly, the decision-making process was driven by reliable data interpreted by experts and performed in an agile and iterative manner. Both political and public health leaders were seen to be cooperating and trustworthy.

Thirdly, the pandemic response was based on a collaboration across health and economic boundaries. The public health response was both willing and strong, which certainly helped to achieve the goal of virus containment.

This resulted in low mortality and infection rates, as well as a rapidly rebounding economy. Localized outbreaks still occur, and are handled on a crisis level. This has come at the cost of many stranded Australians abroad who cannot return home due to the cap on the number of returning passengers.

COVID; Why the Economics of Healthcare Will Never Be the Same | Laura Glenn | TEDxTraverseCity

Healthcare systems in South America

While medical services tend to be cheaper here, they are also universal and publicly funded in countries like Chile and Columbia. As a result, medical tourism has boomed in these places.

Healthcare systems have progressed since the time when only employees in the formal labor market received public health insurance, to which employers, employees and government contributed.

The rest of the people relied on fragmentary services by the Ministry of Health, the church, and charitable or philanthropic organizations. The rich had private health care. The poor had almost nothing.

A few examples

Colombia

Colombia is a success story in South American healthcare. It covers almost 97% of its population by mandatory universal health insurance. All citizens have access to the same healthcare services, with only 14% out-of-pocket spending. This is lower than that in many OECD countries.

The health system is financed through taxes and employment insurance and fully subsidizes the poor. Both public and private insurers are involved, and providers also belong to both public and private sectors, with a healthy competition between the two.

The FOSYGA; Solidarity and Guarantee Fund, is based on cross-subsidies between rich and poor, young and old, and healthy vs sick.

Participants may choose their provider within their network, and receive a package of primary care, some inpatient care, and emergency care, as well as inpatient care at tertiary level public hospitals. Eventually, the government hopes to eliminate supply-side subsidies and provide uniform coverage for all.

Performance management, accountability and efficiency need to be improved to build on these gains.

Chile

Chile has statutory health insurance for workers, with no employer or government contribution. The health funds are managed by ISAPREs (Social Security Health Institutions).

The rest of the population is covered by a public fund manager, the National Health Fund (FONASA). These cover healthcare payments.

Brazil

Brazil has a government-run universal comprehensive public health system, funded by taxes at federal, state and municipality level. While the federal contribution is about 43% of total public health expenditure, municipalities contribute almost a third.

The system covers all types of healthcare for all citizens and visitors. However, wait times are unreasonably long at all stages, leading to out-of-pocket spending for basic care, while the delays push up treatment costs.

Drug unavailability leads to out-of-pocket spending. About a quarter of people have private health insurance, typically as an employment benefit.

National health expenditure is about 9% of the GDP. Most hospitals are public.

Costa Rica

Costa Rica also has a successful healthcare system, under a single-payer model that combines social security with the medical services offered by the Ministry of Health. About 86% of the population has access to high-quality comprehensive care, which is delivered free. The rest are able to pay for care.

Argentina

Argentina has a healthcare system whereby insurance is provided and managed chiefly by workers' unions, while over a third of the population is uninsured and depend on public healthcare.

The good and the bad

South American healthcare systems suffer from poor resources, which are badly distributed to cover some areas. The capacity of the systems is low, and drug shortages are common. Corruption vitiates the process of official appointment and hampers reforms.

Response to COVID-19

The year of COVID-19 has seen over 21 million cases, and 560,000 deaths in South America, along with severe economic stress. Argentina, with a test positivity rate of 60 percent in October 2020 - the highest in the world - reflects both low testing and poor enforcement of non-pharmaceutical interventions.

Brazil has reported 13 million cases with over 330,000 deaths, with intensely divided political and public health messaging leading to it being one of the hardest-hit countries in the world. It is followed by Colombia, with a steadily increasing infection rate. Chile, meanwhile, has among the worst outbreaks in the world, with 1,500 deaths per million inhabitants.

The health response has been marked by its wide variation, with some countries instituting strict lockdowns, closing borders and eventually rolling out millions of vaccinations, while others have done almost nothing meaningful to prevent border crossing.

Limited resources, non-unified health systems, and poor social care, along with pre-existing unemployment and inequities, have led to a less than desirable response to the pandemic in most of Latin America, impacting the disadvantaged most severely, as expected.

Image Credit: REDPIXEL.PL/Shutterstock.com

Healthcare systems in Africa

Sub-Saharan Africa has 13% of the world's population but carries a fourth of the world's disease burden. However, it spends only 1% of the global health expenditure.

Three out of four Africans have a per capita income of below $2 a day, and almost half spend less than $1 a day. Universal free healthcare is a right that is agreed to by all but is slow to become a reality.

Most Africans that are either low or middle-income turn to the public health system or to traditional healers. Only a few are able to afford high-quality private care, but nonetheless, out-of-pocket expenditures are bound to be high in this two-tier system.

Private spending accounts for 60% of all payments on healthcare. However, half of private healthcare expenditure is spent on private providers, and 40% of the lowest-income people in Africa pay for care from for-profit providers.

In Rwanda, national health insurance covers over 90% of the population, whereas less than 9% are covered in other countries.

