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Best Place To Farm Gold- Heading To Specific Dungeons
So many accounts are recipience banned today because gamers believe it’s
a mound easier to purchase in-game gold with TRUE money.
Sure it’s easier, but conjecture of it as a crisp word solution.
Eventually they obtain caught and then find themselves frustrated because their toons retain vanished.
However, you can alleviate this issue by finding the first cranny to farm gold.
How about some of the Dungeons in the game.
Once you scale level 8 on the Horde troupe or standard 10 on the
Alliance group you can onset receiving gain of the miscellaneous
Horde entrust inscribe Ragefire Chasm (RFC) and Alliance players bequeath mobility to the Deadmines.
Each retain their benefits, but the prime body is to accept why we consider both of them the prime cubby-hole to farm gold at this level.
Cloth Gathering- Even though Linen Cloth isn’t worth anything anymore you can still make a few gold looting it.
This is full for the individual that joins a guild and gets some offices for free.
Mining Ability- Don’t forget about all the mining veins that are available in these lowbie Dungeons.
Copper Ores aren’t your biggest gold winner, but they definitely add to your totals.
Unfortunately this only benefits those who train for the Mining profession.
Potions- Although you probably won’t reach an whole mass of potions, you can gain a skipper attack in a Dungeon.
If you deficiency to radius 20 of them before slanting the full
stockpile in the Auction House (AH) you can find other from mixed
vendors around towns and major cities.
Enchanter Help- If you’re an Enchanter then all the green and melancholy items (weapons, gear, etc.
) you receive can be disenchanted and overripe into dust.
Even the low variations like Strange Dust, Vision Dust, and Soul Dust can be sold for gold in the AH.
All other professions cede find Dungeons refreshing one method or another.
Plus when you compass the succeeding doorway of available Dungeons you will beginning assembly bigger and revise items.
Just remember that the trick here is to find the ones that you can either solo or hold 1 fresh symbol run you through it.
Oh, and the faster the better.
These are just some of the reasons why Dungeons are considered the boon nook to farm gold in the game.
Know What You’re Getting
Even though all of this sounds fantastic and helpful, there are over 117 variations of Dungeons available.
This includes typical and heroic options.
The point is you retain to perceive what style of behalf you’re going to receive for entering a specific one.
Are you looking for a particular cloth? Do you enjoy an practicable run
that offers gold for gray, white, green, blue, and chronicle items?
Whatever the case may be, it’s celebrated to notice what you can gain
and how doable it will be to accomplish the feat.
After all, who wants to spend two hours soloing a dungeons for only a span hundred gold.
Don’t worry though, reliable macrocosm of warcraft gold production guides can present you the inside dipper on what to do.
If you can transpire the recipe accordingly you will be able to make thousands of pieces of unchain creation of warcraft gold.
The hindmost result is a safer account, a mountain further money, and you will be able to cipher out the blessing nook to farm gold for each level.
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African Hunting Safaris–hunting Zambia
Zambia is one of the finest, if not the best, dangerous lame hunting motive in Africa.
There are 18 National Parks cope over 14 million acres, and hunting concessions totaling in excess of 34 million acres.
A third of the whole simple is jell aside to wildlife, which system it is an African safari paradise.
What makes Zambia so distinct from fresh African hunting destinations is
the zoning of anchor areas around the public parks as halting
These blocks represent protective buffer zones
to the national parks, putting a innocuous corridor between the parks
and flock areas.
The release motion of animals between the parks
and the crippled guidance areas ensure a reliable supply of superior
It is here that Zambia hosts foreign hunters from
all over the world who seek to stalk their prizes and experience the
adventures of a goodly hunt.
Zambia�s major river valleys, her
Kalahari bushveld to the southwest, plateau woodlands throughout the
interior, as well as her swamps and widespread floodplain savannahs
provide one of the most singular and exciting selections of trophy
animals to be found in a single African nation, fairly some 35 different
Outfitters like Adventure Unlimited work with several of the blessing
hunting operations in Zambia in the Luangwa Valley, the Kafue area, and
the Zambezi Valley and more remote concessions for technical game.
Some of these include Nyampala Safaris, Muchinga Adventures Ltd,
Luawata Conservation, Hunters and Guides Ltd, Vidale Zafaris and wildcat Safaris.
Strong Zambian connections like these enable the most hunting
opportunities in best concessions, and the largest quotas of lion,
leopard and Cape buffalo in the country.
Hunting concessions in Zambia are referred to as GMA�s or Game Management Areas.
They are among the blessing safari hunting motive in all of Africa, and
are closely controlled by both the outfitters and the Zambian wildlife Authority.
There are three primary hunting regions in Zambia which are listed in actuality below.
The eastern portion of the pastoral is home to the important Luangwa Valley.
It is great catchment that funnels down a 200 mile wanting valley with a
widely meandering Luangwa River flowing down the middle.
The Luangwa is superior for is lanky lion, lanky leopard, colossal herds of buffalo, and it variety of plains game.
The Lusemfwa River Valley is a smaller version of the Luangwa that runs
through the Luano defective rule area, and to the east lies the Zambezi
Valley where hunting is furthermore easy impending the confluence of
the Luangwa and Zambezi Rivers.
In south-central Zambia there is a great national park, partly the size of Connecticut, called the Kafue National Park.
Surrounding it are eight lame guidance areas, which together with the state grounds represent the largest single wildlife reserve in Africa.
Interspersed with woodlands, thickets, savannahs and dampish grassy
areas called dambos; this sector of Zambia provides diverse selections
of lofty limping awards that guarantee thrilling and challenging safari
These hunting blocks produce admireable lion, leopard, buffalo, sable and many fresh species.
Zambia�s wetland areas provide unrivaled hunting opportunities for the Black Lechwe, Red Lechwe and Sitatunga.
Bangweulu Swamp is home to the sinisteru lechwe with unit reaching over 30,000 and offering creditable trophy quality.
The Bangweulu floodplains further provide hunters an opportunity to chase some of the biggest Cape buffalo in Africa.
Much less-known to the international hunting fraternity is the West
Zambezi, a sizeable girdle of floodplains, Kalahari sandveld, and
patches of woodland.
Back in the mid to overdue 70�s and early
80�s this cestuses produced the most magnificent trophy lion in Africa-
all huge bodied with jet menacing manes, the true lion prizes of the
It has not been well hunted in gone years due to
the spill-over create of the armed conflict in Angola which contribute
to substantial outbreaks of poaching.
With the cessation of
hostilities in Angola and uncompromising act enforcement by some
anti-poaching disabled scouts, hunters entrust hopefully be able to look
forward to hunting this region in the not too distant future as the
defective populations are starting to recover.
The Zambian wildlife Authority maintains strict break over safari camp structures in the Game Management Areas.
Accordingly, safari camps are usually built out of local materials
consisting of thatch and devotee (non-permanent), or classic canvas
The camp builders over the years keep become discipline
craftsmen turning nature�s bounty into beautiful hunting accommodations.
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Hyperlite® 054065684132 – Aksel 60″ Assorted Colors Nylon Reflective Snap Dog Leashes
ONE YEAR FROM DATE OF ORIGINAL PURCHASE – COMPRESSION HARDGOODS:
HO Sports will inspect any and all products sent in for warranty for the period of up to one year from original date of purchase of that product. The warranty period extends to any repaired or replaced items for the duration of the one year from date of purchase of the original item. Products older than one model year must be accompanied with a customer receipt to verify purchase within one year. Product Defined: Any Water Ski, Wakeboard, Wake Skate, Wake Surf or Kneeboard constructed using the compression molding manufacturing process.
ONE YEAR FROM DATE OF ORIGINAL PURCHASE – WAKEBOARD & WATERSKI BOOTS & BINDINGS
HO Sports will inspect any and all products sent in for warranty for the period of up to one year from original date of purchase of that product. The warranty period extends to any repaired or replaced items for the duration of the one year from date of purchase of the original item. Products older than one model year must be accompanied with a customer receipt to verify purchase within one year. The warranty does not extend to the tearing out of finger holes, pull straps, and laces nor does it extend to normal wear and tear of abrasion of the materials used, or damage due to improper handling, maintenance, modification, use or storage. Product Defined: Wakeboard & Waterski Boots and Bindings.
90 DAYS FROM DATE OF ORIGINAL PURCHASE – WOOD PRODUCTS AND EPOXY WAKE SURFBOARDS
HO Sports will inspect any and all products sent in for warranty for the period of up to 90 Days from original date of purchase of that product. The warranty period extends to any repaired or replaced items for the duration of the 90 days from date of purchase of original item. Products older than one model year must be accompanied with a customer receipt to verify purchase within one year. Product Defined: Any wake skate or flex board constructed of predominantly wood materials and epoxy constructed Wake Surf Boards.
ONE YEAR FROM DATE OF ORIGINAL PURCHASE – SOFTGOODS – ROPES
HO Sports will inspect any and all products sent in for warranty for the period of up to one year from original date of purchase of that product. The warranty period extends to any repaired or replaced items for the duration of the one year from date of purchase of original item. Products older than one model year must be accompanied with a customer receipt to verify purchase within one year. Product Defined: vests, bags, gloves, helmets and ropes.
90 DAYS FROM DATE OF PURCHASE – LEISURE INFLATABLES – PUMPS – APPAREL
HO Sports will inspect any and all products sent in for warranty for the period of up to 90 days from original date of purchase of that product. Upon determination of manufacturer defect, a new item of the same model will be replaced at the discretion of the HO Sports Warranty Department. Valid only 90 days from date of customer purchase and must include copy of customer’s receipt to verify purchase within 90 Days. Product Defined: The Leisure Line of inflatables for warranty purposes consists of coverless tubes with the main intent being applications not involving towing. Inflatable pumps consist of all pumps hand, battery or electric powered. All apparel items clothing, jackets, hats, etc.
INFLATABLES – ONE YEAR FROM DATE OF PURCHASE
HO Sports will inspect any and all products sent in for warranty for the period of up to one year from original date of purchase of that product. The warranty period extends to any replaced items for the duration of the one year from date of purchase of the original item. Upon determination of manufacturer defect, a replacement item will be issued at the discretion of HO Sports Warranty Department. Should said product be discontinued or not available indefinitely, a substitute of equal performance will be issued.
