Rheumatoid arthritis (RA) is a condition that typically causes symmetric arthritis in multiple joints, with the distal interphalangeal joints being spared. Diagnosis is usually based on clinical features, supported by serological testing that shows positive anti-cyclic citrullinated peptide or rheumatoid factor. X-rays may reveal periarticular osteopenia, marginal bony erosions, and joint space narrowing. A biopsy of rheumatoid nodules that shows cholesterol deposits is considered pathognomonic for RA.

Reactive arthritis is characterized by a combination of conjunctivitis, urethritis, and arthritis, often accompanied by diarrhea. Patients may also develop keratoderma blennorhagicum, which is characterized by hyperkeratotic vesicles on the palms and soles.

Septic arthritis typically affects a single joint, causing redness, swelling, and pain. It occurs when the synovial membrane is invaded, resulting in yellow, turbid synovial fluid with high neutrophil levels. Staphylococcus aureus is the most common cause of septic arthritis.

Osteoarthritis (OA) is a condition that causes shorter duration of morning stiffness, with symptoms worsening throughout the day with weight-bearing. X-rays may show loss of joint space, osteophytes, subchondral sclerosis, and subchondral cysts.

Rheumatoid arthritis can be diagnosed clinically, which is considered more important than using specific criteria. However, the American College of Rheumatology has established classification criteria for rheumatoid arthritis. These criteria require the presence of at least one joint with definite clinical synovitis that cannot be explained by another disease. A score of 6 out of 10 is needed for a definite diagnosis of rheumatoid arthritis. The score is based on factors such as the number and type of joints involved, serology (presence of rheumatoid factor or anti-cyclic citrullinated peptide antibody), acute-phase reactants (such as CRP and ESR), and duration of symptoms. These criteria are used to classify patients with rheumatoid arthritis for research and clinical purposes.

The radial nerve supplies all extensor muscles in the upper limb, including the extensor carpi ulnaris. The only exception is the brachioradialis muscle, which is not an extensor. The median nerve is responsible for wrist and finger flexion, as well as thumb opposition, while the ulnar nerve innervates the interossei muscles.

Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.

Salient Features and Possible Causes of Polycythaemia

The patient presents with weight loss, no obvious physical abnormalities, and a polycythaemia with 2+ blood on dipstick analysis. These symptoms suggest the need for investigation of a genitourinary (GU) malignancy, with an ultrasound abdomen being the most appropriate test. It is important to note that smoking may cause polycythaemia, but it could also be caused by a hypernephroma that produces ectopic erythropoietin. Therefore, further investigation is necessary to determine the underlying cause of the patient’s polycythaemia.

Additional genes implicated include MCC, DCC, c-yes, and bcl-2.

Colorectal cancer is a prevalent type of cancer in the UK, ranking third in terms of frequency and second in terms of cancer-related deaths. Every year, approximately 150,000 new cases are diagnosed, and 50,000 people die from the disease. The cancer can occur in different parts of the colon, with the rectum being the most common location, accounting for 40% of cases. The sigmoid colon follows closely, with 30% of cases, while the descending colon has only 5%. The transverse colon has 10% of cases, and the ascending colon and caecum have 15%.

The facial nerve innervates the posterior belly of digastric, while the mylohoid nerve innervates the anterior belly.

The Anterior Triangle of the Neck: Boundaries and Contents

The anterior triangle of the neck is a region that is bounded by the anterior border of the sternocleidomastoid muscle, the lower border of the mandible, and the anterior midline. It is further divided into three sub-triangles by the digastric muscle and the omohyoid muscle. The muscular triangle contains the neck strap muscles, while the carotid triangle contains the carotid sheath, which houses the common carotid artery, the vagus nerve, and the internal jugular vein. The submandibular triangle, located below the digastric muscle, contains the submandibular gland, submandibular nodes, facial vessels, hypoglossal nerve, and other structures.

The digastric muscle, which separates the submandibular triangle from the muscular triangle, is innervated by two different nerves. The anterior belly of the digastric muscle is supplied by the mylohyoid nerve, while the posterior belly is supplied by the facial nerve.