Ghana has a National Health Insurance Scheme (NHIS), and built a public-private partnership network to reach areas without public health services. Funded through taxation, the NHIS covers most common diseases.

All residents must enroll and pay an annual premium, in return for free care. About a quarter lack any insurance, however. Almost 70% of those insured do not have to pay premiums, and underfunding challenges the working of the scheme.

In Kenya, a similar national health insurance program exists, for salaried employees, and for self-employed if they want to enroll. However, even this cost is inaccessible to most citizens.

So is the case with Tanzania, with its NHIF and CHF, for civil servants who pay 6% of their income, and for indigents and low-income people. In fact, most African countries share this situation, and national free healthcare accessible to those living in poverty is still a pipe dream.

Many countries spend only donor money on healthcare. Many times, international loans intended to improve the healthcare infrastructure had many strings attached. As a result, user fees were imposed on primary care. Drug pricing went up. Preventive and primary care was put out of reach of most low-income Africans.

Medicine became commercialized and privatized, and inequalities became more unequal. Infectious diseases like HIV emerged again. Government spending on health was cut due to required austerity measures.

Vacancies in the public sector increased, worsened by a freeze on recruitment and the flight of health professionals outside Africa. Most physicians went into private practice in urban areas, serving about 15% of the population. Drug shortages were endemic and intractable.

Cumbersome bureaucracy at all levels, inadequate coverage by insurance, low benefits for inpatient care, lack of transparency, and poor accountability, are the chief features of African health systems, in general.

This is worsened by the outflow of doctors to the US and other more lucrative and functional locations, and by ignoring the unique conditions of Africa in favor of western theories and policies. Poor sanitation and potable water facilities contribute greatly to this scenario.

Only six African countries spend 15% of their budgets on healthcare, and these are yet to achieve universal access to reasonable-quality healthcare.

COVID-19 response

African leaders showed solidarity in planning and executing interventions such as cross-border electronic cargo driver test result sharing, to prevent the spread of infections across countries. Lockdowns were implemented along with the closure of borders very early in the course of the spread of the pandemic to Africa.

Case finding, testing, contact tracing and isolation services were set up for free, as well as treatment. Public health education was enthusiastically provided to introduce proven non-pharmaceutical interventions such as masks, hand hygiene and social distancing.

Meanwhile, social support was put in place to support the economically weaker sections of society. Some waived fees on electricity and water and reduced house rents were announced in Ethiopia.

Advanced technology was used in Rwanda, including temperature-taking robots, drones for communication and surveillance, and pooled testing. Governmental transparency has been key to expert-driven decision-making, besides the unity displayed by political and health leaders.

Conclusion

Is there a perfect healthcare system? No, but the features that make for a good one include long-term investments in human resources and infrastructure, and in primary care (as in Israel). A Nordic focus on preventive care to improve population health and build capacity is important.

Public funding to allow the poorest to access healthcare and medication is an excellent model to follow, as in many Commonwealth and EU systems. Patient and community engagement, with an innovative streak, and a rapid response, is essential for maximizing coverage, like Rwanda and India.

Due investment in information technology and in research and development are key to making healthcare systems more accessible and improving health outcomes.

Lastly, attention to aged care, as in Japan, and to mental well-being, a mark of the Australian system, along with providing a choice of providers and services to the patient, seen in France, are fundamental to a healthcare system that follows best practices.

References

Tikkanen, R. et al. (2021). U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019

Medical.mit.edu (2021). Healthcare in the United States: The top five things you need to know. https://medical.mit.edu/my-mit/internationals/healthcare-united-states

Healthmanagement.org. (2006). Facts & Figures: The UK Healthcare System. https://healthmanagement.org/c/it/issuearticle/facts-figures-the-uk-healthcare-system

Great Britain: The National Health Service. https://sites.psu.edu/smithcivicblog/2016/01/16/great-britain-the-national-health-service/

Ec.europa.eu (2017). European semester thematic factsheet: Health systems.

Thorlby, R. (2021). International Health Care System Profiles England. https://www.commonwealthfund.org/international-health-policy-center/countries/england

Earn, L. C. (2021). International Health Care System Profiles Singapore. https://www.commonwealthfund.org/international-health-policy-center/countries/singapore

Gupta, I. (2021). International Health Care System Profiles India. https://www.commonwealthfund.org/international-health-policy-center/countries/singapore

Earn, L. C. (2021). International Health Care System Profiles Singapore. https://www.commonwealthfund.org/international-health-policy-center/countries/singapore

World Health Organization. Regional Office for Europe, European Observatory on Health Systems and Policies, Miguel Á González Block, Hortensia Reyes Morales, Lucero Cahuana Hurtado. et al. (‎2020)‎. Mexico: health system review. World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/334334

Kim, S. Universal Healthcare Systems and Fragmentation in Latin America. https://sites.google.com/macalester.edu/phla/key-concepts/universal-healthcare-systems-and-fragmentation-in-latin-america

www.ilo.org. More than 140 million denied access to health care in Latin America and the Caribbean. https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_007961/lang--en/index.htm

www.un.org/africarenewal. December 2016-March 2017 | Vol. 30 No. 3

Fang, H. (2021). China. https://www.commonwealthfund.org/international-health-policy-center/countries/china