Hyperlite Murray w/ Team X Boots 2021
Let’s face it, we all ride hard and the toys we play on are bound to take some abuse. Nearly all manufacturers understand this and provide a warranty against defects and workmanship. Each new product sold by Skiforce is covered by the individual manufacturer’s warranty. Please check the manufacturer’s website for information regarding their specific warranty policy. The manufacturer will make all warranty decisions. All return shipping costs are the responsibility of the buyer. As an Australian Wake and Waterski Retailer we can only warranty products purchased from our store and website. Please have proof of purchase at Skiforce available when dealing with any warranties.
STEPS FOR PROCESSING WARRANTIES
Step 1. Determine whether the damage should be covered by warranty. Here are a few things that are NOT covered by warranty:
• Normal wear resulting from standard usage that occurs over time. (chipped topsheet, sun faded topsheet, etc)
• Damage resulting from contact with objects. (Rails, kickers, logs, stumps, little kids, skiers, etc.)
• Damage to product resulting from improper care or unnecessary roughness. (throwing it around on the bank, product flying off of board racks, etc)
• Parts, hardware, accessories that were lost or have gone missing AFTER receiving your shipment.
Step 2. Email us about your warranty and include CLEAR and detailed pictures explaining the problem. Blurry pictures will not be accepted.
If you have any questions, don’t hesitate to give us a call. We want to see you back out on your product as much as you want to use it and try to get you a response within 48 hours of receiving the product.
Step 3. We will contact you with further instruction.
The next step varies by manufacturer and we will provide you with all the details for the next step. If your warranty claim is accepted you will have to ship your product back to us so that we can confirm the warranty with the manufacturer. Return shipping on warranty claims is the responsibility of the buyer. The manufacturer or Skiforce will cover shipping charges on all items replaced or repaired under warranty.
Let us know if you are in a rush and would like to pay extra for express shipping on your warranty return.
2020 Forest River XLR Hyperlite 31HFX
2020 Forest River XLR Boost 21QBS
The Possibilities are endless.
You can do it all with an XLR Boost toy hauler. Weekend camping, motorcycle rally, ski trips, soccer tournaments, dog shows, canoe / kayak water sports, tailgating, or off the grid side by side fun. Our well equipped XLR Boost and Micro Boost Brand of toy haulers is designed for an “Action Camping” lifestyle. You will find the “Xtra Built” features of the 102” wide body XLR Boost or the 96” wide XLR Micro Boost , will give you a fresh sense of what camping is meant to be. It will afford you the opportunity to take the toys that your passionate about on your next camping Trip. Not all Travel Trailers and Fifth Wheels can do that but an XLR Boost Toy Hauler can make it happen!
Features may include:
- 13.5K Main A/C w/ Ducted Roof Vents
- Friction Hinge Main Entry Door w/ Large Grab Handle
- Color Metal Bands On Sidewall
- Body Armor Enclosed & Insulated Underbelly
- Extra Large 1 1/2” Fresh Water Drain Valve
- Seamless EPDM Rubber Roof
- Premium Electric Coated or Powder Coated Frames
- Marine Grade External Speakers
- Moisture Barrier Floor Enclosure
- 30 Gallon Fuel Station w/ Gen Prep
- 12’-18’ Power Awning w/ LED Lighting
- Under Unit Accent Lighting
- 5” Radius Wood Framed Roof
- Laminated Aluminum Framed Ramp Door
- 100 Gallon Fresh Water Tank
- Oversized Tank Capacities
- Battery Disconnect Switch
- 20 lbs. LP Bottles (2) w/ Cover
- Radius Safety Glass Windows
- Rear Spoiler Over Ramp Door
- Rear LED Strip Lighting Over Door
- Black Steel Wheels w/ Nitrogen Filled Radial Tires
- Dual Zone / HDMI / BT / 2 Zone / APP
- 17” Black Oven w/ Glass Cooktop LED Lighting
- 10CF – 12VDC Black Stainless Steel Refrigerator
- 35,000 BTU Forced Air Ducted Furnance
- Deep Seated Stainless Steel Kitchen Sink
- Oval Residential Stainless Steel Lavy Sink
- Residential Pull Down Sprayer Faucet
- Stainless Steel Sink Cover Grate / Cutting Surface
- Residential Solid Surface Countertops
- Ball Bearing Extension Drawer Guides
- Pre-drilled and Screwed Cabinetry
- Solid Core Cabinet Stiles
- High Definition LED Television
- Quick Recovery Water Heater
- Medicine Cabinet With Mirror
- Plastic Foot Flush Toilet
- Residential Walk In Showers
- Night Stands / Bedside Shelves
- Oil and Gas Resistent Residential Linoleum
- Upgraded Residential Furniture
- Residential Decorative Sheet
Gossamer Gear Mariposa 60 Backpack Review
I typically purchase gear with an eye toward fastpacking and previously thought of high-capacity packs as being useful only for slower thru-hikes or long trips into the backcountry. The Gossamer Gear Mariposa 60 backpack has changed my mind. Though spacious at 60 liters, with solid suspension, durable materials, and a slew of well-planned pockets for organization, the Mariposa weighs only 2 pounds and easily obtains ultralight status. In fact, it quickly has become my go-to pack for backpacking trips regardless of distance or number of days. Below I break down the Mariposa’s performance. To see how it stacks up, see our article on the best backpacking packs.
Table of Contents
Despite an ultralight build that weighs just over 2 pounds, the Gossamer Gear Mariposa 60 is surprisingly comfortable, even when loaded down. Much of the credit goes to its suspension system, which uses an internal aluminum stay that inserts into the hipbelt. This lightweight frame stiffens the pack and helps distribute the weight from the shoulders onto the hips. The stay can be removed to reduce weight by 3.5 ounces, but I prefer to leave it in. Without it, I feel that the pack loses its structure and makes the hipbelt ride up onto my waist.
Further, with a recommended maximum load of 35 pounds, the Mariposa has a fairly high load capacity within the ultralight category. For my trip in the Canadian Rockies, I packed the basics for fastpacking along with a large amount of camera gear, pushing the pack slightly beyond its load limit. Even after multiple eight- to 10-hour days on the trail, the Mariposa remained balanced and comfortable. With proper adjustments to the load-lifter straps and hipbelt, it never felt as though it was hanging off of my back or pulling on my shoulders.
The Mariposa has a number of components that can be removed to save weight and create a more streamlined pack. As I mentioned above, I prefer to leave the stay in for comfort, but I often take out the “SitLight” backpanel. This foam piece slides into two sleeves and doubles as back support and a sit pad, but I find that it can bunch up and lead to pressure points. Unless I ever plan to reduce weight by leaving a sleeping pad behind or have gear with particularly sharp edges, I will continue to leave the backpanel at home.
The Mariposa is an ultralight pack that can weigh as little as 1 pound 1.2 ounces when stripped down. Because it’s so customizable both in terms of features and sizing, your body type and preferences will determine the exact weight. For example, a small pack with a small hipbelt weighs 1 pound 12 ounces, while a large with a large hipbelt weighs just over 2 pounds (a full list of weights can be found on Gossamer Gear’s website). You also have the option of foregoing the hipbelt entirely, which will save you around 10 ounces at $45, but you’ll give up a lot of carrying comfort. For reference, I had a large pack with a medium hipbelt, which clocks in at 2 pounds 0.6 ounces. This is competitive with many other leading UL packs designs including the Hyperlite 3400 Southwest (2 lbs. 0.6 oz.), Granite Gear Crown2 60 (2 lbs. 5.8 oz.), and ULA Circuit 68 (2 lbs. 4.6 oz.). You can go lighter with Zpacks’ Arc Blast 55 at an impressively low 1 pound 4.6 ounces, but that pack is much more compromised in terms of storage and overall comfort.
One of the first things I noticed about the Mariposa is its sheer number of external pockets. Not only does the pack have a cavernous main compartment, it also features a zip pocket on each hip and one on the top flap, two dump pockets on one side and one on the other, and a highly functional rear mesh dump pocket. Although I’ve never owned a backpacking pack with so many external pockets, I was an immediate convert. The four dump pockets are extremely convenient for storing items independently of each other—even large items such as a shelter or sleeping pad—and keeping gear easily accessible. Furthermore, each of these dump pockets features a drainage hole, and the ventilated design of the rear mesh pocket makes it especially ideal for stowing wet gear.
The main compartment is a deep cylinder with a large, bear-canister-friendly opening. I like the option of having a secondary zipper along the main compartment to access my heavy camera gear at the bottom of the pack, but unfortunately the Mariposa omits this feature in the name of weight-savings. For those who don’t have expensive equipment that they prefer to keep stowed away in their main compartment, the lack of side entry likely won’t pose a problem (the external dump pockets are extremely helpful with organization). And to round out the feature set, the Mariposa includes your typical pack essentials such as a hydration sleeve, exit hole, and straps to keep the hydration tube in place. And though I haven’t used them yet, on the rear of the pack are several attachment points for trekking poles and an ice axe, along with loops for customizing a bungee attachment system.
Build Quality and Durability
Gossamer Gear overhauled their backpack lineup a few years back, and one of the most significant changes was shifting from Dyneema fabric to a 100- and 200-denier nylon called Robic. The claim is that the Robic used on the Mariposa 60 is more durable and puncture-resistant, and we can now attest to that. Despite solid abuse on trips through the Canadian Rockies and Coast Mountains, the fabric has not torn, stretched, or visibly worn in any manner. This is a notable improvement over our recent tests of Dyneema packs—both the Hyperlite Mountain Gear 3400 Windrider and Zpacks Arc Blast developed small punctures relatively quickly. Even the large mesh exterior pocket of the Mariposa, which we’ve stuffed to the gills, has held up admirably.
However, one benefit of Dyneema construction is its waterproofing properties. The Robic fabric isn’t waterproof but is decently adept at shedding moisture. We were caught in a few torrential rainstorms while backpacking, during which I was worried about the contents in the bag. However, I was pleasantly surprised that my gear remained dry. That said, while the Gossamer Gear Mariposa can handle brief showers, I would recommend a cover if the forecast calls for heavy rain.
