Discriminatory ability of quantitative ultrasound measurements is similar to dual-energy X-ray absorptiometry in a Brazilian women population with osteoporotic fracture

Validation of Quantitative Ultrasonography for Osteoporosis Diagnosis in Postmenopausal Women Compared to Dual-Energy X-Ray Absorptiometry (DEXA)

Introduction Bone mineral density (BMD) is an essential indicator for diagnosing osteoporosis and evaluating the success of osteoporotic treatment. Dual-energy X-ray absorptiometry (DEXA), quantitative ultrasonography (QUS), and quantitative computed tomography (QCT) are frequently used for measuring BMD. The objective of the study was to evaluate the ability of QUS to screen for osteoporosis and bone density in postmenopausal women by calibrating it against DEXA.  Methods This cross-sectional study was conducted at the Department of Orthopedics and Trauma Center of the tertiary care center, Lucknow. A total of 90 patients visited this department from August 2017 to July 2018 for the present study. BMD in the same patient was evaluated by using DEXA and ultrasonography methods. Data were entered in Microsoft Excel and analyzed by using SPSS Software.  Results According to linear regression analysis, T neck was found statistically significant with T QUS (p<0.001) and z QUS (p<0.001). T lumbar and T wrist were found statistically significant with T QUS (p<0.001) but not with z QUS (p>0.001). Z neck was found statistically significant with T QUS (p<0.001) and z QUS (p<0.001). Z lumbar was found statistically significant with T QUS (p<0.001) but not with z QUS (p>0.005). Z wrist was not found statistically significant with T QUS (p>0.005) or with z QUS (p>0.005). Conclusion In the present study, we found that QUS can be used as a screening tool for detecting osteoporosis by measuring BMD in contrast to DEXA. QUS also can be used to predict the DEXA values for osteoporosis and to detect osteoporosis.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk: An Update

Quantitative ultrasound (QUS) presents a low cost and readily available alternative to DXA measurements of bone mineral density (BMD) for osteoporotic fracture risk assessment. It is performed in a variety of skeletal sites, among which the most widely investigated and clinically used are first the calcaneus and then the radius. Nevertheless, there is still uncertainty in the incorporation of QUS in the clinical management of osteoporosis as the level of clinical validation differs substantially upon the QUS models available. In fact, results from a given QUS device can unlikely be extrapolated to another one, given the technological differences between QUS devices. The use of QUS in clinical routine to identify individuals at low or high risk of fracture could be considered primarily when central DXA is not easily available. In this later case, it is recommended that QUS bone parameters are used in combination with established clinical risk factors for fracture. Currently, stand-alone QUS is not recommended for treatment initiation decision making or follow-up. As WHO classification of osteoporosis thresholds cannot apply to QUS, thresholds specific for given QUS devices and parameters need to be determined and cross-validated widely to have a well-defined and certain use of QUS in osteoporosis clinical workflow. Despite the acknowledged current clinical limitations for QUS to be used more widely in daily routine, substantial progresses have been made and new results are promising.

Clinical Conformity Between Heel Ultrasound and Densitometry in Postmenopausal Women: A Systematic Review

OBJECTIVES

To assess the conformity between heel ultrasound and densitometry, and the clinical application of densitometry T-score "gold standard" in quantitative ultrasound as a method of osteoporosis diagnosis in postmenopausal women.

METHODS

The study is a systematic review of studies published in the last 17 years in PubMed, NLM Gateway, Medline, Embase, and Cochrane Library. Calcaneal quantitative ultrasound sensitivity and specificity were analyzed with regard to densitometry measurements in postmenopausal women. In addition, we summarized the values of ultrasound T-scores, for which their accuracy in osteoporosis diagnosis is the highest.

RESULTS

The inclusion criteria met 15 research studies conducted on postmenopausal women. In 11 of them, the authors concluded that clinical conformity between heel ultrasound and densitometry is good. The recommended quantitative ultrasound T-score for osteoporosis diagnosis ranged between -1 and -3.65.

CONCLUSIONS

Heel ultrasound should be considered to be as accurate as densitometry in diagnosing osteoporosis. Nevertheless, it needs to have separate T-score ranges determined, because those used in densitometry are not adequate.

Primary and secondary osteoporotic fractures prophylaxis: evaluation of a prospective cohort

OBJECTIVE

To measure the prevalence of primary drug prevention of fractures due to osteoporosis in patients admitted to a tertiary teaching hospital, in a medium-sized city, admitted with osteoporotic fractures. Moreover, to identify the incidence of prescribing secondary prophylaxis after the first fracture event. At the same time, the prevalence of risk factors for such fractures as described in the literature was measured.

