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Customs Lawyers and Law Firms in New York (NY)
Customs Law Firms in New York by City
Customs Law Law Firms in New York by City
- Airmont
- Albany
- Albertson
- Altamont
- Ardsley
- Armonk
- Atlantic Beach
- Averill Park
- Baldwin
- Baldwin Harbor
- Bardonia
- Barnum Island
- Bay Park
- Bayville
- Bedford
- Bellerose Terrace
- Bellmore
- Bethpage
- Billington Heights
- Blasdell
- Blauvelt
- Briarcliff Manor
- Brighton
- Bronxville
- Brookville
- Buffalo
- Carle Place
- Castleton-on-Hudson
- Cedarhurst
- Chappaqua
- Cheektowaga
- Chestnut Ridge
- Churchville
- Clarence Center
- Cohoes
- Colonie
- Congers
- Croton-on-Hudson
- Delmar
- Depew
- Dobbs Ferry
- East Atlantic Beach
- East Greenbush
- East Hills
- East Meadow
- East Norwich
- East Rochester
- East Rockaway
- East Williston
- Eastchester
- Elma Center
- Elmont
- Elmsford
- Fairport
- Fairview
- Floral Park
- Flower Hill
- Franklin Square
- Freeport
- Garden City
- Garden City Park
- Garden City South
- Gates-North Gates
- Glen Cove
- Glen Head
- Glenwood Landing
- Great Neck
- Great Neck Estates
- Great Neck Plaza
- Greece
- Green Island
- Greenvale
- Greenville
- Hamburg
- Hampton Manor
- Harris Hill
- Harrison
- Hartsdale
- Hastings-on-Hudson
- Haverstraw
- Hawthorne
- Hempstead
- Herricks
- Hewlett
- Hicksville
- Hillcrest
- Hilton
- Honeoye Falls
- Inwood
- Irondequoit
- Irvington
- Island Park
- Jericho
- Kaser
- Kenmore
- Kings Point
- Lackawanna
- Lake Success
- Lakeview
- Lancaster
- Larchmont
- Lattingtown
- Laurel Hollow
- Lawrence
- Levittown
- Locust Valley
- Lynbrook
- Malverne
- Mamaroneck
- Manhasset
- Manhasset Hills
- Manorhaven
- Menands
- Merrick
- Mineola
- Monsey
- Mount Kisco
- Mount Vernon
- Munsey Park
- Muttontown
- Nanuet
- New Cassel
- New City
- New Hempstead
- New Hyde Park
- New Rochelle
- New Square
- New York
- Niskayuna
- North Bellmore
- North Hills
- North Merrick
- North New Hyde Park
- North Tonawanda
- North Valley Stream
- North Wantagh
- Nyack
- Oceanside
- Old Bethpage
- Old Brookville
- Old Westbury
- Orangeburg
- Orchard Park
- Ossining
- Oyster Bay
- Oyster Bay Cove
- Pearl River
- Pelh
- Pelham
- Pelham Manor
- Piermont
- Pleasantville
- Port Chester
- Port Washington
- Port Washington North
- Ravena
- Rensselaer
- Rochester
- Rockville Centre
- Rotterdam
- Rye
- Rye Brook
- Sands Point
- Scarsdale
- Schenectady
- Scottsville
- Sea Cliff
- Searingtown
- Sleepy Hollow
- Sloan
- South Floral Park
- South Nyack
- South Richmond Hill
- South Valley Stream
- Spencerport
- Spring Valley
- Stewart Manor
- Tappan
- Tarrytown
- Thomaston
- Thornwood
- Tonawanda
- Town Line
- Troy
- Tuckahoe
- University Gardens
- Upper Nyack
- Valhalla
- Valley Cottage
- Valley Stream
- Viola
- Voorheesville
- Waterford
- Watervliet
- Webster
- West Hempstead
- West Nyack
- West Sand Lake
- West Seneca
- Westmere
- White Plains
- Williamsville
- Williston Park
- Woodmere
- Woodside
- Wynantskill
- Yonkers
New York Customs Law Attorneys
Emery Mukendi Wafwana & Associates
International Business, Mining, Oil and Gas, Corporate & Litigation Law Firm in Kinshasa(212) 922-0040
Emery Mukendi Wafwana & Associates is an international African law firm with a prominent business and mining practice. We are based in the Democratic Republic of Congo (Kinshasa, Lubumbashi & Matadi), in Johannesburg, in the Republic of South Africa (Cabemery & Partners...
Law Firm's Overview Articles
Banjoko McGlashan Wieslaw
Business, Real Estate, Personal Injury, & Family Lawyers in New York(212) 618-1327
Banjoko McGlashan Wieslaw is a full-service law firm headquartered in Jamaica, with office locations in California, USA; Toronto, Ontario; and London, England. We are committed to finding practical and affordable solutions to your legal challenges or keeping legal issues and concerns...
Law Firm's Overview ArticlesFree ConsultationCredit Cards
Law Offices of Michael H. Joseph, PLLC
New York Criminal Defense Attorneys(914) 574-8330 or (877) 580-6636
Law Offices of Michael H. Joseph is a criminal defense and personal injury law firm based in White Plains, New York with additional locations in New York City and Forest Hills. The firm provides legal services to clients throughout the greater metropolitan New York area, and its...
Other Offices: Woodside
Law Firm's Overview Free ConsultationCredit Cards
Diaz Reus, LLP
International Law Firm in New York(212) 563-7000
Diaz Reus LLP in Miami is a law firm that specializes in international law. Attorneys at the firm use their multilingual and multicultural skills to be able to help clients facing issues in Latin America, Asia, the Middle East, Europe and the United States. The attorneys have the...
Law Firm's Overview Articles
A&L Goodbody
Corporate Law Firm(212) 582-4499
Insight, experience and commercial acumen are just some of the qualities that make A&L Goodbody successful. Channeling those qualities into powerful partnerships with their clients is what makes them different.
With 62 partners and an additional 215 legal staff, A&L Goodbody...
Law Firm's Overview
Arnold & Porter
International Law Firm(212) 715-1000
Arnold & Porter attorneys, practicing in more than 25 distinct areas of the law, conduct business on six continents. Our global reach, experience, and deep knowledge allow us to work across geographic, cultural, technological, and ideological borders, serving clients whose business...
Law Firm's Overview
Baker & Hostetler, LLP
Full Service Business Law Firm(212) 589-4200
Baker & Hostetler LLP was founded on the belief that we would strive to create successful, long-term relationship with clients, dedicate ourselves to the profession and be good corporate citizens in the communities where we live and work. That belief has helped us grow into one...
Law Firm's Overview
Blank Rome LLP
Business, Corporate, Litigation, Maritime, Regulatory(212) 885-5000
Blank Rome LLP is a full-service law firm providing sophisticated legal services and counsel you need to succeed in business, solve your disputes, and secure your future. Blank Rome takes a practical, business-minded approach to public and corporate transactions, litigation, and regulatory issues.
Law Firm's Overview
Dechert LLP
International Asset Management, Corporate & Securities and Litigation Law Firm(212) 698-3500
Dechert LLP is a worldwide law firm with offices throughout the United States, Europe, and Asia.
In major business transactions, high-stakes litigation, and other matters, we are committed to achieving our clients' objectives effectively and efficiently. Our approach to problem-solving...
Law Firm's Overview
DLA Piper
Global Law Firm(212) 335-4500
DLA Piper became one of the largest legal service providers in the world in 2005 through a merger of unprecedented scope in the legal sector. While large in scale, the merger strategy was simple – to create an international legal practice capable of taking care of the most important...
Other Offices: Albany
Law Firm's Overview
Duane Morris LLP
IP, Telecommunications, Information Technologies, Energy, Endangered Species(212) 692-1000
Duane Morris LLP, a full-service law firm with more than 700 attorneys in 24 offices in the United States and internationally, offers innovative solutions to the legal and business challenges presented by today's evolving global markets.
Evolving from a partnership of prominent...
Law Firm's Overview
Fox Rothschild LLP
Nationwide Full-Service Law Firm212.878.7900
Since our founding in 1907 in Philadelphia, Fox Rothschild LLP has enjoyed a reputation for excellence in the fields of business, corporate and securities, labor and employment, real estate, creditors' rights, litigation and tax and estates law. Over the past twelve years we have...
Law Firm's Overview
Holland & Knight LLP
Full Service Global Firm(212) 513-3200
Holland & Knight LLP offers the experience and resources to handle your most difficult legal challenges. But we are dedicated to going beyond, to being your counselors in the fullest sense of the word. That involves more than knowing the law. It's understanding your business...
Law Firm's Overview
Jun He Law Offices
Full-Service Law Firm in China and the U.S(212) 703-8702
Jun He Law Offices is widely recognized as a leading full-service law firm in China, uniquely positioned to provide superior legal services in commercial transactions and disputes. As one of the first private PRC law firms, we are renowned as a pioneer in the re-establishment and...
Law Firm's Overview
McDaniel & Park, PC
New Jersey Business and Intellectual Property Lawyers(212) 514-8080
McDaniel & Park, PC help their clients in managing all the aspects of their business. It handles various legal matters ranging from the clearing up of the copyright portfolio to trademark protection.