Fit and Sizing
We touched on this in the weight section above, but one of the best features of the Mariposa (and smaller Gorilla) is that it allows for an extremely customizable fit. First, you choose from three unisex torso sizes ranging from small to large. Next, the hipbelt is purchased separately, also available in small, medium, and large. Further, the unisex fitting applies to the shoulder straps, the shape of which impressively accommodates both my wife (narrow shoulders) and me (a relatively large frame). Combined with features such as an aluminum stay that can be bent to further hone in the fit, an adjustable sternum strap, and load-lifter straps above the shoulders, this pack is highly adjustable for a range of body types. And to help, Gossamer Gear provides an extensive fitting chart on their website. For further reference, my large pack and medium hipbelt comfortably fit my 33-inch waist and 42-inch chest.
What We Like
- Robic nylon fabric performs as billed: it’s light, more durable than Dyneema, and sheds light moisture.
- Exterior organization is a standout in the ultralight class.
- The pack is comfortable right up to its weight limit of 35 pounds.
What We Don’t
- We found the removable “SitLight” pad along the backpanel was prone to bunching, and as a result we often left it behind.
- A few more cinch straps would be great for tightening the pack when not fully loaded.
- Some brighter color options would be nice.
Gossamer Gear’s Mariposa is our favorite ultralight backpacking pack design for its impressively lightweight build that doesn’t sacrifice much in the way of storage, comfort, or durability. Among the competition is the Hyperlite Mountain Gear 3400 Southwest, which features an identical weight (2 lbs. 0.6 oz.) and similar levels of carrying comfort but has less organizational features and a significantly higher price tag ($355). The Southwest also uses Dyneema Composite Fabric instead of Robic nylon, which is waterproof along with being lightweight. That said, Dyneema is prone to puncturing from sharp rocks and other objects and is less durable overall than the Mariposa’s Robic construction. All told, the Gossamer Gear wins out in the organization and durability categories, but the Hyperlite’s waterproof design is alluring for those who hike in wet environments.
The Zpacks Arc Blast 55L ($349) is another worthy UL option that uses a mix of Dyneema and polyester fabrics, giving it the added benefit of waterproofing. This combination of materials is impressively lightweight, keeping the pack at 1 pound 4.6 ounces—significantly less than the medium version of the Mariposa with a hipbelt. But with only three external pockets (none of which zip), the Arc Blast is limited in its organizational capacity, and we find that it doesn’t carry a load as well. If pack weight is your number one consideration, it’s hard to argue against the Arc Blast. But we give the overall edge to the Gossamer Gear Mariposa for its added carrying comfort, organization, and durability.
Utah-based ULA Equipment is another standout in the ultralight gear realm, and their Circuit 68 backpack is a well-rounded option in a durable yet streamlined package. Right off the bat, we’ll note that the Circuit is heavier than the packs above at 2 pounds 4.6 ounces (for a medium pack with a medium hipbelt) but offers a nice balance of organization and comfort. Like the Mariposa, the ULA uses a tough Robic nylon construction (400D), which is exceptionally durable and tear-resistant. That said, we’ve found the Gossamer Gear to be plenty hardwearing, and we give it the edge over the ULA for its lower weight.
Osprey’s Levity 60 is yet another attractive option, similar to the Mariposa in its lightweight nylon makeup and large external dump pockets. But at 1 pound 15.2 ounces, the Levity is both lighter and features superior ventilation: the backpanel is constructed from a thin mesh which allows constant airflow between your back and the pack. We find that breathability often is overlooked on ultralight packs but makes a large difference during rigorous hikes and in warmer climates. Unfortunately, this means the Levity has to shave weight somewhere, and its extremely thin 30-denier nylon along the sides requires special care and gives up a lot in terms of durability when compared to the packs above. We give the edge to the Gossamer Gear based on its superior carrying abilities and more robust fabric, but the Osprey is worth considering if you prioritize weight and ventilation.
Finally, REI isn’t known for their ultralight gear—perhaps quite the opposite—but we’ve been impressed with the latest Flash 55. It is a super customizable design that can go from a fully featured traditional pack at 2 pounds 10 ounces to a stripped-down ultralight pack at only 2 pounds 3 ounces. Plus, the Flash features rarely seen (in the ultralight world) backpanel ventilation and a burly 420-denier bottom fabric (for more, see our in-depth Flash 55 review). Similar to the Mariposa, the Flash excels at comfort and support, even with heavier loads, but REI doesn’t offer the same convenience of customizing torso lengths and hipbelt sizes. And at 2 pounds 3 ounces for the most stripped-down version (i.e. no top lid or hipbelt pockets), the Flash 55 is still heavier than the fully featured Mariposa. Despite coming up short in a direct comparison, it’s exciting to see REI entering the ultralight world, and we appreciate the solid construction, entry-level price ($199), and nice feature set of the Flash.
2021 Forest River XLR Hyperlite 2513
2021 Forest River XLR Hyperlite 2513
It’s all in the name, with this versatile, lightweight, lineup. Whether you require an enclosed garage, open passage way, or outside deck, we have a model to suit your needs. Our toy haulers have structural integrity and construction that exceed the demands of mother nature’s landscape, with a nice flair for style and room for your guests to sleep. Plus, our towing capacities can accommodate a variety of applications, across the board.
Our toy haulers are affordable, ½ ton and ¾ ton towable, light weight, quality laminated products that are easy on your tow vehicle, very functional, and offer superior construction. Produced in an exclusive toy hauler facility, XLR boasts the longest running legacy of Sport Utility Trailer production. We provide dedication after the sale, with a service and support team located at the manufacturing facility.
LED lightning, ducted A/C & heat, Dexter axles, solid wood & raised panel cabinetry, roof with 3/8″ decking, standard fully enclosed underbelly, night shades, 5,000 lb cargo tie downs, two-tone grey exterior, optional party deck, and friction hinge doors are just some of the offerings on a Hyper Lite Toy Hauler.
“More than just light, affordable with style”
Features may include:
- Friction Hinge Entry Door(s) w/ Window
- Dual 20# LP Tanks w/ Cover
- 30AMP Service w/Transfer Switch
- UV Resistant Gel-Coated Fiberglass Exterior
- Radius Fully-Walkable Roof
- Singular Roof Membrane w/ 12 Year Warranty
- Insulated Storage Compartment Doors
- Vacuum-Bonded Aluminum-Framed Sidewalls
- Laminated & Insulated Slide Room Walls
- Fully Enclosed “Body-Armor” Underbelly w/ Radiant Foil Layer
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Complex additive for concrete mix and method of its preparation
The invention relates to the field of construction, namely to the composition of complex additives for concrete mixtures and methods of their preparation, and can be used in the production of concrete and reinforced concrete products and structures. The technical result is an increase in the growth rate of concrete strength in the early stages of hardening while maintaining their high final strength, as well as an increase in frost resistance and water resistance.Complex additive for concrete mix contains hyperplasticizer “Hyperlite” and carbon nanostructured material (CNM) “Taunit”, with the following ratio of components, wt.%: Hyperplasticizer “Hyperlit” – 99.5-99.7, carbon nanostructured material “Taunit” – 0.3-0.5. The method of preparation of the proposed complex additive consists in the ultrasonic dispersion of the carbon nanostructured material “Taunit” in the hyperplasticizer “Hyperlit” for 3-7 minutes using the ultrasonic generator UZG13-0.1 / 22.2 n.p. f-ly, 1 tab.
The invention relates to the field of construction, namely to the composition of complex additives for concrete mixtures and methods of their preparation, and can be used in the production of concrete and reinforced concrete products and structures.
A known method for preparing a modified fiber-concrete mixture and a modified fiber-concrete mixture (RU 2397069 C1, publ. 08/20/2010), which is used for road and airfield construction, in the manufacture of prefabricated and monolithic reinforced concrete products and structures.
This mixture includes Portland cement M500, steel fiber “Miksarm”, filler, plasticizing additive “Polyplast SP-3”, multilayer carbon nanotubes (CNT) with the following ratio of components, kg / m 3 mixture: Portland cement 320-330, filler 1900 -1920, steel fiber 70-80, superplasticizer 1.6-1.72, multilayer CNTs 0.010-0.015, mixing water 130-145.
The method of its preparation consists in mixing Portland cement, steel fiber, filler, plasticizing additive and mixing water in a mixer, pre-dispersing Portland cement and superplasticizer in a linear induction rotator, the resulting dry mixture together with mixing water and multilayer carbon nanotubes is processed in an ultrasonic disperser.
The disadvantage of this invention is the low strength of the resulting concrete, as well as the low efficiency of the mixture preparation process.
Known concrete mixture (RU 2355656 C2, publ. 20.11.2008), including cement M500, filler, water and basalt fiber modified with a substance selected from the group including polyhedral multilayer carbon nanostructures of the fulleroid type and multilayer carbon nanotubes, taken in the amount of 0 , 0001 – 0.005 parts by weight.per one wt.h. basalt fiber, and as a filler, the mixture contains a filler selected from the group including a mixture of gravel with sand and a mixture of gravel with aluminosilicate microspheres, and additionally the concrete mixture contains a plasticizer – sodium polynaphthalene methylene sulfonate in the following ratio of components (wt%): cement 24-48 , filler 30-60, modified basalt fiber 2-6, plasticizer 0.9-1.1, water – the rest.
However, the use in this invention of a plasticizer based on sodium polynaphthalene methylene sulfonate does not allow obtaining concrete with high grade strength and durability.
The prototype is a nanomodifier of building materials (RU 2482082 C2, publ. 02/20/2013), containing a carbon nanostructured material (CNM), a filler and a plasticizer, and CNM is introduced in the form of Taunit nanotubes, the mixture contains polyvinylpyrrolidone as a plasticizer, as a filler – polyethylene glycol PEG-1500 and additionally contains sodium bicarbonate and citric acid in the following ratio of components, wt%: CNM “Taunit” 0.1-8, polyvinyl pyrrolidone 0.1-8, sodium bicarbonate 5.5-11.5 , citric acid 5.5-11.5, polyethylene glycol PEG-1500 – the rest.
The use of this complex additive allows you to increase the strength of building materials. The disadvantage of this invention is the low mobility of the concrete mixture, the low strength of concrete in the early stages of hardening, as well as the low durability of the resulting concrete.