METHODS

This longitudinal prospective study was based on a cohort of patients admitted in a tertiary teaching hospital from October 2015 to January 2016. Patients with low energy or fragility fractures were included in the study regardless of gender or race, over the age of 50 years. All patients who did not have these characteristics were excluded. The follow-up lasted four months. Serial questionnaires were applied at admission and in the follow-up consultations at four to eight weeks and at 16 weeks.

RESULTS

Only one patient reported receiving treatment with specific drugs for the disease before hospital admission, resulting in a prevalence of primary chemoprophylaxis of only 2.27%. No patient was prescribed medication for the treatment of osteoporosis after the fracture. The prevalence of risk factors was similar to those found in the literature review.

CONCLUSION

In the present study, the frequency of primary and secondary osteoporosis chemoprophylaxis in patients who were admitted with fragility fractures was low, as well as the early indication of drug treatment after the first fracture. The prevalence of fragility fracture risk factors is similar to those reported in the literature.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk

The use of quantitative ultrasound (QUS) for a variety of skeletal sites, associated with the absence of technology-specific guidelines, has created uncertainty with respect to the application of QUS results to the management of individual patients in clinical practice. However, when prospectively validated (this is not the case for all QUS devices and skeletal sites), QUS is a proven, low-cost, and readily accessible alternative to dual-energy X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) for the assessment of fracture risk. Indeed, the clinical use of QUS to identify subjects at low or high risk of osteoporotic fracture should be considered when central DXA is unavailable. Furthermore, the use of QUS in conjunction with clinical risk factors (CRF),allows for the identification of subjects who have a low and high probability of osteoporotic fracture. Device- and parameter-specific thresholds should be developed and cross-validated to confirm the concurrent use of QUS and CRF for the institution of pharmacological therapy and monitoring therapy.

Fracture Risk Prediction by Non-BMD DXA Measures: the 2015 ISCD Official Positions Part 1: Hip Geometry

Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry is the current imaging procedure of choice to assess fracture risk. However, BMD is only one of the factors that explain bone strength or resistance to fracture. Other factors include bone microarchitecture and macroarchitecture. We now have the ability to assess some of these non-BMD parameters from a dual-energy X-ray absorptiometry image. Available measurements include various measurements of hip geometry including hip structural analysis, hip axis length, and neck-shaft angle. At the 2015 Position Development Conference, the International Society of Clinical Densitometry established official positions for the clinical utility of measurements of hip geometry. We present the official positions approved by an expert panel after careful review of the recommendations and evidence prepared by an independent task force. Each question addressed by the task force is presented followed by the official position with the associated medical evidence and rationale.

Bone mineral density measurements, bone markers and serum vitamin D concentrations in men with chronic non-cirrhotic untreated hepatitis C

Introduction

The high prevalence of chronic hepatitis C (CHC) and its consequent cirrhosis has been associated with bone fragility. Whether CHC may cause bone and mineral abnormalities in the absence of hepatocellular dysfunction is still unknown. In this study we aimed to determine the prevalence of osteoporotic vertebral fractures and low BMD measurements in men with non-cirrhotic CHC. Risk factors for low BMD and fractures were also investigated.

Methods

Morphometric vertebral fractures and BMD measurements were performed in 60 non-cirrhotic untreated men with CHC and 59 healthy controls, matched for age and gender, weight and current smoking. Serum CTx, calcium, phosphate, intact PTH, alkaline phosphatase and vitamin D (25OHD) concentrations were measured in all participants. Clinical risk factors for low BMD and fractures were evaluated by a structured questionnaire as well as details regarding HCV infection.

Results

Trochanter and total femur BMD were significantly lower in CHC patients as compared to healthy men (p = 0.04). In men 50 years and older, the prevalence of osteoporosis was significantly higher among CHC patients (p = 0.01). Lower levels of physical activities and more often report of prolonged immobilization were observed among CHC patients (p<0.05). Liver inflammation and fibrosis, viral load and genotype did not correlate with BMD measurements. Bone markers and 25OHD concentrations were similar in both groups. Only a few vertebral fractures were observed.

Conclusions

Our results demonstrate that non-cirrhotic untreated CHC patients have lower BMD at the femur as compared to healthy men in spite of the absence of significant bone and mineral abnormalities.