We also deal in cases pertaining to the winding up of a business. The firm...
Law Firm's Overview Free Consultation
Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, PC
Corporate, Environmental, Health, Immigration, IP. Litigation, Tax Law(212) 935-3000
Founded in 1933, Mintz Levin has grown into a versatile law firm of 500 highly qualified and dedicated attorneys representing diverse international clients in many industries who turn to us for a wide range of legal services and resources. Our offices are located in Boston, Washington,...
Law Firm's Overview
Nixon Peabody LLP
Comprehensive Legal Services to Individuals and Organizations(585) 263-1000
Nixon Peabody LLP is one of the largest multi-practice law firms in the United States, with offices in 14 cities on the east and west coasts and more than 600 attorneys working in 15 major practice areas. Their size, diversity, and state-of-the-art technical resources enable them...
Other Offices: Albany, Buffalo, New York
Law Firm's Overview
Squire Sanders
Legal Counsel Worldwide(212) 872-9800
Squire Sanders is one of the most geographically diverse legal practices in the world; the firm's global breadth and local depth serve their clients across the globe. They also have strong working relationships with independent firms in Europe and the Middle East as well as in the...
Law Firm's Overview
Teplen Law Group P.L.L.C
New York Immigration Lawyers(212) 401-4040 or (800) 244-5266
At Teplen & Associates, PLLC, our team of experienced attorneys solve all types of immigration issues for a wide range of clients, including physicians, students, laborers/trades people, executives, working professionals, people with extraordinary abilities, families, marriage...
Law Firm's Overview
Abady Law Firm, P.C.New York, NY 10001
Customs, International Trade and Import / Export Law Firm in New York(347) 512-9007
Abady Law Firm, P.C., is a customs law firm focused on international trade regulation and customs law. Our work is global, providing legal services to the international enterprise. The firm is experienced with governmental processes involved in regulating United States imports and exports and...
Cowan, Liebowitz & Latman, PCNew York, NY 10036
Intellectual Property Law Firm(212) 790-9200
Cowan, Liebowitz & Latman offers legal services in six major practice areas: Intellectual Property, Information Technology, Litigation, Commercial, Trusts & Estates, and Private Client Services.
Daniel H. Erskine, Esq.New York, NY 10010
Business Transactions, Civil Litigation, Appeals, International Law(866) 951-4443
Daniel H. Erskine, Esq. engages in the private practice of law in New York, New York and Stamford, Connecticut. He focuses on international law, civil litigation, appeals, and business transactions. Attorney Erskine provides legal services to clients in New York, Connecticut, and in various foreign...
Follick & Obert, P.C.New York, NY 10118
Customs and International Trade Law Attorneys(212) 947-6560
Follick & Obert, P.C., provides a variety of legal services to members of the trade community in the areas of customs, international trade, export control, federal regulatory compliance and related commercial matters. ; The firm's attorneys have represented American, foreign and multinational...
GFI Group IncNew York, NY 10041
Corporate Law Department Profile in Hong Kong212 968 4100
GFI Group Inc provides competitive wholesale market brokerage services in a multitude of global over-the-counter ("OTC") and exchange listed cash and derivatives markets for fixed income, equities, financials and commodities. GFI is an industry leader in various fixed income and energy and...
Gonzalez Law AssociatesNew York, NY 10168
Criminal and Family Law Litigation Attorneys in New York(212) 4505-2234
We are a highly skilled and specialized litigation form focussing mostly in the areas of criminal defense for crimes ranging from misdemanors, felonies, Murder, Manslaughter and attempted murder. With an extra emphasis on all drug crimes including narcotics possession and narcotics sales.; We also...


text: << Back to Gallery Listing Page Swedish Issaquah Medical Center Ben Benschneider and CollinsWoerman Swedish Issaquah Medical Center Jan 20, 2012 VIEW PHOTOS » Gallery Image Page Informaiton [Run Gallery Manager] IMAGE INFORMATION Link Image Title Caption Image Swedish Issaquah Medical Center_01 05_Hospital_01_12 A metal sculpture that resembles blades of grass is a backdrop for a staircase that leads to a second-floor education and conference center. Swedish Issaquah Medical Center_02 04_Hospital_01_12 Avoiding a clinical appearance, a modest emergency reception desk is designed to be welcoming. Swedish Issaquah Medical Center_03 03_Hospital_01-12 A colorful, articulated ceiling in an imaging room helps calm patients. Swedish Issaquah Medical Center_04 02_Hospital_01_12 The outdoor courtyard is landscaped with seating areas and walking paths. Swedish Issaquah Medical Center_05 01_Hospital_01_12 A living room-like waiting area with a stone fireplace leads to a verdant courtyard.

subset: commoncrawl


text:
Rock'It Lanes is the perfect place for
parties, events, and group events of
every kind, including the following:
Birthday Package
Basically, we provide everything except the cake and the candles.
Only $12 per person for either event or $16 per person for the Bowling-Skating combination party.
Call 249-2695 to reserve your date and time. Please ask for the manager on duty.
to Home


text:
ICYMI: Being a Poor, Single Mom Is Hard
A new documentary from Maria Shriver shows exactly how hard.
Skip to content, or skip to search.
Skip to content, or skip to search.
A new documentary from Maria Shriver shows exactly how hard.
She contributed to Maria Shriver's report on the status of women.
Arnold grabs Maria's butt, Justin kisses Selena.
Ninety-four days late or 271 days early?
Probably not a fun thing to hear your dad say.
One source described it to TMZ as "a blowjob for Arnold."
He thought Condi would make a better California governor.
But did the imprisoned Hollywood P.I. know about the Schwarzenegger love child?
"She cried with me and told me to get off my knees."
Including Maria Shriver.
"He DID Have Sex With The Maid!"
Arnold's extra-marital baby mama worked for the family for 20 years.
Ah, young love.
Next Media Animation does it again.
Who made up the seating chart?
He had a long and storied career in politics and charitable work.
The grossest and cheesiest lines from thwarted miniseries 'The Kennedys.'
The Governator signs a law prohibiting paparazzi from taking pictures that "invade a celebrity's right to privacy."


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(07-25-2011 02:06 PM)_ZENAS_ Wrote: Yes, but we don't live back then. Now we have lived in decade after decade of specialized card collecting where we can buy a baseball product and know we are getting only baseball.
Now I don't care if someone wants to collect A&G, because that is their choice, and it doesn't bother me that this set exists either, even though it isn't my cup of tea. But using the comeback that you should be glad you weren't around 125 years ago is tenuous at best. If we were around 125 years ago our collecting choices would be determined by what we knew and the culture of the time. The fact is, we DON'T live 125 years ago and our collecting preferences rightfully reflect that fact.


text:
Quotes from ex-members of the International Church of Christ
(If you have a quote you'd like to contribute, please email it to me. I will update this list as I receive and discover further comments.)
- I quit the church about a month into my so-called membership, and the day ended by my calling the cops at 12:00AM to get one of their members off my front porch. The day after I ended up unplugging my phone and then I ordered "call-block" from my phone co...I remember after my departure from the ICoC about a month later I ran into some of the ICoC members at a football game, I tell you the truth that they would not even look at me. I have no idea what's going through their minds, but I know it has something to do with "mind control," (Ric).
- I must admit, the ICC is a very strong church. I quit after two months of membership and the people who used to be my 'friends and family' no longer wish to speak to me as I am now in ' a church that is not ordained by GOD', i.e. a non-ICC church. Please stay away from this group, they are a very controlling group. Before you realize it, they have taken over your life and the longer you stay, the harder it becomes to quit. (Requested to be anonymous)
- Let me start by saying I think, for the most part, the doctrine of ICC is great. I learned a lot and the discipleship was very intense and insightful. However, They are cult-like in their practices, but if other churches followed similar (not exact) practices, the church as a whole would be a lot better off. I was part ICC for a few months, but decided to leave for several reasons:
- ICC put my friend out of the church because they said she would not submit to her husband and reconcile with him after they separated. they told her that she could not enjoy the benefits of the Kingdom as others did and remain unsubmitted and at ICC. They would not allow her to be baptized unless she reconcile with her husband and confessed her sins to him. They also told her that they hoped that Satan would have his way with her - so that she would self-destruct.
- I disagreed with them that a woman could not teach in a mixed congregation. men and women always had to be separated when a woman taught.
- They were heavily involved in the lives of the members which is fine, but I think they were extreme.
- You could not become a member unless you were baptized in their church regardless if you had been previously baptized.
- I also had issue with a situation occurring with my disciple partner and her family. They needed financial help (i.e., food). ICC told her that they could not help her and her family because of sin that caused them to be in that financial predicament. They had committed no sin to get into that situation. They had been struggling financially - low income people...They had no food and could barely keep the lights on. Therefore, they sought help from ANOTHER CHURCH who gladly came to their aid....(Requested to be anonymous)
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Use EndNoteWeb to organize the citations that you gather in your research. Create a free account and log in from MSU campus at least once a year to maintain access.