A known method for preparing a complex additive for a concrete mixture, which consists in the ultrasonic dispersion of carbon nanotubes “Taunit” in a solution of the plasticizer C-3 and an alcohol suspension (Gabidullin M.G., Khuzin A.F., Rakhimov R.Z. Ultrasonic treatment is an effective method for dispersing carbon nanotubes in the volume of a building composite. Stroitel’nye materialy. 2013. No. 3. S. 57-59).
The use of this mixture improves the strength of the concrete. The disadvantage is the low strength of concrete in the early stages of hardening.
The objective of the present invention is a sharp increase in the growth rate of concrete strength in the early stages of hardening, ensuring high grade strength, increasing frost resistance and water resistance, as well as a uniform distribution of CNM in its structure.
EFFECT: high strength characteristics of concrete in the early hardening period, high grade strength.
The result is achieved by the fact that in a complex additive for a concrete mixture containing a plasticizer and a carbon nanostructured material “Taunit” according to the invention, it contains a hyperplasticizer “Hyperlite” as a plasticizer, with the following ratio of components, wt.%:
Hyperlit plasticizer – 99.5-99.7
Carbon nanostructured material “Taunit” – 0.3-0.5.
The result is achieved by the fact that in the method of preparing a complex additive for a concrete mixture, which consists in the ultrasonic dispersion of the carbon nanostructured material “Taunit” in the plasticizer, according to the invention, the carbon nanostructured material is subjected to ultrasonic dispersion in the hyperplasticizer “Hyperlit” for 3-7 minutes using an ultrasonic generator UZG13-0.1 / 22. Ultrasonic dispersion is characterized by the following parameters: frequency 20.35-23.65 kHz, power 100 W, wavelength 0.127 10 5 -0.147 10 5 m.
For this complex additive, a carbon nanostructured material “Taunit” was used – coaxial multilayer carbon nanotubes with an outer diameter of 8-15 nm and a length of more than 2 microns. The number of layers of one tube is 6-10.
Hyperplasticizer “Hyperlite” – a copolymer based on polyoxyethylene derivatives of unsaturated carboxylic acids, is a light brown liquid, an aqueous solution with a dry matter content of 30-35%.
The complex additive was prepared using ultrasonic dispersion.Carbon nanostructured material “Taunit” was subjected to ultrasonic dispersion in a hyperplasticizer “Hyperlit” for 3-7 minutes using an ultrasonic generator UZG13-0.1 / 22 at the following ratio of components, wt.%:
Hyperplasticizer “Hyperlite” – 99.5-99.7
Carbon nanostructured material “Taunit” – 0.3-0.5.
Further, the additive was introduced into the concrete mixture in the form of an aqueous solution of working concentration with mixing water in an amount of 1-1.5% of the cement mass in terms of dry matter.
For the preparation of a concrete mixture of the production composition, cement M400 PC D20 of the Volsk plant was used, which meets the requirements of GOST 10178-85, sand from the Kamsko-Ustinsky deposit, which meets the requirements of GOST 8736-93 and GOST 8735-88, and crushed stone from the Kamsko-Ustinsky deposit, which meets the requirements of GOSTs for concrete, with the following ratio (mass.h.):
Cement: crushed stone: sand = 1: 1.31: 2.53
Water was added to the concrete mixture until equal mobility (class P2) was achieved in accordance with GOST 7473-94.The water-cement ratio of the composition without the additive was 0.43, with the complex additive – 0.32, with the additive according to the prototype – 0.36.
Samples were made of concrete mixtures – cubes with dimensions of 10 × 10 × 10. After 1, 3, 7, 28 days of normal hardening, the samples were subjected to mechanical tests. The strength of the samples was determined in accordance with GOST 18105-86, frost resistance – in accordance with GOST 10060.0-95, and water resistance – in accordance with GOST 12730.5-84.
Compositions of the complex additive and the results of mechanical tests of concrete are shown in the table.Were also carried out tests of concrete mix and concrete with an analogous additive and without an additive.
Based on the data obtained, it can be concluded that concrete with the use of a complex additive on the first day has a compressive strength higher by 87-131%, on the 3rd day – 50-58%, on the 7th day – 49-55%, and on the 28th day – 39-45% compared to the prototype. At the age of 28 days, frost resistance increases by 100 cycles, and water resistance – by one level.
The results obtained allow us to assert that the complex additive increases the rate of concrete strength gain in the early stages of hardening and makes it possible to achieve high final strength, frost resistance and water resistance.
1. Complex additive for concrete mix containing plasticizer and carbon nanostructured material “Taunit”, characterized in that the hyperplasticizer “Hyperlit” is used as a plasticizer, with the following ratio of components, wt%:
Hyperplasticizer “Hyperlite” – 99.5 -99.7,
Carbon nanostructured material “Taunit” – 0.3-0.5.
2. A method of preparing a complex additive, which consists in dispersing the carbon nanostructured material “Taunit” in a plasticizer, characterized in that the carbon nanostructured material is subjected to ultrasonic dispersion in a hyperplasticizer “Hyperlite” for 3-7 minutes using an ultrasonic generator UZG13-0.1 / 22.
Optimization of the composition of crushed stone-sand mixture treated with Portland cement in combination with a plasticizing and hydrophobizing additive
UDC 691: 624.138
Bulanov P.E. – graduate student
E-mail: [email protected]
Mavliev L.F. – assistant
E-mail: [email protected]
Vdovin E.A. – candidate of technical sciences, associate professor
E-mail: [email protected]
Kazan State University of Architecture and Civil Engineering
Address of the organization: 420043, Russia, g.Kazan, st. Green, d. 1
Optimization of the composition of crushed stone-sand mixture treated with Portland cement in combination with a plasticizing and water-repelling additive
A study of the effect of a complex additive based on the hyperplasticizer “Hyperlit” (GL) and the hydrophobizator octyltriethoxysilane (OTES) on the strength and frost resistance of crushed stone-sand mixture treated with Portland cement (SCHPCS) was carried out.Using the method of planning the experiment, the dependences of the influence of the consumption of Portland cement, the composition and dosage of a complex additive based on the hyperplasticizer GL and the water repellent OTES on the physical and mechanical properties of the material were obtained. The optimal dosages of additives for the production of SCHPTsS grade by strength M40, M60, M75 and frost resistance B50 have been revealed.
Keywords: SCHPTsS, composition optimization, physical and mechanical properties, hydrophobizator, hyperplasticizer.
Introduction. One of the most important factors affecting the durability of road pavements of highways is the increase in traffic speed, intensity and axle loads. This, in turn, leads to the accumulation of residual deformations in the layers of road structures, manifested in rutting, the appearance of a network of cracks and other types of destruction. As a result, the actual turnaround time is reduced in comparison with the normative ones, which requires an increase in the volume of repair work and additional financial investments.From the experience of recent years of operation of highways with high traffic intensity, in order to reduce the accumulation of residual deformations in the layers of road pavements, it is promising to use crushed stone-sand mixtures treated with Portland cement (SCHPTsS) grades M40, M60, M75 and M100 according to GOST 23558-94  …
Also of no small importance is the absence in many constituent entities of the Russian Federation of reserves of durable stone materials, the transportation of which leads to a significant increase in the cost of building highways.At the same time, world and domestic experience has proven the effectiveness and significant advantages of using hardened soils and processed materials in the construction of road pavements in comparison with the use of imported durable crushed stone [2, 3, 4].
However, ShchPTsS are susceptible to cracking under the influence of time-varying temperature and humidity factors and have low frost resistance .
The most promising direction in solving this problem is the modification of SCHPTsS with plasticizing [4, 5] and hydrophobizing additives .The experiments have shown that the use of the hyperplasticizer GL  is effective as a plasticizing additive, and the organosilicon compound OTES as a hydrophobizing agent . Therefore, the purpose of this work was to obtain the optimal composition of SCHPTsS with a complex additive based on the GL hyperplasticizer and the OTES hydrophobizator.
For research, very fine sand from the Imenkovsky quarry of the Republic of Tatarstan with a fineness module of 1.34 according to GOST 8736-93 and crushed stone from the Zhigulevsky deposit in the Samara region with a crushing grade of M400 fr.5-20 in accordance with GOST 8267-93. Portland cement (PC) CEM I 42.5N CJSC Ulyanovskcement was used as a binder in an amount of 5%, 7% and 9% of the mass of crushed stone-sand mixture (SCC). the highest indicators for the strength of the processed material. Hyperplasticizer GL was a copolymer based on polyoxyethylene derivatives of unsaturated carboxylic acids (manufactured by OOO SVAN). The OTES water repellent was an organosilicon liquid C8N1781 (OS2N5) 3 (manufactured by OOO Penta-91).The additives were introduced into the SCHPTsS from the mass of the PC.
The determination of the compressive strength of SCHPTsS was carried out on samples of 10x10x10 cm water-saturated for 2 days; The frost resistance coefficient was determined as the ratio of the strength of the sample after testing for repeated freezing and thawing to the strength of the sample before testing.The frost resistance coefficient was found after 50 freeze-thaw cycles. The samples were 28 days old at the time of testing.
The ultimate compressive strength of the control samples at a PC flow rate of 5%, 7% and 9% was 3.25 MPa, 4.56 MPa and 5.56 MPa, the ultimate tensile strength in bending was 0.74 MPa, 1.12 MPa and 1.38 MPa, the frost resistance coefficient is 0.49, 0.58 and 0.60, respectively.
Taking into account the above, we applied the method of mathematical planning of the experiment to optimize the composition of the SCHPTsS.The percentages were selected as variable factors: PC (X1), OTES (X2) and GL (X3). The main level and intervals of variation of factors are shown in the table.
Coded and natural variables
FIRST FACTOR SECOND FACTOR THIRD FACTOR
X1- PC X2-OTES X3 – GL
Basic value Basic value Basic value
X1o X2o X3o
7 0.3 0.6
Variation interval Variation interval Variation interval
DH1 DH2 DH3
2 0.15 0.3
As optimization parameters (response functions) the following are accepted:
ISZH – ultimate compressive strength, MPa;
Rasg – ultimate tensile strength in bending, MPa;
Kmor – coefficient of frost resistance.X32.
