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Comment and Controversy

Was alendronate really ineffective?…and more

March 2011 · Vol. 23, No. 3
This week's quiz:
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Was alendronate really ineffective?

In his editorial, Dr. Barbieri presented the case of a woman who initiated denosumab after alendronate failed to increase her bone density. He later characterized that alendronate therapy as “unsuccessful.” I wonder if Dr. Barbieri could clarify what he means by that assessment. Given that the woman’s T-score at her hip remained stable despite concomitant use of an aromatase inhibitor, I would not necessarily conclude that it was unsuccessful.

Ronald Orleans, MD
Bethesda, Md

Dr. Barbieri responds: Assessing the effect of alendronate
is not always simple

I appreciate Dr. Orleans’s comment and the time he took from his busy practice to raise a clinically important issue. I agree with him: Determining whether alendronate therapy has been successful in the treatment of osteoporosis is not straightforward. In most patients, if bone density increases or remains stable, alendronate therapy is considered successful. If bone density decreases, as it did in this patient, the question arises: How much of a decrease in bone density is clinically or statistically significant? One approximation that can be made is if bone density, as measured in grams per square centimeter, decreases by 4.16%, there is a 95% likelihood that it represents a real decrease—one that would be reproduced if the test were performed over and over again.1 In addition to a decrease in bone mineral density, this patient also had a low-impact fracture, strongly suggesting that the alendronate was not highly effective in her case.

(JANUARY 2011)

Another maneuver to stanch postpartum hemorrhage

Dr. Brown describes the use of fundal massage and oxytocin administration as first-line strategies to prevent or control postpartum hemorrhage. I would like to add an item to that list. Hemorrhage often is unpredictable and, therefore, sometimes occurs without the ideal personnel and blood products present. Any aortic vascular surgeon can testify that occlusion of the upper abdominal aorta will immediately halt pelvic blood flow. In my experience, compression of the aorta just above the umbilicus is easy in a postpartum abdomen and is very effective in stopping the blood loss. It also gives you time to rally troops and get the blood bank working on those products that might be needed.

Robert Lawrence Shirley, MD
Winchester, Mass

Uterine artery embolization also is useful
in postpartum hemorrhage

Dr. Brown did not mention uterine artery embolization by interventional radiology. We have used this technique successfully at our two area hospitals this past year in at least four cases.

Michael DeStefano, MD
South Bend, Ind.

Dr. Brown responds: Embolization has its place

I agree that uterine artery embolization is a valuable procedure for women who experience postpartum hemorrhage that has been unresponsive to typical medical and surgical intervention. It is especially valuable to control postsurgical bleeding in women who develop a coagulopathy. Embolization is also useful for women who are about to undergo cesarean or cesarean hysterectomy for placental implantation abnormalities, such as placenta accreta, because severe bleeding is anticipated in these cases.

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