- Register for an EndNote Web Account NOTE! Password must be 8+ characters, contain at least 1 digit and at least one of the following special character: !@#$%^*()~`{}[]|\
Career/Graduate School Resources
- Testing & Education Reference CenterUse this database to take GRE (and other) practice exams, study the online GRE guide, explore graduate schools, build your resume and more!
- CollegeSource OnlineSearch profiles of accredited graduate (and other) programs at U.S. colleges and universities. Includes links to college & university websites, career information, and financial aid Information.
- Vault Career LibraryProvides information to more than 3,000 companies, 40 industries, and over fifty career paths, including over ninety full-text career guides, as well as employer profiles, articles, message boards, and advice on careers, resumes, and cover letters.
- Occupational Outlook HandbookSee this U.S. Bureau of Labor Statistics resource for information on hundreds of different types of jobs and careers. Find job search tips, plus information about the job market in each state, etc.
Databases for finding epidemiological research articles
- CINAHL CINAHL is a multidisciplinary bibliographic database covering the nursing, allied health, biomedicine, and consumer health literature. It also includes some full-text documents.
- Medline (on Web of Science)Medline is the premiere medical abstracts database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. This version of Medline provides links to our journal holdings through the CHECK MSU AVAILABILITY feature.
- PubMED (original Medline search interface)The original Medline database interface, PubMED does not provide links to MSU journal holdings. Search the JournaList database to determine if the library owns a journal from which you need an article. See Medline description above for coverage.
- Web of Science Core CollectionBroad coverage of international literature in the sciences and social sciences. Allows citation searching to determine what papers cite a particular author/paper.
- Web of Knowledge (includes Medline & Web of Science) This combined database searches the Web of Science databases (Science Citation Index and Social Science Citation Index), Medline, BIOSIS, and Zoological Record.
- PsycInfoThe primary database for research in psychology, PsycInfo provides access to the international literature in psychology and related behavioral and social sciences, including psychiatry, sociology, anthropology, education, pharmacology, and linguistics.
- Sociological AbstractsCovers the international literature in sociology and related disciplines in the social and behavioral sciences.
- Social Services Abstracts Current research on social work, human services, and related areas, including social welfare, social policy, and community development. Major areas of coverage include Community and mental health services, Crisis intervention, The family and social welfare, Gerontology, Poverty and homelessness, Professional issues in social work, Social and health policy, Social services in addiction, Social work education, Social work practice, Support groups/networks, Violence, abuse, neglect, Welfare service
- Cochrane Library The Cochrane Library consists of a regularly updated collection of evidence-based medicine databases and is a unique source of reliable and up-to-date information on the effects of interventions in health care.
- Epidemiology Resarch Tips Use this handout for tips on brainstorming search terms related to epidemiology.
Select books on epidemiology
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The Handbook of Disease Burdens and Quality of Life Measures
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Western Diseases
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Nick Stahl | Amy Sancetta~AP
Updated: July 19, 2012 6:20AM
Less than one month after checking himself into rehab, "Terminator" actor Nick Stahl checked out — against doctors' advice. A Stahl friend is worried "he's going to kill himself with drugs" — since Stahl was spotted last week in a Los Angeles neighborhood filled with drug "dens." — B.Z.
© 2014 Sun-Times Media, LLC. All rights reserved. This material may not be copied or distributed without permission. For more information about reprints and permissions, visit www.suntimesreprints.com. To order a reprint of this article, click here.


text:
Beyond the Emerging Middle Class
For many years, the rise of the middle class in emerging markets has captivated the imagination of investors. We think this is an illusion. It's the working classes who will be the real engines of consumer growth in developing countries.read more
Ukraine: A Bailout or "Bail In" for Bond Investors?
As the drama of the political showdown over embattled Ukraine plays out, bond investors face less-publicized concerns over the fate of their Ukrainian investments and a potential bailout. But a bailout may not be all good news for investors.read more
Seeing Through Emerging-Market Volatility
Stock markets in emerging markets (EMs) have gotten off to a rough start this year after a challenging 2013. Valuations have fallen and volatility remains high. So should investors add exposure to emerging markets—or is it better to steer clear?read more
The Path to Becoming an Emerging Market
By Henry D'Auria (pictured) and Morgan Harting Why have some equity markets in the developing world flourished more than others? It's a pivotal question for investors hoping to stake an early claim to the potential emerging-market (EM) success stories of the next decade.read more
Thinking Outside the Emerging-Markets Box
Forecasting is never an easy task. In the complex and fast-moving world of emerging markets, it's particularly difficult. We believe investors would benefit from adding a broader approach to their research toolbox.read more
EM Sovereign Debt 2014: Neither Phoenix nor Failure
Emerging-market (EM) sovereign bonds were burned badly in 2013. Will they rise from the ashes in 2014? We believe some will and some won't. The watchword for 2014 will be selectivity.read more
EM Debt Risk: The Devil Is in the Detail
Investors in US dollar-denominated bonds issued by emerging-market (EM) corporates are worried that the greenback's rise, together with a broad decline in EM currencies, could increase the risk of defaults on their holdings. How worried should they be?read more
Value Stocks Beckon in Emerging Markets
Henry D'Auria (pictured) and Morgan Harting Years of playing defense have left many emerging-market (EM) equity portfolios laden with pricey safe-haven stocks. We think they risk missing the big opportunity that's brewing in value stocks, especially as EM economies begin to stabilize.read more
Supersize EM: Obesity Matters for Emerging-Market Investors
Modern lifestyles are closely linked to rising obesity. As emerging markets follow the lead of the US, expanding waistlines could provide a guide to consumption-related investment trends in emerging markets.read more
Predicting Death to Find Life in Emerging Market Stocks
Over the past year, investors have become excessively cautious about emerging markets. To compensate for the additional uncertainty, many underestimate the upside potential. Paradoxically, to get a better handle on the risks, we believe they should assume the worst. By using this "pre-mortem" approach, not only do they have a better chance of avoiding disaster, [...]read more
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Osteoporosis Screening
Bone density testing is recommended for:
- All women over age 65
- Postmenopausal women under age 65 with one or more risk factors for osteoporosis
- All men over age 70
- Men ages 50 - 70 with one or more risk factors for osteoporosis
- Any man or women over age 50 who has suffered a fracture
- People with specific risk factors for osteoporosis. These risk factors include long-term use of medications such as corticosteroids, history of certain medical conditions (diabetes, thyroid imbalances), history of breast or prostate cancer treatment, significant loss of height, or substantial recent weight loss.
Osteoporosis Risk Factors
- Age is the main risk factor for osteoporosis. Aging causes bones to thin and weaken. Although osteoporosis affects mostly postmenopausal women, older men are also at risk.
- Osteoporosis is more common in people who have a small, thin body frame and bone structure.
- Dietary calcium and vitamin D deficiencies are important factors in the risk for osteoporosis.
- Women who smoke, particularly after menopause, have a significantly greater risk of spine and hip fractures than those who do not smoke. Men who smoke also have lower bone density.
- Excessive alcohol consumption increases osteoporosis risk.
- Lack of exercise and a sedentary lifestyle can increase the risk of osteoporosis. Engaging in regular low-impact aerobic exercise (such as walking or swimming) and weight-bearing exercise can help prevent it.
- Bisphosphonates are the main drugs used for osteoporosis prevention and treatment. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) come in pills that are taken by mouth. Zoledronic acid (Reclast) is given by once-yearly injection. Ibandronate is also available as a four-times a year injection.
- Other types of drugs used for osteoporosis treatment and prevention include raloxifene (Evista), calcitonin, and teriparatide (Forteo). The FDA is considering approving denosumab (Prolia), a new type of drug.
Osteoporosis is a skeletal disease in which bones become brittle and prone to fracture. In other words, the bone loses density. Bone density is the amount of bone tissue (such as calcium and minerals) in a certain volume of bone. Osteoporosis is diagnosed when bone density has decreased to the point where the risk of fractures is high even without severe stress or injury to the bones.
Until a healthy adult is around age 40, the process of breaking down and building up bone by cells called osteoclasts and osteoblasts is a nearly perfectly coupled system, with one phase balancing the other. As a person ages, or in the presence of certain conditions, this system breaks down and the two processes become out of sync. The reasons why this occurs during aging are not clear, but declining levels of sex hormone are one factor. Some individuals have a very high turnover rate of bone, some have a very gradual turnover, but the breakdown of bone eventually overtakes the build-up.
The Bones
The Function of Bones. The skeleton has a dual function:
- It provides structural support for muscles and organs.
- It also serves as a storehouse for the body's calcium and other essential minerals, such as phosphorus and magnesium.
The skeleton holds 99% of the body's calcium. The remaining 1% circulates in the blood and is essential for crucial bodily functions, ranging from muscle contraction to nerve function to blood clotting.
Bone Turnover: the Breakdown and Growth of Bones. Bone tissue is constantly being broken down and reformed again. This turnover is necessary for growth, for repair of minor damage that occurs from everyday stress, and for the maintenance of a properly functioning body. Two essential cells are involved in this process:
- Osteoclast cells are formed from certain blood cells and are responsible for the breakdown, or resorption, of the skeleton. These cells dig holes into the bone and release the small amounts of calcium into the bloodstream that are necessary for other vital functions.