The calculated values of B – Fisher’s criterion (assessment of adequacy) for the functions Izz, Rasz, Kmor are equal to 1.80, respectively; 1.07; 3.10, i.e. less than the tabular value, which at a significance level of 5% is equal to 5.05. This indicates that the equations are adequate.
Based on the obtained regression equations, the response functions were constructed in the form of two-parameter dependencies. Figures 1-3 show the dependences of the ultimate compressive strength (ISI), the ultimate tensile strength in bending (Rsr) and the frost resistance coefficient (Kmor) on the content of OTES and GL additives at a PC consumption of 5%, 7% and 9%.
Fig. 1. Dependence of the ultimate compressive strength on the content of additives OTES and HP at a dosage of PC: a) 5%; b) 7%; c) 9%
Fig. 2. Dependence of the ultimate tensile strength in bending on the content of additives OTES and HP at a dosage of PC: a) 5%; b) 7%; c) 9%
Analysis of graphs fig. 1-3 showed the effectiveness of the complex introduction of the GL plasticizer and the OTES hydrophobizator into the SCHPTsS composition.
The complex introduction of additives led to an increase in the compressive strength up to 36%, 42.8% and 48.9% at a PC consumption of 5%, 7% and 9%, respectively. The greatest effect is achieved with the introduction of additives GL – 0.7% and OTES – 0.35% with a PC consumption of 5% and 7%, GL – 0.8% and OTES – 0.35% with a PC consumption of 9%.
At the same time, the ultimate tensile strength in bending increased to 27.0%, 19.6% and 15.9% at a PC consumption of 5%, 7% and 9%, respectively.The greatest effect is achieved from the introduction of additives GL – 0.7% and OTES – 0.35% at all the considered costs of the PC.
Fig. 3. Dependence of the frost resistance coefficient on the content of OTES and HP additives at a PC dosage: a) 5%; b) 7%; c) 9%
There was also an increase in the frost resistance coefficient up to 40.8%, 41.4% and 41.6% at a PC consumption of 5%, 7% and 9%, respectively. The greatest effect was achieved from the introduction of additives GL – 0.6% and OTES – 0.45% at all the considered costs of the PC.
Strength grade M40 was achieved with the introduction of a complex of additives GL – 0.6% and OTES – 0.15% with a PC consumption of 5%, M60 – 0.6% and 0.15% with a PC consumption of 7% and M75 – 0, 4% and 0.2% with a PC consumption of 9%, respectively. The frost resistance grade F50 with a PC content of 5% in combination with GL and OTES additives has not been obtained. With a PC consumption of 7%, the frost resistance grade F50 was achieved with the addition of GL additives – 0.4% and OTES -0.3%, with PC 9% – 0.3% and 0.2%, respectively.It should be noted that ShchPTsS with a PC consumption of 5% and a GL content of 0.3%, OTES 0.15% received a frost resistance grade F25.
Discussion of results
Analysis of the research results showed that the complex use of GL and OTES additives has a multifunctional effect: GL significantly affects the increase in strength, and OTES – frost resistance of SCHPTsS.
The increase in the strength of the SCHPTsS may be explained by the formation of a larger amount of calcium hydrosilicates with the introduction of the GL additive.This is due to the fact that water molecules dispersed in the spatial network of the hyperplasticizer play the role of microreactors for the synthesis of calcium hydrosilicates .
The increase in frost resistance is explained by the increased hydrophobicity of the material with the introduction of the organosilicon compound OTES due to the ongoing chemical adsorption by mineral particles and the formation of mono- or polymolecular water-repellent films on their surface .
Conclusion. Mathematical dependences of the influence of PC consumption, dosages of GL and OTES additives on the physical and mechanical properties of SCHPCS have been established. Optimal compositions of SCHPTsS with a strength and frost resistance grade M40 and F25 were obtained with a PC content of 5%, GL – 0.6%, OTES – 0.15%, M60 and F 50 with a PC content of 7%, GL – 0.6 %, OTES – 0.3%, M75 and F50 with PC content – 7%, GL – 0.4%, OTES – 0.2%.
List of bibliographic references
1.Matua V.P., Sizonets S.V. Investigation of the effect of stabilizing additives on the properties of crushed stone-sand mixtures fortified with mineral binders // New technologies, 2013, No. 1. – P. 50-55.
2. Bezruk V.М. Strengthening of soil in road and airfield construction. – M .: Transport, 1971. – 247 p.
3. Davidson D.T., Pitre G.L., Mateos M., George K.P. Moisture Strength and Compaction Characteristics of Cement-Treated Soil Mixtures // HRB Bulletin, 1962, no. 353.- P. 42-63.
4. Bulanov P.E., Vdovin E.A., Mavliev L.F. The influence of plasticizing additives on the physical and mechanical properties of road cement // Izvestiya KGASU, 2015, No. 1 (31). – S. 160-164.
5. Bazhenov Yu.M. Concrete technology. – Moscow: ASV Publishing House, 2011 .– 528 p.
6. Vdovin E.A., Stroganov V.F., Mavliev L.F., Bulanov P.E. Investigation of the influence of organosilicon compounds on the indicators of standard compaction and physical and mechanical properties of cement soil // Izvestiya KGASU, 2014, No. 4 (30). – S. 255-261.
7. Pimenov A.I., Ibragimov R.A. Izotov V.S. Influence of carbon nanotubes and the method of their introduction on the properties of cement compositions // Izvestiya vuzov. Construction, 2014, No. 6. – P. 26-30.
8.Vernigorova V.N., Kostin D.S., Sadenko D.S., Ulyanov D.V. On the interaction of superplasticizers and hyperplasticizers with water // Regional architecture and construction, 2010, No. 1. – P. 26-30.
9. Kalashnikov V.I., Moroz M.N. Highly hydrophobic multicomponent low-slag fine-grained concretes // Scientific Bulletin of VGASU, 2010, No. 1. – P. 106-112.
Vdovin E.A. – candidate of technical sciences, associate professor
E-mail: vdovin007 @ mail.ru
Bulanov P.E. – post-graduate student
E-mail: [email protected]
Mavliev L.F. – assistant
E-mail: [email protected]
Kazan State University of Architecture and Engineering
The organization address: 420043, Russia, Kazan, Zelenaya st., 1
The optimization of stone-sand mixture treated by portland cement in combination with plasticizer and water-repellent additive
One of the most important factors what affect on the durability of road surfacing to increase speed, intensity and axial loads. From the experience of the last years of operation of highways with heavy traffic, in the layers of road pavement promising is the use of crushed stone, sand mixtures treated with Portland cement.
Also of great importance is the absence in many regions of the Russian Federation reserves durable stone materials, transportation of which leads to a significant increase in the cost of road construction. At the same time global and domestic experience has proven efficacy and significant advantages of application in the construction of road pavement strengthening of soil and processed materials in comparison with using of imported durable rubble.
However, stone-sand mixtures treated Portland susceptible to cracking under the influence of time-varying temperature and humidity factors and have low resistance to frost.
The most promising direction in solving this problem is to modify the rubble-sand mixture, Portland cement treated by plasticizer and water-repellent additives. Therefore, the aim of this work was to obtain the optimal composition of rubble-sand mixture, Portland cement treated with a complex additive based on giperplasticizer “Giperlit” and water repellent octyltriethoxysilane strength and frost rubble-sand mixture treated with Portland cement.Using the method of experiment planning dependences influence consumption of Portland cement, the composition and dosage of supplements on the basis of a comprehensive hiperplasticiser and water repellent on the physical and mechanical properties of the material was determined.
Keywords: stone-sand mixture treated by portland cement, optimization of composition, physico-mechanical properties, water repellent, hiperplasticizer.
1.Matua V.P., Sizonec S.V. Influence of stabilizing additives on the properties of hardened mineral binders stone-sand mixtures // Novye tekhnologii, 2013, No. 1. – P. 50-55.
2. Bezruk V.M. Soil stabilization in road and airfield construction. – M .: Transport, 1971.-247 p.
3. Davidson D.T., Pitre G.L., Mateos M., George K.P. Moisture Strength and Compaction Characteristics of Cement-Treated Soil Mixtures // HRB Bulletin, 1962, no. 353.- P. 42-63.
4. Bulanov P.E., Vdovin E.A., Mavliev L.F. Influence of plasticizers on physical and mechanical properties of soil-cement for road purpose // Izvestiya KGASU, 2015, No. 1 (31). – P. 160-164.
5. Bazhenov Yu.M. Technology of concrete. – M .: Publishers ASV, 2011 .– 528 p.
6. Vdovin E.A., Stroganov V.F., Mavliev L.F., Bulanov P.E. The study of the influence of organosilicon compounds on the performance of standard seals and physico-mechanical properties of soil-cement // Izvestiya KGASU, 2014, No. 4 (30). – R. 255-261.
7. Pimenov A.I., Ibragimov R.A., Izotov V.S. Effect of carbon nanotubes and method of administration for properties of cement compositions // Izvestiya vuzov. Stroitelstvo, 2014, No. 6. – C 26-30.
8.Vernigova V.N., Kostin D.S., Sadenko D.S., Ulyanov D.V. High hydrophobic blended fine-graned concrete with low slag content // Regionalnaya arhitektura i stroitelstvo, 2010, No. 1. – P. 26-30.
9. Kalashnikov V.I., Moroz M.N. Highly hydrophobic multicomponent little slag finegrained concrete // Nauchnyy vestnik VGASU, 2010, No. 1. – P. 106-112.
porozendo Osteoporosis and Osteopathy 2072-26802311-0716 Endocrinology Research Center 10.14341 / osteo2016341-45Research ArticlePRESSRELEASE OF THE SYMPOSIUM “KEY FACTORS OF SUCCESS IN TREATMENT OF OSTEOPOROSIS. TREATMENT TO ACHIEVE THE GOAL “PASSED IN THE VIII ALL-RUSSIAN CONGRESS ON OSTEOPOROSIS IN KAZAN SEPTEMBER 10, 2016 (published in the journal” Effective Pharmacotherapy. Endocrinology “No. 4-5 2016, pp. 50-56, published with permission -151220161934145
Osteoporosis is a systemic disease characterized by a decrease in the mass of bone tissue, a violation of its microarchitectural structure and leading to an increase in the risk of fractures.Currently, special attention is paid to the search for the optimal method of osteoporosis therapy. On September 9, 2016, in Kazan, within the framework of the Russian Congress on Osteoporosis, Osteoarthritis and Other Metabolic Diseases of the Skeleton, a satellite symposium of the Amgen company was held. The event featured reports from Russian and foreign experts on practical issues of osteoporosis treatment and fracture prevention. In particular, the advantages of using modern antiresorptive drugs are considered.