Blumenthal, D. et al. (2020). Covid-19 - Implications for the Health Care System. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/nejmsb2021088

Apps.who.int. (2020). Mexico: health system review. https://apps.who.int/iris/handle/10665/334334

Altman, D. (2020). Understanding the US failure on coronavirus-an essay by Drew Altman. The BMJ. https://doi.org/10.1136/bmj.m3417. https://www.bmj.com/content/370/bmj.m3417

Scally, G. et al. (2020). The UK's public health response to covid-19. https://doi.org/10.1136/bmj.m1932. https://www.bmj.com/content/369/bmj.m1932

Ham, C. (2020). The challenges facing the NHS in England in 2021. https://doi.org/10.1136/bmj.m4973. https://www.bmj.com/content/371/bmj.m4973

www.thelancet.com. (2020). Building a resilient NHS, for COVID-19 and beyond. https://doi.org/10.1016/S0140-6736(20)32035-3. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32035-3/fulltext

Han, E. et al. (2020). Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe. https://doi.org/10.1016/S0140-6736(20)32007-9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32007-9/fulltext

Child, J. et al (2020). Collaboration in crisis: Reflecting on Australia's COVID-19 response. https://www.mckinsey.com/industries/public-and-social-sector/our-insights/collaboration-in-crisis-reflecting-on-australias-covid-19-response#

Ihekweazu, C. et al. (2020). Africa's response to COVID-19. https://doi.org/10.1186/s12916-020-01622-w. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-01622-w#citeas

Allin, S. et al. (2020). Comparing Policy Responses to COVID-19 among Countries in the Latin American and Caribbean (LAC) Region. https://openknowledge.worldbank.org/handle/10986/35002

Gray, R. (2020). Lack of solidarity hampered Europe's coronavirus response, research finds. https://horizon-magazine.eu/article/lack-solidarity-hampered-europe-s-coronavirus-response-research-finds.html

Macri, J. (2016). Australia's Health System: Some Issues and Challenges. Journal of Health & Medical Economics. https://health-medical-economics.imedpub.com/australias-health-system-some-issuesand-challenges.php?aid=8344

Layland, A. et al. (2018). Are rankings the best way to determine healthcare systems? https://healthmanagement.org/c/healthmanagement/issuearticle/are-rankings-the-best-way-to-determine-healthcare-systems

Jabukowski, E. et al. (1998). Public Health and Consumer Protection Series SACO 101 EN. Health care systems in the EU: A comparative study. https://www.europarl.europa.eu>saco>pdf

Zhai, S. et al. (2017). A study on the equality and benefit of China's national health care system. International Journal for Equity in Health. https://dx.doi.org/10.1186%2Fs12939-017-0653-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575878/

Azevedo, M. J. (2017). The State of Health System(s) in Africa: Challenges and Opportunities. In: Historical Perspectives on the State of Health and Health Systems in Africa, Volume II. African Histories and Modernities. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-32564-4_1. https://link.springer.com/chapter/10.1007/978-3-319-32564-4_1

Further Reading

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There are many philosophies shaping healthcare services around the world, and this article glances at some prominent examples. This may help understand why different countries experience healthcare differently. Image Credit: pogonici/Shutterstock.com The USA does not have a universal, free healthcare program, unlike most other developed countries.

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https://sway.office.com/dqKcbxO7VAEHFDoA?ref=email
Zoe's sway document has a list of red flags to look out for

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BY DR ZOE BARBER GP & HONORARY SENIOR LECTURER

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Good recap of different tumours, taken from pathology lecture

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Cancer Research UK information about bony metastases, aka secondary bone cancer

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Secondary bone cancer is when a cancer that started somewhere else in the body has spread to the bones.

Where a cancer starts is called the primary cancer. If some cancer cells break away from the primary cancer they can move through the bloodstream or lymphatic system to another part of the body, where they can form a new tumour. This is called a secondary cancer. Secondary cancers are also called metastases (pronounced met-ass-ta-sees).

The secondary cancer is made of the same type of cells as the primary cancer.

So, if your cancer started in your lung and has spread to your bones, the areas of cancer in the bone are made up of lung cancer cells.

This is different from having a cancer that first started in the bone (a primary bone cancer). In that case, the cancer is made up of bone cells that have become cancerous. This is important because the primary cancer tells your doctor which type of treatment you need.

This video is about secondary cancer, it lasts for 2 minutes and 42 seconds.

Which cancers spread to the bones?

Any cancer can spread to the bones. The most common ones to spread are:

prostate cancer

breast cancer

lung cancer

kidney cancer

thyroid cancer

myeloma

Secondary bone cancer can develop in any of the bones of your body.

What are the symptoms of secondary bone cancer?