- Osteoblast cells are produced by bone cells and are the bone builders. They rebuild the skeleton, first by filling in the holes with collagen, and then by laying down crystals of calcium and phosphorus.
Each year, about 10 - 30% of the adult skeleton is remodeled in this way. The balance of bone build-up (formation) and break down (resorption) is controlled by a complex mix of hormones and chemical factors. If bone resorption occurs at a greater rate than bone build up, your bone loses density and puts you at risk for osteoporosis.
In women, estrogen loss after menopause is associated with rapid resorption and loss of bone density. This group, then, is at highest risk for osteoporosis and therefore for fracture.
Primary and Secondary Osteoporosis
Primary osteoporosis is the most common type of osteoporosis. It can be age-related and associated with the postmenopausal decline in estrogen levels, or related to calcium and vitamin D insufficiency.
Secondary osteoporosis is osteoporosis caused by other conditions, such as hormonal imbalances, diseases, or medications (such as corticosteroids or anti-seizure drugs).
Because the patterns of reforming and resorbing bone often vary from patient to patient, doctors believe several different factors account for this problem. Important chemicals (estrogen, testosterone, parathyroid hormone, and vitamin D) and blood factors that affect cell growth are involved with this process. Changes in levels of any of these factors can play a role in the development of osteoporosis.
The Role of Sex Hormones in Bone Breakdown
Although normally associated with women, sex hormones play a role in osteoporosis in both genders, most likely by controlling the development and activity of both osteoclasts (bone breakers) and osteoblasts (bone builders).
Women and Estrogen. A woman experiences a rapid decline in bone density after menopause, when her ovaries stop producing estrogen. Estrogen comes in several forms:
- The most potent form of estrogen is estradiol. Estradiol deficiency appears to be a very strong factor in the development of osteoporosis.
- The other important but less powerful estrogens are estrone and estriol.
The ovaries produce most of the estrogen in the body, but it can also be formed in other tissues, such as the adrenal glands, body fat, skin, and muscle. After menopause, some amounts of estrogen continue to be manufactured in the adrenals and in peripheral body fat. Even though the adrenals and ovaries have stopped producing estrogens directly, they continue to be a source of the male hormone testosterone, which converts into estradiol.
Estrogen may have an impact on bone density in various ways, including slowing bone breakdown (resorption).
Men and Androgens and Estrogen. In men, the most important androgen (male hormone) is testosterone, which is produced in the testes. Other androgens are produced in the adrenal glands. Androgens are converted to estrogen in various parts of a mans body, including bone.
Studies have suggested that the loss of estrogen as well as testosterone may contribute to bone loss in elderly men. Both hormones appeared to be integral to bone function in men.
Vitamin D and Parathyroid Hormone Imbalances
Low levels of vitamin D and high levels of parathyroid hormone (PTH) are associated with hip fracture in women after menopause:
- Vitamin D is a vitamin with hormone-like properties. It is essential for the absorption of calcium from the intestines and for normal bone growth. Lower levels result in impaired calcium absorption, which in turn causes an increase in PTH.
- Parathyroid hormone (PTH) is produced by the parathyroid glands. These are four small glands located on the surface of the thyroid gland. They are the most important regulators of calcium levels in the blood. When calcium levels are low, the glands secrete more PTH, which then increases blood calcium levels. High persistent levels of PTH stimulate bone resorption (bone loss).
Genetic Factors
Genetic factors may play a role in determining bone density.
Causes of Secondary Osteoporosis
Corticosteroids. Oral corticosteroids (also called steroids or glucocorticoids) can reduce bone mass in both men and women. It is not clear whether inhaled steroids carry the same risks, but some studies indicate that they may cause bone loss when taken at higher doses for long periods of time. (Children on inhaled steroids may have temporary impaired growth, but they do not appear to be at risk for bone loss.)
Diuretics. Diuretics, which are used to treat high blood pressure, have different effects on osteoporosis, depending on the type. Loop diuretics, such as furosemide (Lasix), increase the kidneys excretion of calcium, which can lead to thinning bones. Thiazide diuretics, on the other hand, protect against bone loss, but this protective effect ends after use is discontinued.
Contraceptives. Hormonal contraceptives that use progestin without estrogen (such as Depo-Provera injection or other progestin-based contraceptives), can cause loss of bone density. For this reason, the Food and Drug Administration (FDA) recommends that Depo-Provera injections should not be used for longer than 2 years. Some studies suggest that combination estrogen-progestin oral contraceptives increase the risk for osteoporosis later in life. Women who take birth control pills should be sure to get adequate calcium and vitamin D from diet or supplements.
Other Medications. Anti-convulsant (anti-seizure) drugs increase the risk for bone loss (as does epilepsy itself). Other drugs that increase the risk for bone loss include the blood-thinning drug heparin, and hormonal drugs that suppress estrogen (such as gonadotropin-releasing hormone agonists and aromatase inhibitors). Proton pump inhibitors (PPIs), which are used to treat gastroesophageal reflux disease (heartburn), may also increase the risk for bone loss and hip fractures. These drugs include omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium).
Medical Conditions. Osteoporosis can be secondary to several other conditions, including alcoholism, diabetes, hyperthyroidism, chronic liver or kidney disease, Crohn's disease, celiac disease, scurvy, rheumatoid arthritis, leukemia, cirrhosis, gastrointestinal diseases, vitamin D deficiency, lymphoma, hyperparathyroidism, and rare genetic disorders such as Marfan and Ehlers-Danlos syndrome.
Risk Factors
About 10 million adults in the United States have osteoporosis and another 34 million have low bone mass that places them at risk for developing osteoporosis. According to a report from the Surgeon General's office, by 2020 half of all Americans over age 50 could be at risk for this condition. Seventy percent of people with osteoporosis are women. Men start with higher bone density and lose calcium at a slower rate than women, which is why their risk is lower. Nevertheless, older men are also at risk for osteoporosis.
As people age, their risks for osteoporosis increase. Aging causes bones to thin and weaken.
Although adults from all ethnic groups are susceptible to developing osteoporosis, Caucasian and Asian women and men face a comparatively greater risk.
Body Type
Osteoporosis is more common in people who have a small, thin body frame and bone structure.
Family History
People whose parents had a history of fractures may be more likely to have fractures.
Hormonal Deficiencies
Women. Events associated with estrogen deficiencies are the primary risk factors for osteoporosis in women. These include:
- Menopause. Within 5 years after menopause, the risk for fracture increases dramatically. Fractures occurring during this period are more likely to occur in the wrist or spine than the hip, but their occurrence is a strong predictor of later severe osteoporosis and hip fracture.
- Surgical removal of ovaries
- Missing periods for 3 months or longer
- Never having given birth
- Anorexia nervosa, (an eating disorder), or extreme low body weight can affect the body's production of estrogen
Men. Low levels of testosterone increase osteoporosis risk. Certain types of medical conditions (hypogonadism) and treatments (prostate cancer androgen deprivation) can cause testosterone deficiency.
Lifestyle Factors
Dietary Factors. Diet plays an important role in preventing and speeding up bone loss in men and women. Calcium and vitamin D deficiencies are important factors in the risk for osteoporosis. Other dietary factors may also be harmful or protective for certain people.
Exercise. Lack of exercise and a sedentary lifestyle increases the risk for osteoporosis. Conversely, in competitive female athletes, excessive exercise may reduce estrogen levels, causing bone loss. (The eating disorder anorexia nervosa can have a similar effect.) People who are chairbound or bedbound due to medical infirmities and who do not bear weight on the bones are at risk for osteoporosis.
Lack of Sunlight. The photochemical effect of sunlight on the skin is a primary source for vitamin D. Bone formation peaks in the summer and bone breakdown increases in the winter. People who avoid sun exposure to prevent skin cancer may be at risk for vitamin D deficiency, particularly if they are elderly.
Smoking. Women who smoke, particularly after menopause, have a significantly greater chance of spine and hip fractures than those who don't smoke. Men who smoke also have lower bone density.
Alcohol. Excessive consumption of alcoholic beverages can increase the risk for bone loss.
Risk Factors in Children and Adolescents
The maximum density that bones achieve during the growing years is a major factor in whether a person goes on to develop osteoporosis. People, usually women, who never develop peak bone mass in early life are at high risk for osteoporosis later on. Children at risk for low peak bone mass include those who are:
- Born prematurely
- Have anorexia nervosa
- Have delayed puberty or abnormal absence of menstrual periods
Although to a large extent genetics predict bone health, exercise and good nutrition during the first three decades of life (when peak bone mass is reached) are still excellent safeguards against osteoporosis (and countless other health problems).
Bone density loss from osteoporosis is a major cause of disability and death in the elderly, mostly due to subsequent fractures. The lifetime risk of spinal fracture in women is about one in three, and that for hip fracture is one in six. Women at highest risk for fractures are those with low bone density plus a history of fractures, particularly nonviolent fractures.
Osteoporosis causes more than 1.5 million fractures annually. About 50% of women and 25% of men over age 50 will suffer an osteoporosis-related fracture during their lifetime. Each year, there are about 700,000 spinal fractures, 300,000 hip fractures, 250,000 broken wrists and more than 300,000 fractures of other bones. About 80% of these fractures occur after relatively minor falls or accidents.