Prevalence and risk factors associated with low-impact fractures in men with rheumatoid arthritis

The aim of this study is to describe the prevalence of fractures in men with rheumatoid arthritis (RA) and identify potential risk factors associated with skeletal fragility. We consecutively studied 50 men with RA. Clinical risk factors were evaluated by clinical questionnaire, functional capacity by M-HAQ1, and disease activity by DAS-28. RA men were compared to 52 healthy controls paired for age and BMI. Bone mineral density (BMD) and quantitative ultrasound (QUS) at the heel were performed in all participants. Morphometric vertebral fractures (VF) were classified by a semiquantitative method. Men with RA were 51.7 years old on average and had mean disease duration of 115 months. Fragility fractures were found in 40% of individuals, of which 36% were VF, significantly higher than in healthy controls (p < 0.01). Age, anthropometric data, and lifestyle were similar between RA men with and without fractures. About 94% of the men with RA were on long-term glucocorticoid (GC) use. Patients with fractures were more frequently positive for rheumatoid factor (RF), had longer morning stiffness, and higher DAS-28 when compared to patients without fractures (p ≤ 0.05). In addition, they had significantly lower spine and hip BMD as well as a lower stiffness index (p ≤ 0.05). There was no statistically significant correlation between fracture and cumulative GC use. The final model of logistic regression showed a significant association and interaction between lower weight and physical activity in men with RA and fragility fractures. RA in men as well as in women is a risk factor for fragility fractures. The risk of fractures is higher in patients with positive RF, prolonged morning stiffness, higher scores of disease activity, and lower values of BMD and QUS.

Diet, body composition, and bone mass in well-trained cyclists

Cycling is believed to be associated with low bone mass. In this study, we investigate food intake, body composition, and bone mass in well-trained young adult cyclists compared with those in sedentary controls. Four-day estimated diet records were used to study dietary intake in 31 cyclists and 28 sedentary controls (all male, 24yr old on average), together with maximal oxygen uptake (VO(2max)), body composition, and bone mass measurements (dual-energy X-ray absorptiometry). The VO(2max) values were twice as high as those in the cyclists, whereas no significant difference in bone mass was observed between cyclists and controls. A total of 10 cyclists and 9 controls had low bone mass. Total-body lean mass and appendicular skeletal muscle mass were higher in cyclists (p<0.001), whereas percentage of body fat was lower (p<0.001) compared with that of the controls. Energy and macro- and micronutrient intake was higher in the cyclists than in the controls (p<0.01). Energy consumption was considered adequate in the cyclists, whereas lipid and protein intake was higher than the American College of Sports Medicine recommendation. Lipid consumption negatively correlated with bone mass in the athletes. Our results demonstrate that cycling was associated with greater aerobic conditioning and lean mass without significant association with bone mass compared with sedentary controls.

Prevalência de diagnóstico auto-referido de osteoporose, Brasil, 2006

OBJETIVO: Estimar a prevalência de osteoporose auto-referida (com diagnóstico médico prévio) e de fatores de risco e proteção associados. MÉTODOS: Estudo transversal baseado em dados do sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (VIGITEL). Foram entrevistados 54.369 indivíduos com idade >18 anos residentes em domicílios servidos por pelo menos uma linha telefônica fixa nas capitais brasileiras e Distrito Federal em 2006. Estimativas de osteoporose segundo fatores socioeconômicos, comportamentais e índice de massa corporal foram estratificadas por sexo. Foram calculados riscos de ocorrência de osteoporose para cada variável individualmente, e em modelo multivariado, considerando-se odds ratio como proxy da razão de prevalência. RESULTADOS: A prevalência de osteoporose referida foi de 4,4%, predominantemente entre mulheres (7,0%), com idade >45 anos, estado civil não solteiro e ex-fumante. Entre homens, ter mais de 65 anos, ser casado ou viúvo e sedentário associaram-se positivamente ao desfecho. CONCLUSÕES: Dentre os fatores associados à osteoporose, destacam-se aspectos modificáveis relacionados com a prevenção da doença, como a atividade física e tabagismo.

FRAX TM: construindo uma ideia para o Brasil

Diferenças genéticas, raciais e antropométricas, bem como da composição corporal, densidade óssea, dieta, atividade física e outros hábitos de vida, contribuem para explicar as divergências na incidência e prevalência de baixa densidade óssea e fraturas em diversos países do mundo. Recentemente, foi desenvolvida uma ferramenta, denominada FRAX TM, para aglutinar os fatores clínicos de risco (genéticos e ambientais) e a densidade óssea, a fim de quantificar a probabilidade de fratura osteoporótica nos próximos dez anos. Em breve, ela será utilizada para indicação de tratamento em pacientes de risco. No entanto, atualmente, está disponível somente para uso em algumas populações que possuem banco de dados prospectivos e consistentes - o que não inclui o Brasil. Este estudo teve o objetivo de fazer uma revisão dos estudos epidemiológicos nacionais e internacionais para melhor compreender peculiaridades e diferenças de fatores clínicos de risco, densidade óssea e probabilidade de fratura entre essas populações. Os autores concluíram que se faz necessária a obtenção de mais dados epidemiológicos representativos da população brasileira para utilização da ferramenta FRAX TM. Para isso, os estudos brasileiros deverão possuir características adequadas, como o delineamento prospectivo, avaliação da qualidade de vida, mortalidade e incapacidade física após as fraturas, levando em consideração a expectativa de vida da população brasileira e a análise de custos diretos e indiretos relacionados às fraturas por osteoporose. À luz do conhecimento atual, a utilização de qualquer um dos bancos de dados das populações, disponibilizadas pelo FRAX TM, não é recomendada no Brasil.