Symptoms can include:

pain - the pain is continuous, and people often describe it as gnawing

backache, which gets worse despite resting

breaks in the bones because they are weaker

dehydration, confusion, being sick, tummy (abdominal) pain and constipation due to high levels of calcium in the blood (hypercalcaemia)

increased risk of infection, breathlessness and looking pale, bruising and bleeding due to low levels of blood cells. Blood cells are made in the bone marrow and can be crowded out by the cancer cells

pain, weakness in your legs, numbness, paralysis and loss of bladder and bowel control (incontinence) this could be because of pressure on the spinal cord (spinal cord compression)

Remember that aches and pains are common and may be a muscle strain or an everyday ache. Tell your doctor if you have a new pain. They can check what is causing it and treat it as soon as possible. This helps to avoid further problems such as bone fractures or severe pain.

Tests

There are different tests you might need to diagnose secondary bone cancer. You may have one or more of the following:

MRI scan

PET scan

X-rays

bone scan

CT scan

PET-CT scan

PET-MRI scan

bone biopsy - a small sample of bone is sent to the laboratory for a specialist doctor to look at under a microscope

What is the treatment for secondary bone cancer?

The aim of treatment for secondary cancer is usually to control the cancer and relieve symptoms. It may also help prevent problems from developing. Some people with secondary cancer may be too unwell to have treatment for the cancer.

What are the survival rates for secondary bone cancer?

Most people worry about their outlook (prognosis) when they have a secondary cancer. Your individual outlook depends on many factors including whether the cancer has spread to more than one part of your body, how quickly it is growing, and how it responds to treatment. It is usually difficult to predict and this uncertainty can be hard to deal with.

It is usually difficult to predict and this uncertainty can be hard to deal with. Speak to your doctor who can give you more information about your outlook.

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Secondary bone cancer is also called bone metastases. It's when a cancer that started somewhere else in the body has spread to the bones. Find out how cancer spreads, what the symptoms might be and the tests you might have.

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Bone Pain: Causes, Symptoms, Treatments, and More (healthline.com)

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We include products we think are useful for our readers. If you buy through links on this page, we may earn a small commission. Here's our process.

What is bone pain?

Bone pain is extreme tenderness, aching, or other discomfort in one or more bones. It differs from muscle and joint pain because it's present whether you're moving or not. The pain is commonly linked to diseases that affect the normal function or structure of the bone.

Many conditions and events can lead to bone pain.

Injury

Injury is a common cause of bone pain. Typically, this pain arises when a person goes through some form of trauma, such as a car accident or fall. The impact may break or fracture the bone. Any damage to the bone can cause bone pain.

Mineral deficiency

To stay strong, your bones require a variety of minerals and vitamins, including calcium and vitamin D. A deficiency in calcium and vitamin D often leads to osteoporosis, the most common type of bone disease. People in the late stages of osteoporosis often have bone pain.

Metastatic cancer

This is cancer that started somewhere else in the body but spread to other body parts. Cancers of the breast, lung, thyroid, kidney, and prostate are among the cancers that commonly spread to the bones.

Bone cancer

Bone cancer describes cancer cells that originate in the bone itself. Bone cancer is much rarer than metastatic bone cancer. It can cause bone pain when the cancer disrupts or destroys the bone's normal structure.

Diseases that disturb blood supply to bones

Some diseases, such as sickle cell anemia, interfere with the blood supply to the bone. Without a steady source of blood, bone tissue begins to die. This causes significant bone pain and weakens the bone.

Infection

If an infection originates in or spreads to the bones, it can cause a serious condition known as osteomyelitis. This infection of the bone can kill bone cells and cause bone pain.

Leukemia

Leukemia is cancer of the bone marrow. Bone marrow is found in most bones and is responsible for the production of bone cells. People with leukemia often experience bone pain, especially in the legs.

The most noticeable symptom of bone pain is discomfort whether you're still or moving.

Other symptoms depend on the particular cause of your bone pain.

Pelvic bone pain is a common occurrence for many pregnant women. This pain is sometimes referred to as pregnancy-related pelvic girdle pain (PPGP). Symptoms include pain in the pubic bone and stiffness and pain in the pelvic joints.

PPGP typically doesn't resolve until after delivery. Early treatment can reduce symptoms, though. Treatment options may include:

manual therapy to move the joints correctly

physical therapy

water exercises

exercises to strengthen the pelvic floor

While common, PPGP is still abnormal. You should contact your doctor for treatment if you experience pelvic pain.

A doctor needs to identify the pain's underlying cause to recommend treatment. Treating the underlying cause can drastically reduce or eliminate your pain.

Your doctor will perform a physical exam and ask about your medical history. Common questions include:

Where is the pain located?

When did you first experience the pain?

Is the pain getting worse?

Are there any other symptoms that accompany the bone pain?

Your doctor may order blood tests to look for vitamin deficiencies or cancer markers. Blood tests may also help your doctor detect infections and adrenal gland disorders that can interfere with bone health.

Bone X-rays, MRIs, and CT scans can help your doctor evaluate the affected area for injuries, bone lesions, and tumors within the bone.

Urine studies can be used to detect abnormalities within the bone marrow, including multiple myeloma.

In some cases, your doctor will need to run multiple tests to rule out certain conditions and to diagnose the exact cause of your bone pain.

When the doctor has determined the cause of the bone pain, they'll start treating the underlying cause. They may advise you to rest the affected area as much as possible. They'll likely prescribe you a pain reliever for moderate to severe bone pain.