Overall, the anterior triangle of the neck is an important anatomical region that contains many vital structures, including blood vessels, nerves, and glands. Understanding the boundaries and contents of this region is essential for medical professionals who work in this area.

Glycogen and Other Glucose Polymers

Glycogen is a type of storage polymer made up of glucose units that are linked together through α1-4 glycosidic linkages. It is highly branched, with glucose molecules at the branch points bound together using α1-6 glycosidic linkages. The glycogen polysaccharide has a central protein core that contains an enzyme called glycogenin, which is involved in glycogen synthesis.

Starch is another type of glucose polymer found in nature. Amylose is an unbranched polysaccharide chain made up of glucose units linked together through α1-4 glycosidic linkages. It is insoluble in water and generally indigestible in the human gut. Amylopectin is a plant-based starch molecule that is similar in structure to glycogen. It contains both α1-4 and α1-6 glycosidic linkages, giving it a highly branched and relatively soluble structure.

Early-onset neonatal sepsis in a two-day-old infant may be caused by maternal group B Streptococcus (GBS) colonisation, which is a common coloniser of the vaginal tract and can be transmitted to the newborn during delivery. This can lead to symptoms such as lethargy, jaundice, dyspnoea, tachycardia, and poor capillary refill time, which may indicate septic shock.

However, being large for gestational age, advanced maternal age, or having multiple gestations are not known risk factors for neonatal sepsis. Instead, they are associated with other complications such as shoulder dystocia, neonatal hypoglycaemia, spontaneous abortions, chromosomal abnormalities, congenital malformations, IUGR, and twin-to-twin transfusion syndrome.

Neonatal sepsis is a serious bacterial or viral infection in the blood that affects babies within the first 28 days of life. It is categorized into early-onset (EOS) and late-onset (LOS) sepsis, with each category having distinct causes and presentations. The most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli. Premature and low birth weight babies are at higher risk, as well as those born to mothers with GBS colonization or infection during pregnancy. Symptoms can range from subtle signs of illness to clear septic shock, and may include respiratory distress, jaundice, seizures, and poor feeding. Diagnosis is usually established through blood culture, and treatment involves early identification and use of intravenous antibiotics. Other important management factors include maintaining adequate oxygenation and fluid/electrolyte status, and preventing or managing hypoglycemia and metabolic acidosis.

The proximal convoluted tubule of the nephron is where the majority of glucose reabsorption occurs. Empagliflozin, which inhibits the SGLT-2 receptor, prevents glucose reabsorption in this area. Insulin receptors are found throughout the body, not SGLT-2 receptors. The distal convoluted tubule regulates sodium, potassium, calcium, and pH, while the loop of Henle is involved in water resorption. Sulphonylureas act on pancreatic beta cells to increase insulin production and improve glucose metabolism.

The Loop of Henle and its Role in Renal Physiology

The Loop of Henle is a crucial component of the renal system, located in the juxtamedullary nephrons and running deep into the medulla. Approximately 60 litres of water containing 9000 mmol sodium enters the descending limb of the loop of Henle in 24 hours. The osmolarity of fluid changes and is greatest at the tip of the papilla. The thin ascending limb is impermeable to water, but highly permeable to sodium and chloride ions. This loss means that at the beginning of the thick ascending limb the fluid is hypo osmotic compared with adjacent interstitial fluid. In the thick ascending limb, the reabsorption of sodium and chloride ions occurs by both facilitated and passive diffusion pathways. The loops of Henle are co-located with vasa recta, which have similar solute compositions to the surrounding extracellular fluid, preventing the diffusion and subsequent removal of this hypertonic fluid. The energy-dependent reabsorption of sodium and chloride in the thick ascending limb helps to maintain this osmotic gradient. Overall, the Loop of Henle plays a crucial role in regulating the concentration of solutes in the renal system.

Aspiration pneumonia is a common occurrence in stroke patients during the recovery phase, with a higher likelihood of affecting the right lung due to the steeper course of the right bronchus. This type of pneumonia is often caused by unsafe swallowing and can lead to prolonged hospital stays and increased mortality rates. The right middle and lower lobes are the most susceptible to aspirated gastric contents, while the right upper lobe is less likely due to gravity. It’s important to consider aspiration pneumonia as a differential diagnosis when assessing stroke patients, especially those with severe pathology.