Unfortunately, studies continue to report inadequate treatment after a fracture. Few patients with sustained fractures are tested or treated for osteoporosis.
Risk Factors for Fracture and Falling. In addition to low bone density, falling is the primary risk factor for fractures. Additional risk factors for fracture are those that increase the risk for falling. They include:
- Having chronic medical problems (emphysema, heart disease, stroke, arthritis, and depression), with the risk increasing with multiple health problems
- Taking multiple medications (especially tranquilizers and antidepressants)
- Poor physical function, importantly slow gait and reduced muscle strength. Inactivity that results in weak thigh muscles and poor balance particularly puts any older person at risk for fracture and particularly those with low bone density.
- Poor concentration or mental impairment
- Impaired vision
- Hazardous environment (such as the presence of throw rugs in the house)
Mortality after Fracture
Hip fractures can increase the risk of death in both men and women. Complications of hip fractures include hospital-acquired infections and blood clots in the lungs.
Many people confuse osteoporosis with arthritis and mistakenly believe it is safe to wait for symptoms such as swelling and joint pain to occur before seeing a doctor. However, arthritis is entirely different from osteoporosis. Osteoporosis is quite advanced before symptoms appear.
All too often, osteoporosis becomes apparent in dramatic fashion: A fracture of a vertebra (backbone), hip, forearm, or any bony site if sufficient bone mass is lost. These fractures frequently occur after apparently minor trauma, such as bending over, lifting, jumping, or falling from the standing position.
Pain, disfigurement, and debilitation are common in the latter stages of the disease. Early spinal compression fractures may go undetected for a long time, but after a large percentage of calcium has been lost, the vertebrae in the spine start to collapse, gradually causing a stooped posture called kyphosis, or a "dowagers hump." Although this is usually painless, patients may lose as much as 6 inches in height.
Candidates for Bone Density Testing
Because osteoporosis can occur with few symptoms, testing is important. Bone density testing is recommended for:
- All women over age 65
- Postmenopausal women under age 65 with one or more risk factors for osteoporosis
- All men over age 70
- Men ages 50 - 70 with one or more risk factors for osteoporosis
- Any man or woman over age 50 who has suffered a fracture
Risk factors that may indicate a need for bone mineral density testing include:
- Long-term use of medications associated with low bone mass or bone loss such as corticosteroids, some anti-seizure medications, Depo-Provera, thyroid hormone, or aromatase inhibitors. Long-term use of corticosteroids (more than 5 mg/day for more than 3 months) is a specific risk factor.
- History of treatment for prostate cancer or breast cancer
- History of medical conditions such as diabetes, thyroid imbalances, estrogen or testosterone deficiencies, early menopause, anorexia nervosa, rheumatoid arthritis
- Significant loss of height
- Significant recent weight loss or low body mass index
Tests Used for Measuring Bone Density
Central DXA. The standard technique for determining bone density is a form of bone densitometry called dual-energy x-ray absorptiometry (DXA). DXA is simple and painless and takes 2 - 4 minutes. The machine measures bone density by detecting the extent to which bones absorb photons that are generated by very low-level x-rays. (Photons are atomic particles with no charge.) Measurements of bone mineral density are generally given as the average concentrations of calcium in areas that are scanned.
Central DXA measures the bone mineral density at the hip and spine.
Other Tests. Other tests may be used, but they are not usually as accurate as DXA. They include ultrasound techniques, DXA of the wrist, heels, fingers, or leg (peripheral DXA) and quantitative computed tomography (QCT) scan.
Screening tests using these technologies are sometimes given at health fairs or other non-medical settings. These screening tests typically measure peripheral bone density in the heels, fingers, or leg bones. The results of these tests may vary from DXA measurements of spine and hip. While these peripheral tests may help indicate who requires further BMD testing, a central DXA test is required to diagnose osteoporosis and to monitor treatment response.
Diagnosing Osteoporosis and Predicting the Risk for Fracture
Osteoporosis is diagnosed when bone density has decreased to the point where fractures will happen with mild stress, the so-called fracture threshold. This is determined by measuring bone density and comparing the results with the norm, which is defined as the average bone mineral density in the hipbones of a healthy 30-year-old adult.
The doctor then uses this comparison to determine the standard deviation (SD) from this norm. Standard deviation results are given as Z and T scores:
- A T score gives the standard deviation of the patient in relationship to the norm in young adults. Doctors often use the T-score and other risk factors to determine the risk for fracture.
- A Z score gives the standard deviation of the patient in relationship to the norm in the patients own age group and body size. Z scores may be used to for diagnosing osteoporosis in younger men and women. They are not normally used for postmenopaual women or for men age 50 and older.
Results of T-scores indicate:
- Higher than -1 indicates normal bone density.
- Between -1 and -2.5 indicates low bone density (osteopenia).
- A score of -2.5 or lower indicates a diagnosis of osteoporosis.
The lower the T-score, the lower the bone density, and the greater the risk for fracture. In general, doctors recommend beginning medication when T-scores are -2.5 or below. Patients who have other risk factors may need to begin medication when they have osteopenia (scores between -1 and -2.5). Osteopenia is considered a precursor to osteoporosis.
Laboratory Tests
In certain cases, your doctor may recommend that you have a blood test to measure your vitamin D levels. A standard test measures 25-hydroxyvitamin D, also called 25(OH)D. Depending on the results, your doctor may recommend you take vitamin D supplements.
Lifestyle Changes
Healthy lifestyle habits, including adequate intake of calcium and vitamin D, are important for preventing osteoporosis and are also a useful accompaniment to medical treatment.
Calcium and Vitamin D
A combination of calcium and vitamin D can reduce the risk of osteoporosis. (For strong bones, people need enough of both calcium and vitamin D.) The National Osteoporosis Foundation (NOF) recommends:
- Adults under age 50 should have 1,000 mg of calcium and 400 - 800 IU of vitamin D daily.
- Adults age 50 and older should have 1,200 mg of calcium and 800 - 1,000 IU of vitamin D daily.
Dietary Sources. Good dietary sources of calcium include:
- Milk, yogurt, and other dairy products
- Dark green vegetables such as collard greens, kale, and broccoli
- Sardines and salmon with bones
- Calcium-fortified foods and beverages such as cereals, orange juice, soymilk
Certain types of foods can interfere with calcium absorption. These include foods high in oxalate (such as spinach and beet greens) or phytate (peas, pinto beans, navy beans, wheat bran). Diets high in animal protein, sodium, or caffeine may also interfere with calcium absorption.
Dietary sources of vitamin D include:
- Fatty fish such as salmon, mackerel, and tuna
- Egg yolks
- Liver
- Vitamin D-fortified milk, orange juice, soymilk, or cereals
However, many Americans do not get enough vitamin D solely from diet or exposure to sunlight.
Supplements. Adults who consume adequate amounts of calcium in their diets may not need to take a supplement. Many require vitamin D, particularly if they do not get enough exposure to sunlight. Vitamin D is made in the skin using energy from the ultra-violet rays in sunlight. Because sun exposure increases the risk for skin cancer and premature skin aging, many Americans restrict their sunlight exposure. People's vitamin D levels decline as they age.
Calcium and vitamin D supplements can be taken as separate supplements or as a combination supplement. If taken separately, the supplements do not need to be taken at the same time.
- Calcium supplements include calcium carbonate (Caltrate, Os-Cal, Tums), calcium citrate (Citracal), calcium gluconate, and calcium lactate. Although each kind provides calcium, they all have different calcium concentrations, absorption capabilities, and other actions.
- Vitamin D is available either as D2 (ergocalciferol) or D3 (cholecalciferol). They work equally well for bone health.
Both calcium and vitamin D supplements can increase the risks for kidney stones. If you have a history of kidney stones, discuss with your doctor whether these supplements are appropriate for you.
Calcium supplements can also have other side effects and drug interactions:
- Some people may experience gas, bloating, or constipation. These effects can usually be relieved by increasing fluid and fiber consumption.
- Calcium supplements can interfere with the actions of certain medications such as tetracycline antibiotics, thyroid hormone, and proton pump inhibitors. Iron supplements should not be taken at the same time as calcium supplements.
Exercise is very important for slowing the progression of osteoporosis. Although mild exercise does not protect bones, moderate exercise (more than 3 days a week for more than a total of 90 minutes a week) reduces the risk for osteoporosis and fracture in both older men and women. Exercise should be regular and life-long. Before beginning any strenuous exercise program, older patients or those who have serious medical conditions should talk to their doctors.
Specific exercises may be better than others:
- Weight-bearing exercise applies tension to muscle and bone and, in young people, can increase bone density by as much as 2 - 8% a year. In premenopausal women these exercises are very protective. Careful weight training is also very beneficial for middle-aged and older people, especially women.
- Regular brisk long walks improve bone density and mobility. Most older individuals should avoid high-impact aerobic exercises (step aerobics), which increase the risk for osteoporotic fractures. Although low-impact aerobic exercises such as swimming and bicycling do not increase bone density, they are excellent for cardiovascular fitness and should be part of a regular regimen.