KEY FACTORS OF SUCCESS IN TREATMENT OF OSTEOPOROSIS: TREATMENT TO ACHIEVE THE GOAL Professor of Columbia University (USA), Ph.D. John BILEZiKiAN focused the audience’s attention on changing the strategy of osteoporosis therapy. It is based on the principle of “treatment to achieve the goal”, that is, when developing tactics for managing patients, it is necessary to determine clinically significant endpoints, the achievement of which will improve the outcome of the disease. This strategy proved to be most effective in the treatment of chronic diseases such as diabetes mellitus, arterial hypertension, hyperlipidemia, and rheumatoid arthritis.However, it must be stated that for osteoporosis, clear target values of therapy have not yet been determined. Since osteoporosis is a systemic skeletal disorder characterized by a decrease in bone strength, which increases the risk of fractures1, and bone strength is determined by its density and quality, it is logical to assume that treatment should help achieve optimal bone density, quality and strength. This, in turn, will reduce the risk of osteoporotic fractures.Current recommendations for the treatment of postmenopausal osteoporosis include identifying and treating patients at risk to prevent such fractures2. Determining the target values of osteoporosis therapy is important for its individualization (depending on the risk of fractures and / or indicators of bone mineral density (BMD)), assessing the benefit / risk ratio, simplifying decisions about changing or canceling therapy, and increasing patient compliance with treatment3 … The speaker noted that there are potential limitations to achieving target values.For example, setting one target value can lead to underestimation of other potential risk factors. A borderline target does not guarantee a comparable reduction in fracture risk across patients. It is not decided what to do when the patient reaches the target values. In addition, when implementing the modern concept of treatment, it is necessary to take into account such problems of clinical practice as insufficient diagnosis and therapy of osteoporosis, as well as non-compliance with its regimen. Currently, the criteria of the World Health Organization are used to diagnose osteoporosis.In accordance with them, BMD values deviating from the peak bone mass (T-test) by less than 1 standard deviation (SD) are regarded as normal, by -1-2.5 SD – as osteopenia, by more than -2 , 5 SD – like osteoporosis. In the course of numerous studies, a significant correlation has been established between the decrease in BMD and the risk of fractures. The results of the FLEX study, which assessed the dynamics of BMD after ten years in groups of patients who continued to take alendronate during the entire observation period or transferred to placebo after the first five years of active treatment, demonstrated the dependence of the incidence of clinical bone fractures and BMD of the proximal femur, achieved after five years of anti-osteoporotic drug therapy.Thus, the risk of fractures in those who continued taking alendronate was significantly lower4. At the same time, a more significant increase in BMD in the spine and hip during therapy is associated with a decrease in the risk of vertebral fracture5. For the treatment of osteoporosis, antiresorptive drugs are used, the leading place among which is occupied by bisphosphonates and denosumab. To date, data have been obtained on the efficacy and safety of long-term continuous use of denosumab – for eight years (extended phase of the FREEDOM study).Such therapy was associated with a continued increase in BMD of the spine and hip and a decrease in the risk of extravertebral fractures compared with placebo therapy6. Taking denosumab for eight years allows women with osteoporosis to achieve non-osteoporotic T-scores. Research results indicate the need to continue the treatment of osteoporosis with denosumab after reaching the target. Thus, after the termination of the use of the drug, the parameters of the BMD of the lumbar spine are significantly reduced and restored after the resumption of use7.Professor J. Bilezikyan emphasized that primary fractures in osteoporotic patients are associated with a high risk of future fractures. A number of studies have recorded serious osteoporotic fractures within five years after fractures of the hip, shoulder or clinics No. 3/2016 Osteoporosis and osteopathy of vertebral fractures. After a fracture of any localization, the risk of a second fracture doubles8-9.In conclusion, the speaker noted that when choosing a drug, it is necessary to take into account the characteristics of each patient: the presence of risk factors for fractures, BMD indicators, markers of bone resorption. The physician’s job is to assess the short-term and long-term likelihood of a fracture and, based on this, make a decision about treatment. In some cases, conventional oral bisphosphonate treatments are ineffective. Patients at high risk of osteoporotic fractures, including recurrent fractures, are indicated for continuous long-term treatment with an effective antiresorptive agent such as denosumab.1. Osteoporosis prevention, diagnosis, and therapy // NIH Consens. Statement 2000. Vol. 17. No. 1. P. 1-45. 2. Kanis J. A., McCloskey E., Branco J. et al. Goal-directed treatment of osteoporosis in Europe // Osteoporos. Int. 2014. Vol. 25. No. 11. P. 2533-2543. 3. Lewiecki EM., Cummings S.R., Cosman F. Treat-to-tar-get for osteoporosis: is now the time? // J. Clin. Endocrinol. Metab. 2013. Vol. 98. No. 3. P. 946-953. 4. Bauer D. C., Schwartz A., Palermo L. et al. Fracture prediction after discontinuation of 4 to 5 years of alendronate therapy: the FLEX study // JAMA Intern.Med. 2014. Vol. 174. No. 7. P. 1126-1134. 5. Wasnich R.D., Miller P.D. Antifracture efficacy of antire-sorptive agents are related to changes in bone density // J. Clin. Endocrinol. Metab. 2000. Vol. 85. No. 1. P. 231-236. 6. Papapoulos S., Lippuner K., Roux C. et al. The effect of 8 or 5 years of denosumab treatment in postmenopausal women with osteoporosis: results from the FREEDOM extension study // Osteoporos. Int. 2015. Vol. 26. No. 12. P. 2773-2783. 7. Miller P.D., Bolognese M.A., Lewiecki E.M. et al.Effect of denosumab on bone density and turnover in postmenopausal women with low bone mass after long-term continued, discontinued, and restarting of therapy: a randomized blinded phase 2 clinical trial // Bone. 2008. Vol. 43. No. 2. P. 222-229. 8. Van Geel T.A., Huntjens K.M., van den Bergh J.P. et al. Timing of subsequent fractures after an initial fracture // Curr. Osteoporos. Rep. 2010. Vol. 8. No. 3. P. 118-122. 9. Ryg J., Rejnmark L., Overgaard S. et al. Hip fracture patients at risk of second hip fracture: a nationwide population-based cohort study of 169,145 cases during 1977-2001 // J.Bone Miner. Res. Vol. 24. P. 1299-1307. LONG-TREATMENT OF OSTEOPOROSIS: DATA OF CLINICAL STUDIES Professor of the Department of Family Medicine, Northwestern State Medical University named after I.I. Mechnikova, President of the Russian Osteoporosis Association, MD Olga Mikhailovna Lesnyak presented the results of clinical studies on the efficacy and safety of long-term treatment of osteoporosis. Olga Mikhailovna noted that osteoporosis, like other chronic diseases, requires long-term treatment.When choosing a drug, it is necessary to analyze the data on its safety and the preservation of the clinical effect for a long time. Numerous studies confirm the feasibility of long-term treatment with denosumab. The optimal regimen is 60 mg s / c once every six months. The effectiveness of denosumab in postmenopausal osteoporosis was studied in the FREEDOM study. The first part of the FREEDOM study, which lasted three years, showed that against the background of treatment with denosumab at a dose of 60 mg sc, the BMD in the spine, the total hip, and the femoral neck increased compared to taking placebo.The extended phase of the FREEDOM study (extension) included 4550 women who completed the study: 2343 of them continued to take denosumab (data for ten years), 2207 were switched from placebo to denosumab (data for seven years). In the patients of the first group, the increase in BMD continued in all parts of the skeleton. Thus, the average increase in BMD over ten years was 21.6% in the spine and 9.1% in the hip. In patients of the second group, the frequency of vertebral and femoral fractures decreased6. According to the researchers, the annual incidence of vertebral and extravertebral fractures during treatment with de-nosumab remained low throughout the observation period.There was also a low incidence of adverse events, including serious ones. Previously unreported side effects were not observed10. In the FREEDOM study, the denosumab and placebo groups experienced a comparable number of side effects. In the extended phase of the study, their number did not increase. Of particular interest is the analysis of the incidence of various infections during therapy with denosumab. This is due to the fact that RANK (Receptor Activator of Nuclear Factorkappa B) and RANK ligand (RANKL) are expressed not only by bone tissue cells, but also by cells of the immune system, including activated T- and B-lymphocytes, dendritic cells, which implies a change in their functions while using denosumab.According to the FREEDOM study, the total number of infectious complications in the denosumab group was no higher than in the placebo group. Serious infections of the abdomen, urinary tract, and ear were observed in patients receiving denosumab in the first part of the study, but there was no increase in the risk of sepsis or death. With an increase in the duration of therapy, the incidence of side effects decreased. Cases of hypocalcemia have been reported during therapy with denosumab. For its prevention, all patients should receive calcium and vitamin D preparations.It should be noted that the presence of hypocalcemia is a contraindication to the use of the drug. In the extended phase of the study, eight cases of severe symptomatic hypocalcemia were recorded, which quickly resolved after the administration of calcium supplements with vitamin D. At the same time, seven out of eight patients suffered from severe renal failure. In the extended phase of the FREEDOM study, the development of osteonecrosis of the mandible was confirmed in four cases: in two in patients who started treatment with de-nosumab, and in two in patients who continued to use it.In addition, denosumab did not slow down fracture consolidation and did not increase the risk of developing cancer. Despite the fact that denosumab and bisphosphonates belong to the same group of drugs, their mechanisms of action differ significantly. Denosumab is a fully human recombinant anti-RANKL IgG2 monoclonal antibody. RANKL is a cytokine of the tumor necrosis factor family. It is the main bone resorption protein produced by osteoblasts. Denosumab