Aspiration pneumonia is a type of pneumonia that occurs when foreign substances, such as food or saliva, enter the bronchial tree. This can lead to inflammation and a chemical pneumonitis, as well as the introduction of bacterial pathogens. The condition is often caused by an impaired swallowing mechanism, which can be a result of neurological disease or injury, intoxication, or medical procedures such as intubation. Risk factors for aspiration pneumonia include poor dental hygiene, swallowing difficulties, prolonged hospitalization or surgery, impaired consciousness, and impaired mucociliary clearance. The right middle and lower lung lobes are typically the most affected areas. The bacteria involved in aspiration pneumonia can be aerobic or anaerobic, with examples including Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella, Bacteroides, Prevotella, Fusobacterium, and Peptostreptococcus.

The most likely diagnosis for the patient is a perforated peptic ulcer, which may have been caused by their use of ibuprofen. The recommended first-line treatment according to NICE guidelines is endoscopic intervention, which can confirm the diagnosis and stop the bleeding. This involves injecting adrenaline into the bleeding site and using cautery and/or clip application. Helicobacter pylori eradication therapy is not appropriate in this case, as the patient’s symptoms suggest a perforated peptic ulcer rather than peptic ulcer disease caused by H. pylori. IV proton-pump inhibitor infusion may be considered later, but the patient requires immediate management with endoscopic intervention.

Managing Acute Bleeding in Peptic Ulcer Disease

Peptic ulcer disease is a condition that can lead to acute bleeding, which is the most common complication of the disease. In fact, bleeding accounts for about three-quarters of all problems associated with peptic ulcer disease. The gastroduodenal artery is often the source of significant gastrointestinal bleeding in patients with this condition. The most common symptom of acute bleeding in peptic ulcer disease is haematemesis, but patients may also experience melaena, hypotension, and tachycardia.

When managing acute bleeding in peptic ulcer disease, an ABC approach should be taken, as with any upper gastrointestinal haemorrhage. Intravenous proton pump inhibitors are the first-line treatment, and endoscopic intervention is typically the preferred approach. However, if endoscopic intervention fails (which occurs in approximately 10% of patients), urgent interventional angiography with transarterial embolization or surgery may be necessary. By following these management strategies, healthcare providers can effectively address acute bleeding in patients with peptic ulcer disease.

The Respiratory Tract and its Infections

The respiratory tract can be divided into two parts: the upper and lower respiratory tract. The upper respiratory tract consists of the nose, nasal passages, paranasal sinuses, pharynx, and larynx. On the other hand, the lower respiratory tract includes the bronchi, bronchioles, and alveoli, which are all located distal to the trachea.

Acute upper respiratory tract infections are usually caused by viruses and can affect the nose, sinuses, pharynx, and larynx. These infections include rhinosinusitis, pharyngitis, and laryngitis. Symptoms of these infections may include coughing, sneezing, sore throat, and nasal congestion.

Lower respiratory tract infections, on the other hand, are more severe and can affect the bronchi, bronchioles, and alveoli. These infections include pneumonia, bronchitis, and lung abscesses. Symptoms of lower respiratory tract infections may include coughing, chest pain, shortness of breath, and fever.

It is important to understand the different parts of the respiratory tract and the infections that can affect them. Proper diagnosis and treatment can help prevent complications and promote recovery.

The Development of Haematopoiesis in the Foetus

The development of haematopoiesis in the foetus is a complex process that involves several organs. Initially, the yolk sac is the primary site of haematopoiesis until around two months gestation when the liver takes over. The liver remains the most important site of haematopoiesis until about month seven when the bone marrow becomes the predominant site throughout life.

After the age of 20, haematopoiesis occurs mainly in the proximal bones, with production in the distal lone bones decreasing. However, in certain disease states such as β-thalassaemia, haematopoiesis can occur outside of the bone marrow, known as extra-medullary haematopoiesis. the development of haematopoiesis in the foetus is important for identifying potential abnormalities and diseases that may arise during this process.

Streptococcal organisms are the most frequent cause of bacterial tonsillitis, which can lead to quinsy.