- Exercises specifically targeted to strengthen the back may help prevent fractures later on in life and can be beneficial in improving posture and reducing kyphosis (hunchback), even in people with existing severe conditions.
- Low-impact exercises that improve concentration, balance, and strength, particularly yoga and tai chi, may help to decrease the risk of falling.
Other Lifestyle Factors
Other lifestyle changes that can help prevent osteoporosis include:
- Limit alcohol consumption. Excessive drinking is associated with brittle bones.
- Limit caffeine consumption. Caffeine may interfere with the bodys ability to absorb calcium.
- Quit smoking. The risk for osteoporosis from cigarette smoking appears to diminish after quitting.
Preventing Falls and Fractures
An important component in reducing the risk for fractures is preventing falls. Risk factors for falling include:
- Slow walking
- Inability to walk in a straight line
- Certain medications (such as tranquilizers and sleeping pills)
- Low blood pressure when rising in the morning
- Poor vision
Recommendations for preventing falls or fractures from falls in elderly people include:
- Exercise to maintain strength and balance if there are no conflicting medical conditions.
- Do not use loose rugs on the floors.
- Move any obstructions to walking, such as loose cords or very low pieces of furniture, away from traveled areas.
- Rooms should be well lit.
- Have regular eye checkups.
- Consider installing grab bars in bathrooms especially near shower, tub, or toilet.
Two types of drugs are used to prevent and treat osteoporosis:
- Antiresorptive Drugs. Antiresorptives include bisphosphonates, hormone replacement therapy, selective estrogen-receptor modulators (SERMs), and calcitonin. Bisphosphonates are the standard drugs used for osteoporosis. These drugs block resorption (preventing bone break down), which slows the rate of bone remodeling, but they cannot rebuild bone. Because resorption and reformation occur naturally as a continuous process, blocking resorption may eventually also reduce bone formation.
- Anabolic (Bone-Forming) Drugs. Drugs that rebuild bone are known as anabolics. The primary anabolic drug is low-dose parathyroid hormone (PTH), which is administered through injections. This drug may help restore bone and prevent fractures. PTH is still relatively new, and long-term effects are still unknown. Fluoride is another bone-building drug, but it has limitations and is not commonly used.
Both types of drugs are effective in preventing bone loss and fractures, although they may cause different types of side effects.
Bisphosphonates are the primary drugs for preventing and treating osteoporosis. They can help reduce the risk of both spinal and hip fractures, including among patients with prior bone breaks.
Studies indicate that these drugs are effective and safe for at least 10 years. Eventually, however, bone loss continues with bisphosphonates. This may be due to the fact that bone breakdown is one of two phases in a continuous process of rebuilding bone. Over time, blocking resorption interrupts this process and impairs the second half of the process -- bone formation. Some, but not all, patients who are at low risk for fracture may be able to stop using the drug after 5 years. Other patients need to continue taking this type of drug on a continuous basis.
Candidates. National Osteoporosis Foundation guidelines recommend that the following people should take or consider taking bisphosphonates:
- Any woman who has a T score of -2.5 or lower on a DXA scan
- Women who have a T score between -1 and -2.5 (indicates low bone density [osteopenia]) and a history of fractures
Brands. Bisphosphonates for osteoporosis prevention and treatment are available in different forms:
- Oral bisphosphonates. These pills include alendronate (Fosamax, generic), risedronate (Actonel), and ibandronate (Boniva). Alendronate and risedronate are taken once a week. Ibandronate is available as a once-monthly pill. Risedronate is also available as a once-a-month pill and in a pill that contains calcium. Alendronate is available in a formulation that has vitamin D . Risedronate and alendronate are approved for both men and women.
- Injectable bisphosphonates. Zoledronic acid (Reclast) is approved for treatment and prevention of osteoporosis in postmenopausal women. It is given as a once-yearly injection. The injectable form of ibandronate (Boniva) requires injections 4 times a year. Injectable bisphosphonates are an alternative for patients who may have difficulty swallowing pills or sitting upright after oral bisphosphonate treatment.
Side Effects. The most distressing side effects of bisphosphonates are gastrointestinal problems, particularly stomach cramps and heartburn. These symptoms are very common and occur in nearly half of all patients. Other side effects may include irritation of the esophagus (the tube that connects the mouth to the stomach) and ulcers in the esophagus or stomach. Some patients may have muscle and joint pain. To avoid stomach problems, doctors recommend:
- Take the pill on an empty stomach in the morning with 6 - 8 ounces of water (not juice or carbonated or mineral water).
- After taking the pill, remain in an upright position. Do not eat or drink for at least 30 - 60 minutes. (Check your drugs dosing instructions for exact time.)
- If you develop chest pain, heartburn, or difficulty swallowing, stop taking the drug and see your doctor.
Other Concerns. Osteonecrosis (bone death) of the jaw is a rare side effect that has occurred mainly in patients who received intravenous bisphosphonates for cancer treatment (not osteoporosis). Many of these patients had major dental procedures before developing osteonecrosis. However, this bone decay condition has also been reported in some patients who have taken bisphosphonates by mouth (mainly alendronate). Symptoms may include jaw pain or swelling, gum infections, and poor healing of the gums. Talk to your doctor or dentist if you experience any jaw or gum discomfort while taking a bisphosphonate drug.
There have also been concerns raised that bisphosphonates may increase the risk for atrial fibrillation, a heart rhythm disorder common in elderly patients. The FDA is monitoring reports of atrial fibrillation among patients who use bisphosphonates but at this time does not recommend any changes to prescribing practices. As of late 2008, the FDA had evaluated almost 20,000 patients who had received bisphosphonates without identifying a clear link between these drugs and the risk of atrial fibrillation.
Raloxifene (Evista) belongs to a class of drugs called selective estrogen-receptor modulators (SERMs). These drugs are similar, but not identical, to estrogen. Raloxifene provides the bone benefits of estrogen without increasing the risks for estrogen-related breast and uterine cancers. Raloxifene was approved in 1997 to prevent osteoporosis in postmenopausal women, and in 1999 for the treatment of osteoporosis in postmenopausal women. In 2007, the Food and Drug Administration approved raloxifene for prevention of breast cancer in postmenopausal women with osteoporosis, as well as postmenopausal women at high risk for invasive breast cancer.
While there are many SERM drugs, raloxifene is the only one approved for both treatment and prevention of osteoporosis. Only postmenopausal women who have or are at risk for osteoporosis should take this drug. Studies indicate that raloxifene can stop the thinning of bone and help build better quality and stronger bone.
Side Effects. Raloxifene increases the risk for blood clots in the veins. Because of this side effect, raloxifene also increases the risk for stroke (but not other types of heart disease). These side effects, though rare, are very serious. Women should not take this drug if they have a history of blood clots, or if they have certain risk factors for stroke and heart disease. More common mild side effects include hot flashes and leg cramps.
Produced by the thyroid gland, natural calcitonin regulates calcium levels by inhibiting the osteoclastic activity, the breakdown of bone. The drug version is derived from salmon and is available as a nasal spray (Miacalcin) and an injected form (Calcimar). Calcitonin is not used to prevent osteoporosis. It treats osteoporosis. It may be effective for spinal protection (but not hip) in both men and women. Calcitonin may be an alternative for patients who cannot take a bisphosphonate or SERM. It also appears to help relieve bone pain associated with established osteoporosis and fracture.
Side Effects. Side effects include headache, dizziness, anorexia, diarrhea, skin rashes, and edema (swelling). The most common adverse effect experienced with the injection is nausea, with or without vomiting. This occurs less often with the nasal spray. The nasal spray may cause nosebleeds, sinusitis, and inflammation of the membranes in the nose. Also, many people who take calcitonin develop resistance or allergic reactions after long-term use.
Parathyroid Hormone
Teriparatide (Forteo), an injectable drug made from selected amino acids found in parathyroid hormone, may help reduce the risks for spinal and non-spinal fractures. Although high persistent levels of parathyroid hormone (PTH) can cause osteoporosis, daily injections of low and intermittent doses of this hormone actually stimulate bone production and increase bone mineral density. Teriparatide is usually recommended for patients with osteoporosis who are at high risk of fracture.
Side effects of PTH are generally mild and include nausea, dizziness, and leg cramps. No significant complications have been reported to date. A nasal spray version of PTH is currently in clinical trials.
Early animal studies reported bone tumors in mice that were given parathyroid long-term. Such effects have not been observed in humans to date. However, people with Paget disease, (a disorder in which bone thickens but also weakens), should not take parathyroid hormone, because they are at higher than normal risk for bone tumors.
Hormone Replacement Therapy
Hormone replacement therapy (HRT) was formerly used to prevent osteoporosis, but is rarely used for this purpose today. Studies have shown that estrogen increases the risk for breast cancer, blood clots, strokes, and heart attacks. For this reason, women need to balance the benefits that HRT has on bone-loss protection, with the risks it carries for other serious health conditions. The FDA recommends that women first try other medications for prevention of osteoporosis.
[For more information on HRT, see In-Depth Report #40: Menopause.]