binds and inhibits RANKL, prevents it from binding to RANK, and also inhibits osteoclast formation, activity and survival.42 No. 3/2016 Osteoporosis and Osteopathy CONGRESS NEWS Bisphosphonates do not affect RANK, RANKL, they bind to bone tissue and are absorbed by osteoclasts. Accumulating in mitochondria, the substance disrupts the energy balance of the cell and accelerates its apoptosis. Unlike bisphosphonates, denosumab circulates in the blood and intercellular fluid for six months. This explains its more pronounced clinical effect11-12. Further, the speaker presented the results of two comparative multicenter randomized trials of denosumab with bisphosphonate alendronate – DECIDE and STAND.The DECIDE study involved postmenopausal women who had not previously received treatment. The study found that denosumab therapy is characterized by a more pronounced increase in hip BMD compared with alendronate therapy13. In the STAND study, involving patients with postmenopausal osteoporosis and low BMD, there was a higher increase in BMD and a decrease in markers of bone resorption in the group switched to denosumab compared to the group continued with alendronate therapy.Denosumab and alendronate had similar safety profiles14. A phase III study was conducted to assess the effectiveness of switching to denosumab or ibandronate in postmenopausal women who previously received suboptimal daily or weekly bisphosphonate therapy. The main endpoints were the assessment of the safety of therapy, the percentage change in BMD of the hip, hip and lumbar spine by 12 months of therapy from baseline, as well as the percentage change in the level of markers of bone resorption after one and six months from baseline15.The data obtained confirmed the ability of Denosumab to quickly and significantly inhibit bone resorption, as well as significantly increase the BMD level in all parts of the skeleton. The groups did not differ in the number of side effects, with the exception of cases of eczema, hypersensitivity and gastrointestinal disorders. There were more of them in the group of patients taking denosumab. Another comparative phase III study examining the efficacy of switching to denosumab or risedronate in postmenopausal women who are not sufficiently adherent to alendronate therapy, demonstrated a more pronounced positive dynamics of BMD of the hip, femoral neck and lumbar spine by 12 months from baseline in the denosumab group compared with the risedronate group16.The use of denosumab for six months led to a rapid decrease in markers of bone resorption – by an average of 60.6%. Often, when oral bisphosphonates are ineffective, patients are switched to one of the intravenous bisphosphonates because they are believed to be more effective. In clinical practice, zoledronic acid is the most widely used. Comparison of the effectiveness of denosumab and zoledronic acid was carried out in a double-blind, randomized study.It included 643 patients with postmenopausal osteoporosis who received oral bisphosphonates for at least two years. The participants were randomized into two groups. The first received denosumab at a dose of 60 mg s.c. once every six months, the second – zoledronic acid at a dose of 5 mg i.v. once a year. At 12 months, the increase in BMD was significantly higher in the denosumab group. The decrease in serum C-telopeptide and N-terminal procollagen type 1 propeptide in the denosumab group was also more significant than in the zoledronic acid group.The incidence of side effects in both groups was similar. Cases of mandibular osteonecrosis, hypocalcemia, and delayed fracture consolidation were not reported. Three atypical hip fractures were recorded: two in the denosumab group and one in the zoledronic acid group17. Thus, denosumab, which is a monoclonal antibody RANKL, is a powerful anti-resorptive drug, the inhibitory effect of which on bone resorption leads to an increase in BMD in all parts of the skeleton and a decrease in the risk of fractures.The reversibility of the mechanism of action necessitates long-term and possibly permanent use. The effectiveness of the drug remains high throughout the entire period of use with a good safety profile. 10 Bone H.G., Brandi M.-L., Brown J.P. et al. Ten years of denosumab treatment in postmenopausal women with osteoporosis: results from the FREEDOM extension trial // American Society of Bone and Mineral Research Meeting, 2015. Baron R., Ferrari S., Russell R.G. 11 Baron R., Ferrari S., Russell R. G. Denosumab and bisphosphonates: different mechanisms of action and effects // Bone. 2011. Vol. 48. No. 4. P. 677-692. 12 KostenuikPJ., NguyenH.Q., McCabe J. et al. Denosumab, a fully human monoclonal antibody to RANKL, inhibits bone resorption and increases BMD in knock-in mice that express chimeric (murine / human) RANKL // J. Bone Miner. Res. 2009. Vol. 24. No. 2. P. 182-195. 13 Brown J.P., Prince R.L., Deal C. et al. Comparison of the effect of denosumab and alendronate on BMD and biochemical markers of bone turnover in postmenopausal women with low bone mass: a randomized, blinded, phase 3 trial // J.Bone Miner. Res. 2009. Vol. 24. No. 1. P. 153-161. 14 Kendler D.L., Roux C., Benhamou C.L. et al. Effects of denosumab on bone mineral density and bone turnover in postmenopausal women transitioning from alendronate therapy // J. Bone Miner. Res. 2010. Vol. 25. No. 1. P. 72-81. 15 Recknor C., Czerwinski E., Bone H.G. et al. Denosumab compared with ibandronate in postmenopausal women previously treated with bisphosphonate therapy: a randomized open-label trial // Obstet. Gynecol. 2013. Vol. 121. No. 6. P.1291-1299. 16 Roux C., Hofbauer L.C., Ho P.R. et al. Denosumab Vol. 58. P. 48-54. 17 Miller P., Pannacciulli N., Brown J. et al. A randomized double-blind study of denosumab compared with zoledronic acid in postmenopausal women with osteoporosis previously treated with oral bisphosphonate // Arthritis Rheumatol. 2015. Vol. 67. Suppl. 10. P. 1181. Abstr. 898. CLINICAL EXPERIENCE OF APPLICATION PROLIA (DENOSUMAB) Chief Researcher, Department of Neuroendocrinology and Osteopathy, Endocrinological Research Center, Ministry of Health of Russia, Dr.MD, Professor Lyudmila Yakovlevna ROZHINSKAYA presented data from her own observations of the use of denosumab in clinical practice. There were 144 patients under observation who used the drug Prolia from one to four years. The overwhelming majority of patients were women with postmenopausal osteoporosis at the age of 54-91 years, of which 73% with previous fractures. Another group included 27 postmenopausal women and men over 50 years of age with osteoporosis and primary hyperparathyroidism (PHPT). Of these: in 7 – an unspecified topic of formation of the parathyroid glands, in 5 – a relapse of a mild course after the first operation, in 15 – a refusal from the operation or contraindications due to concomitant diseases.The patients’ age is 63 – 92 years old. 10 of them received cinacalcet. The department 43 NEWS TO CONGRESS № 3/2016 Osteoporosis and osteopathy group of patients included 10 women aged 54-75 years with postmenopausal osteoporosis, who had a history of estrogen-dependent breast cancer and received therapy with aromatase inhibitors. Three of them had previously suffered a fracture. Another five postmenopausal women with fractures of the vertebral bodies who took glucocorticosteroids, and six men with senile osteoporosis with previous fractures at the age of 76-92 years were observed.In 45 out of 144 patients with a history of chronic kidney disease III-II stage – the glomerular filtration rate (GFR) 55-24 ml / min. One patient was on hemodialysis, two patients with severe osteoporosis after kidney allotransplantation. In 90 patients, the level of BMD was measured in dynamics, in all patients – the level of calcium, creatinine, phosphorus, alkaline phosphatase. Vitamin D was measured at baseline in 60% (85) of patients. The level of bone resorption markers in dynamics was determined in 65% (93) patients. Denosumab was prescribed as primary therapy in 15% of patients, the rest received various bisphosphonates for two to eight years, before the appointment of denosumab.Three patients were treated with strontium ranelate and three with teriparatide. Vitamin D supplements are recommended for all patients, calcium supplements are recommended for patients without PGPT. If there was a confirmed deficiency or deficiency of vitamin D, they were corrected before the initiation of denosumab therapy. Initially, none of the patients had hypocalcemia. Analysis of the results of treatment with denosumab showed a decrease in markers of bone resorption in the first three to six months in almost all patients – from 0.353-0.96 to 0.09-0.01 ng / ml, regardless of diagnosis, gender and age.The increase in BMD in the vertebrae ranged from 2.5 to 6.8% per year, in the femoral neck – from 1.8 to 3%. In patients with PHPT, the increase in BMD in the radius in the second year of treatment is from 1.3 to 2.1%. The BMD level did not increase in three patients with glucocorticosteroid osteoporosis, in a patient on hemodialysis. At the same time, the loss of BMD in patients taking glucocorticoids was not recorded. Of the entire sample, one patient with postmenopausal osteoporosis had a fracture of the radius (falling on ice) and one surgical fracture of the shoulder neck five months after the first injection of denosumab.There was no decrease in growth during the observation period. Denosumab therapy was characterized as safe and well tolerated. Among the adverse events, skin reactions were encountered in two patients with postmenopausal osteoporosis, which required discontinuation of treatment. One patient experienced an increase in bone and back pain, which caused her to refuse a second injection of the drug. A 92-year-old patient did not want to continue therapy after three injections of denosumab due to fear of cataract progression.Hypocalcemia, including in patients with chronic kidney disease, decreased GFR and increased creatinine levels were not observed. Further, Professor L.Ya. Rozhinskaya analyzed several clinical cases. Clinical case 1. Patient T., 88 years old, with complaints of back pain, menopause since 42 years old. Family history of hip fracture in his father at the age of 82. Osteoporosis was diagnosed ten years before treatment, a fracture of the radius at 70 years old, a humerus at 72 years old, compression fractures of the vertebral bodies at 75 years old were established during examination.In 2006, the BMD in L1-L4 was 3.5% SD according to the T-criterion, the femoral neck was 3.0%. The patient received treatment for three years with alendronate, then for three years with ibadronat. In the first years of therapy, an increase in BMD of up to 4% in the vertebrae and up to 2.5% in the hip was noted. In 2012, a decrease in the level of vitamin D to 10.6 ng / ml was recorded. Added colecalciferol. In 2013, the patient suffered three falls and a