Understanding Acute Tonsillitis

Acute tonsillitis is a condition that is characterized by pharyngitis, fever, malaise, and lymphadenopathy. It is caused by bacterial infections in over half of all cases, with Streptococcus pyogenes being the most common organism. The tonsils become swollen and may have yellow or white pustules. It is important to note that infectious mononucleosis may mimic the symptoms of acute tonsillitis.

Treatment for bacterial tonsillitis involves the use of penicillin-type antibiotics. Failure to treat bacterial tonsillitis may result in the formation of a local abscess known as quinsy.

Hydrops fetalis is a condition where the fetus has fluid accumulation in at least two compartments, such as the kidneys and polyhydramnios. One cause of this condition is infection with parvovirus B19, which suppresses fetal erythropoiesis and leads to fetal anemia and heart failure. This, in turn, causes fluid accumulation seen on ultrasound. Parvovirus B19 commonly affects children and can cause erythema infectiosum, also known as slapped cheek disease.

While autoimmune hemolysis can also cause hydrops fetalis, it is typically associated with ABO or rhesus incompatibility. This occurs when maternal antibodies attack fetal red blood cells, leading to immune-mediated hemolysis and hydrops fetalis. This is not the same mechanism as that caused by parvovirus B19 infection.

Cardiac malformations and exposure to teratogens during pregnancy can also cause heart failure and hydrops fetalis, but this is not typically associated with parvovirus B19 infection. Similarly, fetal kidney failure can lead to fluid accumulation and hydrops fetalis, but it is not caused by antenatal parvovirus B19 infection. Pulmonary hypertension is another cause of heart failure, but it is not common in fetuses and is more commonly seen in the elderly population. It is not caused by parvovirus B19 infection in fetuses.

Parvovirus B19: A Virus with Various Clinical Presentations

Parvovirus B19 is a type of DNA virus that can cause different clinical presentations. One of the most common is erythema infectiosum, also known as fifth disease or slapped-cheek syndrome. This illness may manifest as a mild feverish condition or a noticeable rash that appears after a few days. The rash is characterized by rose-red cheeks, which is why it is called slapped-cheek syndrome. It may spread to other parts of the body but rarely involves the palms and soles. The rash usually peaks after a week and then fades, but it may recur for some months after exposure to triggers such as warm baths, sunlight, heat, or fever. Most children recover without specific treatment, and school exclusion is unnecessary as the child is no longer infectious once the rash emerges. However, in adults, the virus may cause acute arthritis.

Aside from erythema infectiosum, parvovirus B19 can also present as asymptomatic, pancytopenia in immunosuppressed patients, or aplastic crises in sickle-cell disease. The virus suppresses erythropoiesis for about a week, so aplastic anemia is rare unless there is a chronic hemolytic anemia. In pregnant women, the virus can cross the placenta and cause severe anemia due to viral suppression of fetal erythropoiesis, which may lead to heart failure secondary to severe anemia and the accumulation of fluid in fetal serous cavities such as ascites, pleural and pericardial effusions. This condition is called hydrops fetalis and is treated with intrauterine blood transfusions.

It is important to note that parvovirus B19 can affect an unborn baby in the first 20 weeks of pregnancy. If a woman is exposed early in pregnancy, she should seek prompt advice from her antenatal care provider as maternal IgM and IgG will need to be checked. The virus is spread by the respiratory route, and a person is infectious 3 to 5 days before the appearance of the rash. Children are no longer infectious once the rash appears, and there is no specific treatment. Therefore, school exclusion is unnecessary.

The histological appearance of a medulloblastoma is small, blue cells with rosette patterns, which is the most common malignant primary tumour in the paediatric population and frequently found in the infratentorial region.

Brain tumours can be classified into different types based on their location, histology, and clinical features. Metastatic brain cancer is the most common form of brain tumours, which often cannot be treated with surgical intervention. Glioblastoma multiforme is the most common primary tumour in adults and is associated with a poor prognosis. Meningioma is the second most common primary brain tumour in adults, which is typically benign and arises from the arachnoid cap cells of the meninges. Vestibular schwannoma is a benign tumour arising from the eighth cranial nerve, while pilocytic astrocytoma is the most common primary brain tumour in children. Medulloblastoma is an aggressive paediatric brain tumour that arises within the infratentorial compartment, while ependymoma is commonly seen in the 4th ventricle and may cause hydrocephalus. Oligodendroma is a benign, slow-growing tumour common in the frontal lobes, while haemangioblastoma is a vascular tumour of the cerebellum. Pituitary adenoma is a benign tumour of the pituitary gland that can be either secretory or non-secretory, while craniopharyngioma is a solid/cystic tumour of the sellar region that is derived from the remnants of Rathke’s pouch.