If your doctor is unsure of the cause and suspects an infection, they'll start you on antibiotics. Take the full course of the medication, even if your symptoms go away within a few days. Corticosteroids are also commonly used to reduce inflammation.

The treatment options for bone pain include:

Pain relievers

Pain relievers are among the most commonly prescribed medications to reduce bone pain, but they don't cure the underlying condition. Over-the-counter treatments such as ibuprofen (Advil) or acetaminophen (Tylenol) can be used. Prescription medications such as Paracetamol or morphine may be used for moderate or severe pain.

Running low? Get Tylenol and ibuprofen now.

Antibiotics

If you have a bone infection, your doctor may prescribe powerful antibiotics to kill the germ that's causing the infection. These antibiotics may include ciprofloxacin, clindamycin, or vancomycin.

Nutritional supplements

People who have osteoporosis need to restore their calcium and vitamin D levels. Your doctor will give you nutritional supplements to treat the mineral deficiency. Supplements are available in liquid, pill, or chewable form.

Find calcium supplements and vitamin D supplements online.

Cancer treatments

Bone pain caused by cancer is difficult to treat. The doctor will need to treat the cancer to relieve the pain. Common cancer treatments include surgery, radiation therapy, and chemotherapy (which can increase bone pain). Bisphosphonates are a type of medication that help prevent bone damage and bone pain in people with metastatic bone cancer. Opiate pain relievers may also be prescribed.

Surgery

You may need surgery to remove parts of bone that have died due to infection. Surgery may also be required to re-set broken bones and remove tumors caused by cancer. Reconstructive surgery may be used in severe cases where joints can be replaced or substituted.

Maintaining strong, healthy bones makes it easier to avoid bone pain. To maintain optimal bone health, remember to:

maintain a healthy exercise plan

get enough calcium and vitamin D

drink only in moderation

avoid smoking

Read more: 8 fast facts about calcium "
Aside from improving bone health, you can also avoid injuries that lead to bone pain. Try to prevent falls by keeping your floors clutter-free and watching for loose rugs or poor lighting. You should also be careful when going up or down the stairs. For sporting activities, especially contact sports like football or boxing, wear proper protective gear.

In many cases, it takes some time to heal the issue causing the bone pain, whether the pain comes from chemotherapy or a fracture.

During recovery, avoid aggravating or bumping the affected areas. This can prevent further injury and pain and allow healing. Rest the affected areas as much as possible and immobilize the area if there's a risk of further injury.

For some people, aids such as braces, splints, and casts can offer support that can both protect the bone and relieve pain.

Serious conditions are often the cause of bone pain. Even mild bone pain may indicate an emergency condition. If you experience unexplained bone pain that doesn't improve within a few days, consult your doctor.

You should also see a doctor if the bone pain is accompanied by weight loss, decreased appetite, or general fatigue.

If you don't already have a primary care doctor, you can browse doctors in your area through the Healthline FindCare tool.

Bone pain that results from injury should also prompt a doctor's visit. Medical treatment is required for fractures from direct trauma to the bone. Without proper treatment, bones can heal in incorrect positions and inhibit movement. Trauma also predisposes you to infection.

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Bone Pain: Causes, Symptoms, Treatments, and More

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We include products we think are useful for our readers. If you buy through links on this page, we may earn a small commission. Here's our process. What is bone pain? Bone pain is extreme tenderness, aching, or other discomfort in one or more bones.

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Bone metastasis - Diagnosis and treatment - Mayo Clinic

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Diagnosis

Imaging tests are used to investigate signs and symptoms that may indicate bone metastasis. Which tests you undergo depends on your specific situation.

Tests may include:

X-ray

Bone scan (bone scintigraphy)

Computerized tomography (CT)

Magnetic resonance imaging (MRI)

Positron emission tomography (PET)

Biopsy

More Information

Show more related information

Treatment

Common treatments for bone metastasis include medications, radiation therapy and surgery. What treatments are best for you will depend on the specifics of your situation.

Medications

Medications used in people with bone metastasis include:

Bone-building medications. Medications commonly used to treat people with thinning bones (osteoporosis) may also help people with bone metastasis. These medications can strengthen bones and reduce the pain caused by bone metastasis, reducing the need for strong pain medications. Bone-building medications may also reduce your risk of developing new bone metastasis.

These drugs can be administered every few weeks through a vein in your arm or through an injection. Oral forms of these medications are available, but they generally aren't as effective as the IV or injectable forms, and may cause digestive tract side effects.

Bone-building medications can cause temporary bone pain and kidney problems. They increase your risk of a rare but serious deterioration of your jawbone (osteonecrosis).

Chemotherapy. If cancer has spread to multiple bones, your doctor may recommend chemotherapy. Chemotherapy travels throughout your body to fight cancer cells. Chemotherapy can be taken as a pill, administered through a vein or both. Side effects depend on the specific chemotherapy drugs you're given. For cancers that are sensitive to chemotherapy, chemotherapy may be the best way to alleviate pain from bone metastases.