Investigational Drugs
- Biologic Drugs. Denosumab (Prolia) is a monoclonal antibody drug that is given once every 6 months by injection. In August 2009, an FDA advisory panel recommended approving the drug for treatment of postmenopausal women with osteoporosis and treatment of bone loss in men with prostate cancer. The committee voted against approving denosumab for osteoporosis and bone loss prevention. There are safety concerns that denosumab may increase the risk of skin infections.
- New SERMs. Bazedoxifene (Viviant) and lasofoxifene (Fablyn) are two new selective estrogen receptor modulators (SERMs) that are currently being considered for approval by the FDA. The FDA is weighing the potential benefits of these drugs against their risks, which include stroke. If approved, the FDA may limit these drugs to certain groups of women, such as those at significantly high risk for fractures.
- www.nof.org -- National Osteoporosis Foundation
- www.niams.nih.gov/Health_Info/Bone -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
- www.iofbonehealth.org -- International Osteoporosis Foundation
- www.healthywomen.org -- National Women's Health Resource Center
- www.menopause.org -- North American Menopause Society
Avenell A, Gillespie WJ, Gillespie LD, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD000227.
Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009 Aug 20;361(8):756-65. Epub 2009 Aug 11.
Ebeling PR. Clinical practice. Osteoporosis in men. N Engl J Med. 2008; 358(14): 1474-82.
Greenspan SL, Bone HG, Ettinger MP, Hanley DA, Lindsay R, Zanchetta JR, et al. Effect of recombinant human parathyroid hormone (1-84) on vertebral fracture and bone mineral density in postmenopausal women with osteoporosis: a randomized trial. Ann Intern Med. 2007;146(5): 326-39.
Greenspan SL, Nelson JB, Trump DL and Resnick NM. Effect of once-weekly oral alendronate on bone loss in men receiving androgen deprivation therapy for prostate cancer: a randomized trial. Ann Intern Med. 2007;146(6): 416-24.
Heckbert SR, Li G, Cummings SR, Smith NL, Psaty BM. Use of alendronate and risk of incident atrial fibrillation in women. Arch Intern Med. 2008;168(8):826-31.
Kennel KA, Drake MT. Adverse effects of bisphosphonates: implications for osteoporosis management. Mayo Clin Proc. 2009 Jul;84(7):632-7.
Khosla S. Increasing options for the treatment of osteoporosis. N Engl J Med. 2009 Aug 20;361(8):818-20. Epub 2009 Aug 11.
Kothawala P, Badamgarav E, Ryu S, Miller RM and Halbert RJ. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc. 2007;82(12): 1493-501.
Lim LS, Hoeksema LJ, Sherin K; ACPM Prevention Practice Committee. Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice. Am J Prev Med. 2009 Apr;36(4):366-75.
Loke YK, Jeevanantham V, Singh S. Bisphosphonates and atrial fibrillation: systematic review and meta-analysis. Drug Saf. 2009;32(3):219-28. doi: 10.2165/00002018-200932030-00004.
MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V, Suttorp M, et al. Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med. 2008;148(3): 197-213.
National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis -- 2008. Washington, DC.
Qaseem A, Snow V, Shekelle P, Hopkins R Jr., Forciea MA and Owens DK. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;149(6): 404-15.
Recker RR, Lewiecki EM, Miller PD, Reiffel J. Safety of bisphosphonates in the treatment of osteoporosis. Am J Med. 2009 Feb;122(2 Suppl):S22-32.
Silverman SL, Landesberg R. Osteonecrosis of the jaw and the role of bisphosphonates: a critical review. Am J Med. 2009 Feb;122(2 Suppl):S33-45.
Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007 Aug 25;370(9588):657-66.
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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It's just another day in paradise, as Dr. Catherine Banfield's (new series star Angela Bassett) arrival and tough attitude causes the whole ER staff to feel defensive. Gates (series star John Stamos) and the new interns fight to save the life of a terrorist while risking their own lives. Neela finds an unlikely advocate in her fight to get Dr. Dubenko (series regular Leland Orser) back on the surgery staff.
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Provident Financial Services, Inc. Schedules Second Quarter Earnings Conference Call
ISELIN, N.J., July 1, 2014 (GLOBE NEWSWIRE) -- Provident Financial Services, Inc. (NYSE:PFS) announced that it expects to release financial results for the quarter ended June 30, 2014 on Friday, July 25, 2014 at approximately 8:00 a.m. Eastern Time. A copy of the earnings release will be immediately available on the Company's web site, www.providentnj.com , by going to Investor Relations and clicking on Press Releases.
Chairman, President and Chief Executive Officer Christopher Martin, together with Executive Vice President & Chief Financial Officer Thomas M. Lyons, will hold a conference call for investors at 10:00 a.m. Eastern Time on Friday, July 25, 2014 to discuss highlights of the Company's second quarter financial results. Information about the conference call is as follows:
|Canada Dial-in
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A replay of the call will be available beginning at 12:00 noon (ET) on July 25, 2014 until 9:00 a.m. (ET) on August 11, 2014.
|(Toll Free):
CONTACT: Investor Relations, Provident Financial Services, Inc. 1-732-590-9300 Web Site: http://www.providentnj.com
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Police say a Pennsylvania store clerk with a real gun thwarted an attempted robbery by a suspect armed only with a BB-gun. The store's surveillance camera caught the entire event Saturday
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Naga City – Alumni of Mariners Polytechnic Colleges Foundation (MPCF) Camarines Sur - 2nd Engineer John Arnante and Maritime Chief Cook Allan Arnante shared their views and opinions to radio listeners on their success as seafarers in the October 25, 2014 presentation of the weekly radio show 'Buhay Marinero'.
The two enthusiastically and frankly divulged the ups and downs they have passed through before they finally say they are happy with what they have reached in their profession. They now work as maritime officers in international shipping companies which enable them to enjoy modest compensation.
Read More...
Originally posted on Mariners' System Website
Scenes at the 'eruption drill' simulation exercise held at the main campus of MPCF-Legazpi with students, faculty and staff participating during the commemoration of World Maritime Day.
The 2014 World Maritime Week observed from September 21 to 28, 2014 was celebrated by the two Mariners schools in Bicol – the Mariners Polytechnic Colleges Foundation (MPCF) in Canaman, Camarines Sur and MPCF in Legazpi City, Albay.
Commodore Dante La. Jimenez, President of both campuses announced that the International Maritime Organization (IMO) has adopted the theme 'IMO Convention, Effective Implementation'.
Read More...
The fully-enclosed lifeboat, the latest addition to the state-of-the-art training equipment is now mounted on the Landship at the Survival Training Swimming Pool of MPCF-Camarines Sur.
Canaman, Camarines Sur – The Mariners Polytechnic Colleges Foundation (MPCF), this province has moved to upgrade its training capability with the acquisition of the state-of-the-art fully-enclosed lifeboat replacing the old conventional open craft.
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Canaman, Camarines Sur – The Mariners Polytechnic Colleges Foundation (MPCF) community in Baras, Canaman this province celebrated the victories achieved by students in the series of activities held in the month of September of this year with an awards rites held at the campus.
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Midshipman Niño Copones (seated –3rd from left) of MPCF-Camarines Sur is flanked by fellow awardees from other maritime schools in the country and MARINA officials at the Ninoy Aquino stadium in Metro Manila during the TOMSP awards rites.
Metro Manila – Midshipman Niño C. Copones, a BS Marine Engineering Student of the Mariners Polytechnic Colleges Foundation (MPCF) Camarines Sur has been chosen as one of the Ten Outstanding Maritime Students of the Philippines (TOMSP) with the awarding ceremony held at the Ninoy Aquino Stadium in Metro Manila on September 28, 2014.
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Midshipman Alvin Alvaro (2nd from left) joins school officials and fellow awardee do the 'thumbs-up' sign after having been awarded the First Prize in the 'on-the-spot Poster Making Contest' held in Metro Manila. (Left to right) MPCF-Cam Sur VPAA Marian Her. Lazaro, Cadet Alvaro, TOMSP Awardee Niño Copones and President Dante La. Jimenez.
Ninoy Aquino Stadium, Metro Manila – Mariners Polytechnic Colleges Foundation (MPCF) Camarines Sur received a double honor at the celebration of the 19th National Seafarers' Day held at the Ninoy Aquino Stadium on September 28, 2014 when the entry submitted by Midshipman Alvin Alvaro at the On-The-Spot Poster Making Contest won First Prize.
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Canaman, Camarines Sur – The Mariners System exalts in another feat reached by one of its graduates who placed 3rd in the recently concluded Board Examination for Naval Architects and Marine Engineers.
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The MPC/F Band and Majorettes (Naga and Canaman) performing with the morning show's hosts of Umagang Kay Ganda on September 30, 2014 after winning the National Competition held at Bacoor, Cavite (photo credits Umagang Kay Ganda Official FB Page)
Bacoor City, Cavite – The composite team of Band and Majorettes from the Mariners Polytechnic Colleges/Foundation (MPC/F) in Naga City and Canaman Camarines Sur has carved another name for the institutions by garnering the highest honor in the recently concluded National Marching Band and Majorettes Competition held in this city on September 27, 2014.