fracture of the left radius. The densitometry results showed a negative dynamics of the BMD level. Upon further examination: calcium, phosphorus, creatinine, alkaline phosphatase, calcium in daily urine – normal, vitamin D – 18.2 ng / ml, bone resorption marker – normal, osteocalcin – 32.4 ng / ml.Radiographs of the vertebrae show a decrease in the height of Th22 to the third degree. The patient was diagnosed with postmenopausal osteoporosis, severe form with fractures of the vertebral bodies, both radial bones, humerus, negative dynamics during therapy with bisphosphonates. She was prescribed colecalciferol 50,000 IU per week for six weeks, followed by a maintenance dose of 15,000 IU per week, calcium carbonate – one tablet after dinner, Prolia 60 mg sc once every six months. Three months after the first injection of Prolia, there was a significant decrease in the marker of bone resorption – 0.08 ng / ml (by 78%), an increase in the level of vitamin D – up to 31 ng / ml, all other indicators were normal.No adverse events were observed during treatment. Six months after the start of therapy, the patient noted an improvement in her general condition, absence of back pain, and increased motor activity. A year later, the target values of vitamin D were maintained, and the level of bone resorption markers continued to decrease. Increase in BMD in the vertebrae by 3.2%, in the femur by 3.4%. No new fractures or a decrease in growth were recorded. After three years of treatment, no new fractures were noted, the patient continues to be active.BMD in the vertebrae + 8.4%, in the femur + 4.7%. It was recommended to continue treatment with Prolia, colecalciferol 15,000 IU per week, CalceminAdvance, one tablet after dinner. Clinical case 2. Patient Sh., 76 years old, complains of pain in the hip joints and weakness in the legs. History: coronary heart disease, unstable angina pectoris, two stentings of the coronary arteries (1999 and 2012), grade 3 arterial hypertension. Widespread spondyloarthrosis with severe secondary radicular syndrome, coxarthrosis.In 2011, osteoporosis without fractures was diagnosed, the BMD level decreased to -2.8 SD according to the T-criterion. In the spine, there was no decrease in BMD, in the radius – 3.6 SD. Examination revealed a hypercalcemia of 2.6-2.75 mmol / l, an increase in the level of parathyroid hormone – 180 pg / ml, a marker of bone resorption and osteocalcin. During the ultrasound examination (ultrasound), hyperplasia of three parathyroid glands with a size of 0.9 * 0.7 to 1.2 * 0.9 cm, calculi in the kidneys up to 0.6 cm without a clinic of urolithiasis were revealed.The patient was diagnosed with HGPT with hypercalcemia, hypercalciuria, hyperplasia of the three parathyroid glands, osteo-visceral form (osteoporosis without fractures, nephrolithiasis), mild course. In 2011, a drip infusion of zoledronic acid was prescribed at a dose of 5 mg once a year. Against the background of Aklasta’s injections in December 2012, there was an increase in BMD in the femur up to 4%, there were no changes in the vertebrae and radius. In 2014, after three years of treatment with zoledronic acid, a negative dynamics of the BMD level was recorded in the femoral neck – -5.2%, in the radius – -2.4%.Six months after administration of zoledronic acid, there was no decrease in bone resorption markers. The level of calcium in the blood remained in the range of 2.68-2.71 mmol / l. The level of parathyroid hormone is 208-230 pg / ml. 44 № 3/2016 Osteoporosis and Osteopathy CONGRESS NEWS It was decided to prescribe the patient Prolia in a dose of 60 mg sc once every six months since March 2014. To date, the patient has received five injections, the last one in March 2016. In April 2016, an examination was carried out: calcium – 2.55 mmol / l (upper limit of the norm), parathyroid hormone – 166 pg / ml, phosphorus – 1.01 mmol / l, marker of bone resorption – 0.069 ng / ml, osteocalcin – 14 ng / ml, calcium in urine – 8 mmol / day, vitamin D – normal.The results of densitometry showed an increase in BMD in the spine by 8.4%, in the femoral neck by 4.6%, in the middle third of the radius by 2.6%. Ultrasound of the parathyroid glands and kidneys – no negative dynamics. The patient continues therapy with denosumab. Clinical case 3. Patient A., 58 years old. There are no active complaints. In 2011, she underwent thyroidectomy, radioiodine therapy for papillary thyroid cancer. Until 2016, she received suppressive doses of thyroid hormones, then replacement therapy. In 2013 – right-sided mastectomy, radiation therapy followed by the use of the aromatase inhibitor Arimidex.In January 2014, the patient suffered a low-traumatic fracture of the left radius. Analytical data: calcium – 2.31 mmol / l, vitamin D – 17.1 ng / ml, creatinine – 55 µmol / l, calcium in urine – 3.69 mmol / day. There is a slight increase in the level of beta-crosslapse (0.74 ng / ml), a decrease in the level of thyroid-tropic hormone (TSH) to 0.009 mU / L. Free thyroxine – 16 pmol / l, thyroilobulin – 0.1 ng / ml. According to densitometry data: BMD L1-L4 – -3.2%, femoral neck – -1.9%, right radius (33% radius) – -2.9%.No decrease in growth was noted. Lateral radiographs of the spine showed no decrease in the height of the vertebral bodies. The patient was diagnosed with postoperative hypothyroidism, compensation after thyroidectomy and radioiodine therapy for thyroid cancer, condition after right-sided mastectomy and radiation therapy for estrogen-dependent cancer, therapy with aromatase inhibitors. Osteoporosis of mixed genesis without fractures with a maximum decrease in the BMD level in the vertebrae to -3.2 CO according to the T-criterion, fracture of the radius, vitamin D deficiency.In this clinical case, the risk factors for the development of osteoporosis and fractures were the patient’s low body weight (height 158 cm, body weight 53 kg), low calcium intake, suppressive therapy with levothyroxine and aromatase inhibitors. Since March 2014, the patient has been prescribed Prolia in a standard dose once every six months. Six injections were performed, the last one in September 2016. 1000 mg of calcium daily, 30,000 IU of col-calciferol once a week were also recommended (later the dose was reduced to 5000 IU).The results of the examination after two years of therapy with denosumab (May 2016): the level of calcium, creatinine, vitamin D is normal, markers of bone resorption remain within 0.06 ng / ml, TSH – 0.9 mU / l, parathyroid hormone – 36, 5 pg / ml. According to densitometry data, the BMD values for two years of therapy with Prolia in the spine changed from -3.2 to -2.7%, in the femoral neck from -1.9 to -1.6%, in the right radius – s-2. 9 to -2.8%. Tamoxifen has been known to be the mainstay of breast cancer therapy for decades.To date, aromatase inhibitors have been proven to be effective in preventing the recurrence of estrogen-dependent breast cancer18. They are increasingly included in standard breast cancer treatment regimens as they have a better safety profile than tamoxifen19. However, their use in the postmenopausal period is accompanied by an increase in bone remodeling, which leads to a decrease in BMD and an increase in the frequency of fractures. Therefore, osteomodifying drugs should be added to the treatment regimen for such patients.A number of studies have proven the effectiveness of denosumab for preventing BMD loss and reducing the risk of fractures in patients taking aromatase inhibitors for a long time20. At the end of his speech, Professor L.Ya. Rozhinskaya emphasized that indications for the use of the drug Pro-Lia (denosumab) are postmenopausal osteoporosis, senile osteoporosis in men, bone loss in women receiving therapy with aromatase inhibitors for breast cancer, and in men receiving hormone-deprivation therapy. …18 Cheung K.L. Endocrine therapy for breast cancer: an overview // Breast. 2007. Vol. 16.No. 4. P. 327-343. 19 Carpenter R., Miller W.R. Role of aromatase inhibitors in breast cancer // Br. J. Cancer. 2005. Vol. 93. Suppl. 1. S1-S5. 20 Ellis G. K., Bone H. G., Chlebowski R. et al. Randomized trial of denosumab in patients receiving adjuvant aromatase inhibitors for nonmetastatic breast cancer // J. Clin. Oncol. 2008. Vol. 26. P. 4875-4882. CONCLUSION Drug therapy for osteoporosis prevents further bone loss in patients with osteoporosis, improves the microarchitectonics of bones, and increases their strength.As part of the drug Prolia – an inhibitor of bone resorption denosumab. Denosumab is a fully human monoclonal antibody, a highly specific RANKL inhibitor. It suppresses the formation, reduces the functioning and survival of osteoclasts. Against the background of the use of denosumab, the intensity of bone resorption decreases. To date, data have been obtained on the effectiveness and safety of long-term continuous use of denosumab. Denosumab therapy increases the level of BMD not only in the trabecular bone, but also in the cortical bone.At the same time, positive dynamics is noted early and increases over time. De-nosumab suppresses markers of bone resorption. Their stably lowered level persists for up to six months. Prolia is intended for the treatment of postmenopausal osteoporosis. It has also been shown to be effective in preventing fractures in men receiving androgen deprivation therapy for prostate cancer. In addition, denosumab reduces the risk of new vertebral fractures in women receiving treatment for hormone-dependent breast cancer without skeletal metastases.Prolia is well tolerated and safe.
(PDF) ACTOVEGIN® IN THERAPY OF SUBCLINICAL DISTAL SYMMETRICAL SENSOR-MOTOR POLYNEUROPATHY IN 2ND TYPE DIABETES MELLITUS
DISEASES PERIPHERAL3 ®
significant differences were found in the indicators of SRV (p = 0.03) and RL
(p = 0.01) for the peroneal nerve, the amplitude of the M-response
(p = 0.01) and SRV (p = 0 02) for the tibial nerve,
amplitudes of the S-response (p = 0.002) and CPV (p = 0.01) for the calf
of the leg nerve.
From a clinical and pathophysiological point of view,
does not raise doubts that Actovegin®, which has an antihypoxic and
antioxidant effect, can be widely used
for such a widespread neurological complication of diabetes as diabetic polyneuropathy.
Of particular interest is its ability to influence
the state of peripheral nerves in subclinical
form of DPN, when there is only a change in the morphological
and electrophysiological characteristics of peripheral nerves, but the clinic of the beta
has not yet been formed. polyneuropathy.The number of diabetic patients in the entire
world is rapidly increasing, type 2 diabetes
is “getting younger”, and treatment is usually prescribed on
on the background of an already formed rather pronounced lesion of peripheral nerves. The study of the
efficacy of treatment with Actovegin® at the stage of subclinical
diabetic polyneuropathy opens
new perspectives for preventing disability in
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