External radiation therapy

Radiation therapy uses high-powered energy beams, such as X-rays and protons, to kill cancer cells. Radiation therapy may be an option if your bone metastasis is causing pain that isn't controlled with pain medications or if the pain is confined to a small number of areas.

Depending on your situation, radiation to the bone can be administered in one large dose or several smaller doses over many days. Side effects of radiation depend on the site being treated and its size.

Surgery

Surgical procedures can help stabilize a bone that is at risk of breaking or repair a broken bone.

Surgery to stabilize the bone. If the bone is in danger of breaking due to bone metastasis, surgeons can stabilize the bone using metal plates, screws and nails (orthopedic fixation). Orthopedic fixation can relieve pain and improve function. Often, radiation therapy is given when you have healed after surgery.

Surgery to inject a bone with cement. Bones that can't be easily reinforced with metal plates or screws, such as pelvic bones and bones in the spine, may benefit from bone cement. Doctors inject bone cement into a bone that is broken or damaged by bone metastasis. This procedure can reduce pain.

Heating and freezing cancer cells

Procedures to kill cancer cells with heat or cold may help control pain. These procedures may be an option if you have one or two areas of bone metastasis and aren't helped by other treatments.

During a procedure called radiofrequency ablation, a needle containing an electric probe is inserted into the bone tumor. Electricity passes through the probe and heats the surrounding tissue. The tissue is allowed to cool down, and the process is repeated.

A similar procedure called cryoablation freezes the tumor and then allows it to thaw. The process is repeated multiple times.

Side effects can include damage to nearby structures, such as nerves, and damage to bones that can increase the risk of a broken bone.

Clinical trials

Clinical trials are studies of new treatments and new ways of using existing treatments. Enrolling in a clinical trial gives you the chance to try the latest treatments. But a cure isn't guaranteed, and the side effects of new treatments may not be known. Discuss the available clinical trials with your doctor.

Physical therapy

A physical therapist can work with you to devise a plan that will help you increase your strength and improve your mobility. A physical therapist may suggest assistive devices to help you cope. Examples might include crutches or a walker to take weight off an affected bone while walking, a cane to improve balance, or a brace to stabilize the spine.

A physical therapist may also suggest specific exercises to help you keep your strength up and reduce your pain.

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Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Coping with bone metastasis requires more than enduring bone pain. It also involves coming to terms with the news that your cancer has spread beyond its original site.

Cancer that has metastasized can be very difficult to cure, though people can live several years with bone metastasis. Your doctor will work to minimize your pain and to maintain your function so that you can continue your daily activities.

Each person finds his or her own way to cope with a cancer diagnosis. Until you find what works best for you, consider trying to:

Find out enough about bone metastasis to make decisions about your care. Ask your doctor about the details of your cancer and your treatment options. Ask about trusted sources of further information. If you do research on your own, good places to start include the National Cancer Institute and the American Cancer Society.

Find someone to talk with. Although friends and family can be your best allies, in some cases they may have difficulty coping with the shock of your diagnosis. In these cases, talking with a counselor, medical social worker, or a pastoral or religious counselor can be helpful. Ask your doctor for a referral.

Connect with other cancer survivors. You may find comfort in talking with other cancer survivors. Cancer survivors can provide unique insight into your situation. Contact your local chapter of the American Cancer Society to find cancer support groups in your area.

Preparing for your appointment

Start by making an appointment with your primary care doctor if you have any signs or symptoms that worry you. Tell your doctor if you've been treated for cancer in the past, even if you received cancer treatment many years ago. If you're diagnosed with bone metastasis, you'll be referred to a cancer specialist (oncologist).

Because appointments can be brief, it's a good idea to be well prepared. Here's some information to help you get ready and know what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. Note how long you've been experiencing your symptoms and what makes the symptoms worse or better.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins or supplements that you're taking.

Consider taking a family member or friend along. Sometimes it can be difficult to remember all of the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your time with your doctor. For bone metastasis, some basic questions to ask your doctor include:

What's the most likely cause of my symptoms?

Are there other possible causes for my symptoms?

What kinds of tests do I need?

What treatments are available, and which do you recommend?

What's my prognosis?

Are there any experimental treatments or clinical trials available to me?

I have these other health conditions. How will those affect my treatment?

Is there a generic alternative to the medicine you're prescribing me?

Are there brochures or other printed material that I can take with me? What websites do you recommend?

What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask any additional questions that occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover other points you want to address. Your doctor may ask:

When did you first begin experiencing symptoms?

Have your symptoms been continuous, or do they come and go?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

Does anything make your symptoms worse?

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Imaging tests are used to investigate signs and symptoms that may indicate bone metastasis. Which tests you undergo depends on your specific situation. Tests may include: X-ray Bone scan (bone scintigraphy) Computerized tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET) Biopsy Show more related information Common treatments for bone metastasis include medications, radiation therapy and surgery.

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I used the lecture

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Mode of action | Background information | Analgesia - mild-to-moderate pain | CKS | NICE

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The NICE Clinical Knowledge Summary (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories

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What do cancer stages and grades mean? - NHS (www.nhs.uk)

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The stage of a cancer describes the size of a tumour and how far it has spread from where it originated. The grade describes the appearance of the cancerous cells.