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The Mariners-Camarines Sur's CGA-OTC unit with its officers and men in their trade mark performance, earning them the title - 'The Most Disciplined' ROTC Unit at the 2014 Peñfrancia Festival Street Military Parade competition.
Canaman, Camarines Sur – The Coast Guard Auxiliary- Officer Training Corps (CGA-OTC) Unit of Mariners Polytechnic Colleges Foundation (MPCF) Camarines Sur has been adjudged as "Most Disciplined Unit' in the 2014 Peñafrancia Festival Street Military Parade Competition held on September 19, 2014, this city.
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|Students, maritime cadets, members of the faculty and staff of Mariners school fetched the image of Our Lady of Peñafrancia from the Canaman Church to the school via a solemn procession marking the traditional yearly 'Pagsunko' or Visitation to the campus.
Mariners launches 'OrganiKo' for healthy Marinero
Mariners community
Fun and serious look at seafaring career mark Family Day at MPCF-Camarines Sur
MPCF supports BAM-Cam Sur's move to appoint provincial district coordinators
Congratulations to Midn. Niño Copones for being selected as one of the Ten Outstanding Maritime Students for 2014 and Midn. Alvin Alvaro for winning First Place in the On-the-Spot Poster Making Contest in the 2014 National Seafarers' Week celebration! The awarding was held at Ninoy Aquino Stadium last September 28, 2014.
Read article on Midn. Niño Copones
Read article on Midn. Alvin Alvaro
|ANA THERESA SIBULO MERCADO, Naval Architect and Marine Engineer
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PRC Board Passers
Students and staff from MPCF-Camarines Sur join 'Scrap the Pork' rally and concert
Mariners System accepts Elsevier Foundation's grant of Library for Safe Seafaring
L4SS Committee reviews status of Library; moves on to higher gear of operation
Smooth start of First Semester marks opening of classes at MPCF Camarines Sur
Singapore shipping executive graces MPCF-Cam Sur Commencement Exercises;
Marlow Navigation Philippines recruits seafarers for immediate deployment overseas
566 maritime cadets graduate from MPCF Cam Sur CGA-OTC course
ELSEVIER Foundation and MPCF unveil billboard of Library for Safe Seafaring at Mariners'...
Cam Sur's education sector conducts electricity forum on Mariners' 40th anniversary
Veritas Maritime Corporation visits MPCF Camarines Sur for cadetship tie-up
Jifrey Azor brings home honor to school and country from South Africa's international...
Misuga Kaiun and Maine Marine shipping officials visit MPCF-Camarines Sur
Who is Midshipman Mark Angelo Brillo?
MPCF Camarines Sur pushes for a pro-active approach to stop drugs and spread...
MPCF Camarines Sur signs agreement with Elsevier Foundation on establishment...
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Red Sea Lion team bags 2014 Intrams championship at MPCF-CamSur
MPCF's Jifrey Azor goes to South Africa to compete in international swimfest
Japanese university students visit MPCF-Camarines Sur; amazed how future...
Mariners System forms core group to make operational Project L4SS of Elsevier Foundation
MPCF's Jifrey Azor qualifies in South Africa's February 2014 swimming competition
Personnel of MPCF-Camarines Sur attends new year Holy Mass of 'Hope and Thanksgiving'
MPCF Camarines Sur remembers Engr. Jaime 'Boboy' Jimenez, Jr. in simple...
Last Updated: November 20, 2014 | 12:00 PM
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Reef guardian Council program
Land-based runoff is a major pressure on the reef.
In 2007 the Great Barrier Reef Marine Park Authority developed the Reef Guardian Council program to work with Councils on this issue.
Since then, thirteen councils from Bundaberg to Cooktown have joined the program, covering an area of 317 271 km2 and a combined population of greater than 890 000.
As a Reef Guardian Council, Cairns Regional Council is committed to driving improvement in:


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Four Armenian soldiers killed in Karabakh skirmish (updated)
Published: Saturday June 19, 2010
Washington - (Story last updated June 23)
An Azerbaijani raid across the Line of Contact on the night of June 18-19 left Armenian forces with heaviest casualties in many years; the incident took place just a day after the latest Armenian-Azerbaijani presidential summit.
Armenia's defense ministry reported that four were killed and another four wounded at a defensive position near Chailu (also known as Getk) in Karabakh's Mardakert district as a result of Azerbaijani attack. Body of one of the Azerbaijani attackers was left at the post, as the Azerbaijani raiding party retreated.
Azerbaijan's defense ministry confirmed the incident, describing it as a "shootout." APA news agency identified the Azerbaijani dead as a non-commissioned officer.
Officials have so far provided few details of the incident but judging by the high number of casualties soldiers at the Armenian forward position appear to have been caught off guard.
On June 21 Armenian officials published the names of Armenian servicemen who were killed or wounded in the attack. According to the announcement junior sergeant Mnatsakan Gasparian, privates Araik Barseghian, Edward Manukian and Paruir Melkonian lost their lives; and junior sergeant Garik Matevosian, privates Galust Badasian, Andranik Arzumanian and Harutiun Mesropian were among the wounded.
The same general area but closer to nearby Levonarkh in Mardakert district was the site of previous deadly Azerbaijani raid in March 2008. That incident took place just a day after clashes between opposition activists and police forces in Yerevan on March 1-2.
An "act of provocation"
Armenian officials and commentators have noted that the latest raid occurred just twenty-four hours after the meeting between Armenian and Azerbaijani presidents hosted by Russia's Dmitry Medvedev.
The three met on the sidelines of St. Petersburg economic forum. Observers have pointed out that Ilham Aliyev - apparently unhappy with the meeting - left for Azerbaijan immediately after it, while Serge Sargsyan stayed for other planned events, including meetings with the local Armenian community.
Speaking from St. Petersburg on the morning of June 19, Sargsyan condemned what he called a "provocation" and expressed condolences to the families of the soldiers killed in in the incident.
"We are full of determination and confidence that we will achieve [international] recognition of the Nagorno Karabakh Republic," Pres. Sargsyan said, when asked about the impact of the incident on the peace process.
"This means that Karabakh mediatiors [from France, Russia and U.S.] must take stock since provocations left unpunished and unanswered can lead to worse consequences," Sargsyan was quoted as saying by News.am. "This is also evidence of disrespect towards the mediators."
On the same day Russia's foreign ministry which took note of Armenian officials' statements and expressed "deep regret" over reports of casualties.
In a joint statement on June 21, envoys from the mediating troika described the "armed incident" as "unacceptable violation of the 1994 Ceasefire Agreement [that] is contrary to the stated commitment of the sides to refrain from the use of force or the threat of the use of force."
Noting that the violence came immediately after the June 17 summit, the mediators called as "an attempt to damage the peace process."
In Washington co-chairs of the congressional Armenian caucus Rep. Frank Pallone (D-N.J.) and Mark Kirk (R-Ill.) condemned the Azerbaijani attack and called for restrictions on U.S. military aid to Azerbaijan and strengthening of the sanctions regime against the country.
Major border incidents since 1994 cease-fire:
In March 2008 an Azerbaijani attack near Levonarkh in Mardakert district leaves an estimated eight Azerbaijani soldiers dead and two Armenian soldiers wounded; mortars and artillery reportedly used.
In March 2005 Azerbaijanis report more than 10 service members dead as they try to bring up their positions closer to Armenian defenses in the Aghdam district.
In June 2004 Azerbaijanis try to take control of a water pumping station near the Joghaz reservoir that supplies several villages on the border of Armenia's Tavush province and Azerbaijan's Kazakh district; there were dead on both sides, but Armenians retain control.
In June-July 2003, Azerbaijanis report about 10 service members dead as they try to bring their position into the no-man's land in the village of Karakhanbeili in the Fizuli district; mortars reportedly used.
In March 2000, an Azerbaijani special forces unit raids Nagorno- Karabakh's Mardakert district, with Azerbaijani losses estimated at 15.
In June 1999, Azerbaijanis initiate intensive fighting near the village of Karmiravan in Mardakert district. Casualties on both sides.
Since May 1994 cease-fire and throughout the 1990s skirmishes were frequent as the sides had not yet established permanent fortified positions.


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Mens and Womens Tennis
Spring Schedule
The Spring 2014 Schedule
Spring Roster
The Spring 2014 Roster
Game Shots
Dr. Ritchie Dulaney, Head Coach
1-800-231-3752 ext. 2114
(251) 580-2114
Coach Dulaney has coached the tennis team for 13 years. The men's team has qualified for the NJCAA National Tournament two times and placed 13th in 2007 and 23rd in 2008.
Coach Dulaney is a graduate of McGill-Toolen High School where her volleyball team won the state title three out of four years. She was also a member of the basketball team which won two state titles, the track team which won a state title, and the tennis team. She has a bachelor's degree from the University of Missouri-Columbia, a master's degree from the University of South Alabama, and a doctorate degree from the University of Nova Southeastern.
She is currently the head coach for Volleyball and Tennis, and is the Chair of the Physical Education Department and is also a Physical Education instructor at Faulkner State.
May 6, 2014
Three new players from Saraland High School signed with the Sun Chief Tennis Team. From left to right are Iesha Peoples, Tanner Grow and Alesha Peoples.


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