When the pCO2 is low, the oxygen dissociation curve shifts to the left, which increases the affinity of haemoglobin for oxygen. This can limit the amount of oxygen available to tissues. On the other hand, high levels of pCO2 (hypercarbia) shift the curve to the right, decreasing the affinity of haemoglobin for oxygen and increasing oxygen availability to tissues.

In acidosis, the concentration of 2,3-diphosphoglycerate (DPG) increases, which binds to deoxyhaemoglobin and shifts the oxygen dissociation curve to the right. This results in increased oxygen release from the blood into tissues.

Hyperthermia also shifts the oxygen dissociation curve to the right, while the performance-enhancing substance myo-inositol trispyrophosphate (ITPP) has a similar effect.

Understanding the Oxygen Dissociation Curve

The oxygen dissociation curve is a graphical representation of the relationship between the percentage of saturated haemoglobin and the partial pressure of oxygen in the blood. It is not influenced by the concentration of haemoglobin. The curve can shift to the left or right, indicating changes in oxygen delivery to tissues. When the curve shifts to the left, there is increased saturation of haemoglobin with oxygen, resulting in decreased oxygen delivery to tissues. Conversely, when the curve shifts to the right, there is reduced saturation of haemoglobin with oxygen, leading to enhanced oxygen delivery to tissues.

The L rule is a helpful mnemonic to remember the factors that cause a shift to the left, resulting in lower oxygen delivery. These factors include low levels of hydrogen ions (alkali), low partial pressure of carbon dioxide, low levels of 2,3-diphosphoglycerate, and low temperature. On the other hand, the mnemonic ‘CADET, face Right!’ can be used to remember the factors that cause a shift to the right, leading to raised oxygen delivery. These factors include carbon dioxide, acid, 2,3-diphosphoglycerate, exercise, and temperature.

Understanding the oxygen dissociation curve is crucial in assessing the oxygen-carrying capacity of the blood and the delivery of oxygen to tissues. By knowing the factors that can shift the curve to the left or right, healthcare professionals can make informed decisions in managing patients with respiratory and cardiovascular diseases.

The most common nerve injury that occurs with a mid-shaft fracture of the humerus is radial nerve injury. This type of injury can cause a dropped wrist presentation, which is characterized by weakness in wrist extension and difficulty making a fist. The patient in the scenario describes difficulty accelerating on their motorcycle, which requires normal wrist extension and the ability to make a fist.

Other nerve injuries that can occur include axillary nerve injury, which affects shoulder abduction and external rotation and is usually caused by anterior shoulder dislocation. Median nerve injury can result in weakness of forearm pronation, wrist flexion, and thumb flexion, and is associated with carpal tunnel syndrome. Musculocutaneous nerve injury, on the other hand, does not typically affect wrist movements and is responsible for elbow flexion and certain shoulder movements.

The humerus is a long bone that runs from the shoulder blade to the elbow joint. It is mostly covered by muscle but can be felt throughout its length. The head of the humerus is a smooth, rounded surface that connects to the body of the bone through the anatomical neck. The surgical neck, located below the head and tubercles, is the most common site of fracture. The greater and lesser tubercles are prominences on the upper end of the bone, with the supraspinatus and infraspinatus tendons inserted into the greater tubercle. The intertubercular groove runs between the two tubercles and holds the biceps tendon. The posterior surface of the body has a spiral groove for the radial nerve and brachial vessels. The lower end of the humerus is wide and flattened, with the trochlea, coronoid fossa, and olecranon fossa located on the distal edge. The medial epicondyle is prominent and has a sulcus for the ulnar nerve and collateral vessels.