If you're diagnosed with cancer, you may have more tests to help determine how far it has progressed. Staging and grading the cancer will allow the doctors to determine its size, whether it has spread and the best treatment options.

Cancer stages

Different types of staging systems are used for different types of cancer. Below is an example of one common method of staging:

stage 0 - indicates that the cancer is where it started (in situ) and hasn't spread

stage I - the cancer is small and hasn't spread anywhere else

stage II - the cancer has grown, but hasn't spread

stage III - the cancer is larger and may have spread to the surrounding tissues and/or the lymph nodes (part of the lymphatic system)

stage IV - the cancer has spread from where it started to at least one other body organ; also known as "secondary" or "metastatic" cancer

Cancer grades

The grade of a cancer depends on what the cells look like under a microscope.

In general, a lower grade indicates a slower-growing cancer and a higher grade indicates a faster-growing one. The grading system that's usually used is as follows:

grade I - cancer cells that resemble normal cells and aren't growing rapidly

grade II - cancer cells that don't look like normal cells and are growing faster than normal cells

grade III - cancer cells that look abnormal and may grow or spread more aggressively

Cancer Research UK has more information about the stages of cancer and the grading of different types of cancer.

Further information:

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The stage of a cancer describes the size of a tumour and how far it has spread from where it originated. The grade describes the appearance of the cancerous cells. If you're diagnosed with cancer, you may have more tests to help determine how far it has progressed.

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https://www.healthline.com/health/pathologic-fracture

This website explains what a pathological fracture is, what conditions make you more likely to get one and the treatments of each.

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https://www.youtube.com/watch?v=S0Ne7vrmNTw

This video explains what Paget's disease of bone is, the symptoms, diagnosis and treatment.

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Paget’s Disease of Bone (Osteitis Deformans) | Causes, Pathogenesis, Symptoms, Diagnosis & Treatment

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https://www.youtube.com/watch?v=QDQ4d5V0K7o

This video clearly explains what osteomalacia is, how it arises, and how to treat it.

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https://my.clevelandclinic.org/health/diseases/9495-osteomyelitis\

This website provides really good information on osteomyelitis, the symptoms, causes, treatment etc.

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What is osteomyelitis?

Osteomyelitis is a bone infection caused by bacteria or fungi. It causes painful swelling of bone marrow, the soft tissue inside your bones. Without treatment, swelling from this bone infection can cut off blood supply to your bone, causing bone to die.

What is bone marrow?

Certain bones in your skeletal system, such as the hip and thighbones, contain soft, spongy tissue. This tissue, called bone marrow, makes stem cells that produce blood cells and platelets.

How common is osteomyelitis?

Osteomyelitis affects about 2 to 5 out of every 10,000 people. It's one of the oldest diseases on record. Scientists have traced it back more than 250 million years.

Who might have osteomyelitis?

Osteomyelitis affects people of all ages and genders. Children younger than 3, the elderly and people with serious medical conditions are more prone to the condition.

In children, the infection is more likely to affect long bones, such as those found in the legs and arms. In adults, bone infections more often target the spine.

What are the types of osteomyelitis?

Types of osteomyelitis include:

Acute: This infection comes on suddenly. You may have a fever and then develop pain in the infected area days later.

Chronic: Chronic osteomyelitis is a bone infection that doesn't go away with treatments. It causes bone pain and recurring drainage (pus). Rarely, chronic osteomyelitis doesn't have symptoms. The infection may go undetected for months or even years.

Vertebral: This type affects the spine. It causes chronic back pain that gets worse when you move. Treatments like resting, heating and pain relievers don't help. It rarely causes a fever. People who live in nursing homes, misuse intravenous drugs or are on dialysis are more prone to spinal bone infections.

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Osteomyelitis (Bone Infection): Causes, Symptoms & Treatment

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Osteomyelitis is a painful bone infection. Without antibiotics or other treatment, bone damage and bone loss may occur.

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https://www.youtube.com/watch?v=jUQ_tt_zJDo

This video provides key information of the investigation, treatment and pathophysiology of osteoporosis

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https://my.clevelandclinic.org/health/drugs/21483-analgesics

This website provides great information on the indications of analgesics and their indications

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https://www.youtube.com/watch?v=EaCfFbZvGIM

Very short but useful video on how the role of vitamin D is critical to body functions

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https://www.youtube.com/watch?v=1mo80kTZgW4

This video is easy to follow and goes into detail about oncogenes and tumour suppressor genes and how their actions are vital to the formation of a tumour

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https://www.youtube.com/watch?v=lGZOTh_tk4Q

This video outlines what tumour staging and grading is, and the classification used to name benign and malignant tumours

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https://www.youtube.com/watch?v=t2tKyjj7u5Y&t=126s

This video clearly explains the role of opioids and the pathophysiology behind them, highly recommend it

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Very useful article with bone pain presentation, red flag symptoms, differential diagnoses, investigations etc from point of view of a UK GP.

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Red flag symptoms

History of malignancy

Weight loss

Night sweats

Reduction in appetite

Night pain

Pain that is progressive or persistent

Pain in children

Any history of recent trauma

Symmetrical joint swelling

Thoracic pain, specifically pain that wakes up the patient

History of fever

Presentation

Bone pain is not an uncommon presentation, particularly in an increasingly ageing population. Patients often refer to pain in their bones, but this is a non-specific symptom and there are a range of differential diagnoses to consider (see possible causes box below).

A detailed description of what the patient means by 'bone pain' is crucial. It is also important to establish why the patient has presented at this time and what their ideas, concerns and expectations are. This will help to guide your management plan.

Questions to ask the patient

Where do you feel the pain?

Can you localise it, or is it generalised?

What sort of pain is it?

Does the pain radiate?

Are there aggravating or relieving factors?

Is there any pattern of pain - for example, is it worse at night or in the morning?

Have you tried any analgesia and, if so, has it worked?

How long has the pain been present?

Has it developed suddenly or insidiously?

Is it continuous or intermittent?

Is there a history of trauma?

Is a specific joint affected? If so, is there any associated heat or swelling?

Is the arthralgia symmetrical?

Are there associated symptoms such as nausea, vomiting, fever, swelling of the affected area, weight loss or pain at night?

Do you take any regular or over-the-counter medication?

Have you experienced any mood disturbance?

How is the pain affecting your quality of life? Is it affecting work, school, university or hobbies?

History

Bone pain is generally described as a dull, deep-seated pain. Sharp, shooting pains, in contrast, should lead you to focus on a neuropathic aetiology. Widespread bone pain may be a physical manifestation of an underlying psychological problem, such as in a patient presenting with whole body pain.

A sexual history may be relevant if Reiter's syndrome is suspected. You should also ask about any history of malignancy or TB, particularly in patients from migrant populations.

The patient's smoking and alcohol history may be important, as may a family history of osteoporosis.

In addition to the questions listed on the previous page, it may be useful to find out what the patient thinks the problem could be and what have they done to try to alleviate it. Many patients will have researched their symptoms online and will have developed an idea of why they are experiencing these symptoms.

A systemic review may reveal important information if metastatic bone disease is suspected. Be alert to the malignancies that commonly metastasise to bone. These include breast, renal, lung and prostate. Do not forget melanomas and gynaecological malignancies.

Clinical examination: remote and face to face

The clinical examination will be guided by the history. Depending on information revealed in the history and systemic review, examination of a specific system may be required.

Examination can occur either remotely via telephone or video consultation, or by face-to-face examination.

Remote examination via telephone will be limited, but establish how much pain the patient is in, and ask if they can send a picture of an affected area, as well as describe any swelling.
When performing a remote video consultation, if a specific joint is involved can you visualise the joint?

Can you ask the patient to do any specific movements for you? Are you able to assess their mental state?

For face-to-face examinations, ensure you wear appropriate PPE. A focused neurological exam may be necessary if the spine is the main area causing problems.

Possible causes of bone pain

Fracture

Primary bone cancer, such as osteosarcoma

Metastatic bone disease

Vitamin D deficiency leading to osteomalacia

Multiple myeloma

Paget's disease

Osteoporosis

Osteoarthritis

Hypercalcaemia, for example, secondary to hyperparathyroidism

Inflammatory arthropathy - for example, rheumatoid arthritis (RA)

TB of the bone

Psychosomatic

Iatrogenic - for example, bisphosphonates can cause osteonecrosis of the jaw, or prednisolone can cause vertebral fractures

Osteomyelitis

Prolapsed intervertebral disc

Frailty can lead to generalised aches and pains

Investigations and referral

The decision about which investigations to perform will be largely determined by the history and examination.

FBC, U&Es, ESR, calcium, phosphate and LFTs

Vitamin D level

Prostate specific antigen (PSA) test, after appropriate counselling

Parathyroid hormone (PTH) level -this generally needs to be sent to the laboratory on ice within an hour

If raised alkaline phosphatase is detected, isoenzymes may be required to discover whether this is from a liver or a bone source

Myeloma screen, to include serum paraprotein and urinary Bence Jones protein

Anti-cyclic citrullinated peptide and rheumatoid factor may also be necessary if RA is suspected

A plain chest X-ray may be required if bronchogenic carcinoma is suspected

A FRAX score to evaluate bone fracture risk may be necessary if osteoporosis is suspected and, if appropriate, a DEXA (dual energy X-ray absorptiometry) scan to assess bone mineral density

Plain X-rays may be necessary if the pain is localised to a specific area, such as in the hands or wrists

Hospital Anxiety and Depression Scale score

Tumour markers can be done but are generally not recommended in primary care. If a malignancy is suspected, appropriate referral under the 2-week wait is mandatory. Referral pathways will differ across different localities.

Dr Pipin Singh is a GP in Northumberland. This article was reviewed and updated by Dr Singh in April 2021

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History of malignancy Weight loss Night sweats Reduction in appetite Night pain Pain that is progressive or persistent Pain in children Any history of recent trauma Symmetrical joint swelling Thoracic pain, specifically pain that wakes up the patient History of fever Bone pain is not an uncommon presentation, particularly in an increasingly ageing population.

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Spinal fractures_NBT03193.pdf
useful to get info on the management of spinal fractures