Different Types of Data

When analyzing data, it is important to understand the different types of variables that can be encountered. One such variable is socio-economic status, which is not a numerical value but can be categorized into four ordinal categories. Ordinal categorical data has a logical order to its categorization, but mathematical functions cannot be performed with the numbers assigned to each category.

Continuous metric data, on the other hand, can take any value and allows for mathematical functions to be performed. Examples of continuous data include height and weight. Discrete metric data is numerical but only takes certain values, such as the number of children in a family. Nominal categorical data has no hierarchy or gradation, such as blood group or yes/no questions.

Normal parametric data assumes that variables are normally distributed, but this may not be the case for small sample populations. It is important to note that data can often fall into multiple categories. For example, systolic blood pressure can be considered continuous metric data, but in practice, it is often recorded as integers, making it somewhat like a discrete variable. Additionally, if a cut-off point is used, such as 140 mmHg, the data may become dichotomous and fall into the nominal category. the different types of data is crucial for accurate analysis and interpretation.

Individuals with Marfan syndrome may exhibit various connective tissue disorders, including bilateral inguinal hernia. They are particularly susceptible to aortic dissection, as demonstrated in this instance.

Aortic dissection is a serious condition that can cause chest pain. It occurs when there is a tear in the inner layer of the aorta’s wall. Hypertension is the most significant risk factor, but it can also be associated with trauma, bicuspid aortic valve, and certain genetic disorders. Symptoms of aortic dissection include severe and sharp chest or back pain, weak or absent pulses, hypertension, and aortic regurgitation. Specific arteries’ involvement can cause other symptoms such as angina, paraplegia, or limb ischemia. The Stanford classification divides aortic dissection into type A, which affects the ascending aorta, and type B, which affects the descending aorta. The DeBakey classification further divides type A into type I, which extends to the aortic arch and beyond, and type II, which is confined to the ascending aorta. Type III originates in the descending aorta and rarely extends proximally.

Oesophageal problems can be caused by bisphosphonates, which are commonly used to prevent and treat osteoporosis. These drugs can lead to gastrointestinal issues, including oesophagitis, which should prompt discontinuation of the medication. Long-term use of bisphosphonates can also result in atypical femoral fractures and osteonecrosis of the jaw. Therefore, patients should be periodically re-evaluated to assess the benefits and risks of continuing treatment, especially after five or more years of use. Before starting bisphosphonate treatment, patients should have a dental check-up and any necessary dental work should be performed.

Gliclazide, a sulfonylurea drug, can cause hypoglycemia symptoms such as dizziness, lack of energy, drowsiness, headache, and sweating.

Metformin is associated with lactic acidosis and gastrointestinal problems.

Bisoprolol can cause erectile dysfunction, cold hands and feet, bradycardia, and hypotension.

Paracetamol, unlike NSAIDs, is not known to cause indigestion.

Bisphosphonates: Uses, Adverse Effects, and Patient Counselling

Bisphosphonates are drugs that mimic the action of pyrophosphate, a molecule that helps prevent bone demineralization. They work by inhibiting osteoclasts, the cells responsible for breaking down bone tissue. Bisphosphonates are commonly used to prevent and treat osteoporosis, hypercalcemia, Paget’s disease, and pain from bone metastases.

However, bisphosphonates can cause adverse effects such as oesophageal reactions, osteonecrosis of the jaw, and an increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. Patients may also experience an acute phase response, which includes fever, myalgia, and arthralgia following administration. Hypocalcemia may also occur due to reduced calcium efflux from bone, but this is usually clinically unimportant.

To minimize the risk of adverse effects, patients taking oral bisphosphonates should swallow the tablets whole with plenty of water while sitting or standing. They should take the medication on an empty stomach at least 30 minutes before breakfast or another oral medication and remain upright for at least 30 minutes after taking the tablet. Hypocalcemia and vitamin D deficiency should be corrected before starting bisphosphonate treatment. However, calcium supplements should only be prescribed if dietary intake is inadequate when starting bisphosphonate treatment for osteoporosis. Vitamin D supplements are usually given.

The duration of bisphosphonate treatment varies depending on the level of risk. Some experts recommend stopping bisphosphonates after five years if the patient is under 75 years old, has a femoral neck T-score of more than -2.5, and is at low risk according to FRAX/NOGG.