Clinical risk factors for osteoporotic fractures in Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS)

The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older. The prevalence of fragility fractures is about 15.1% in the women and 12.8% in the men. Moreover, advanced age, sedentarism, family history of hip fracture, current smoking, recurrent falls, diabetes mellitus and poor quality of life are the main clinical risk factors associated with fragility fractures.

INTRODUCTION

The Brazilian Osteoporosis Study (BRAZOS) is the first epidemiological study carried out in a representative sample of Brazilian men and women aged 40 years or older with the purpose of identifying the prevalence and the main clinical risk factors (CRF) associated with osteoporotic fracture in our population.

METHODS

A total of 2,420 individuals (women, 70%) from 150 different cities in the five geographic regions in Brazil, and all different socio-economical classes were selected to participate in the present survey. Anthropometrical data as well as life habits, fracture history, food intake, physical activity, falls and quality of life were determined by individual quantitative interviews. The representative sampling was based on Brazilian National data provided by the 2000 and 2003 census. Low trauma fracture was defined as that resulting of a fall from standing height or less in individuals 50 years or older at specific skeletal sites: forearm, femur, ribs, vertebra and humerus. Sampling error was 2.2% with 95% confidence intervals. Logistic regression analysis models were designed having the fragility fracture as the dependent variable and all other parameters as the independent variable. Significance level was set as p < 0.05.

RESULTS

The average of age, height and weight for men and women were 58.4 +/- 12.8 and 60.1 +/- 13.7 years, 1.67 +/- 0.08 and 1.56 +/- 0.07 m and 73.3 +/- 14.7 and 64.7 +/- 13.7 kg, respectively. About 15.1% of the women and 12.8% of the men reported fragility fractures. In the women, the main CRF associated with fractures were advanced age (OR = 1.6; 95% CI 1.06-2.4), family history of hip fracture (OR = 1.7; 95% CI 1.1-2.8), early menopause (OR = 1.7; 95% CI 1.02-2.9), sedentary lifestyle (OR = 1.6; 95% CI 1.02-2.7), poor quality of life (OR = 1.9; 95% CI 1.2-2.9), higher intake of phosphorus (OR = 1.9; 95% CI 1.2-2.9), diabetes mellitus (OR = 2.8; 95% CI 1.01-8.2), use of benzodiazepine drugs (OR = 2.0; 95% CI 1.1-3.6) and recurrent falls (OR = 2.4; 95% CI 1.2-5.0). In the men, the main CRF were poor quality of life (OR = 3.2; 95% CI 1.7-6.1), current smoking (OR = 3.5; 95% CI 1.28-9.77), diabetes mellitus (OR = 4.2; 95% CI 1.27-13.7) and sedentary lifestyle (OR = 6.3; 95% CI 1.1-36.1).

CONCLUSION

Our findings suggest that CRF may contribute as an important tool to identify men and women with higher risk of osteoporotic fractures and that interventions aiming at specific risk factors (quit smoking, regular physical activity, prevention of falls) may help to manage patients to reduce their risk of fracture.

Assessment of clinical risk factors to validate the probability of osteoporosis and subsequent fractures in Korean women

This cross-sectional, observational study was designed to identify clinical risk factors of osteoporosis and fractures in Korean women to validate the probability of osteoporosis and subsequent fractures. A total of 1541 Korean women were recruited nationally. Fracture history of any site, risk factors of osteoporosis, and fall-related risk factors were surveyed and physical performance tests were conducted. Peripheral dual-energy X-ray absorptiometry was used to measure calcaneus bone mineral density (BMD). The number of positive responses on the modified 1-min osteoporosis risk test was related to the risk of osteoporosis. The frequency of osteoporosis was higher in those with a height reduction of >4 cm and a reduced body mass index (BMI). Multivariate analysis showed that older age and lower BMI were related to higher relative risk of osteoporosis. Time required to stand up from a chair and questions related to fall injury were significantly related to clinical fracture history of any site. Multivariate analysis showed that the relative risk of fractures at any site was higher in older subjects with a lower T-score and parental hip fracture history. This study shows that age and BMI are the most significant clinical risk factors for osteoporosis and that age, BMD, and parental history of hip fracture are highly applicable risk factors for validating the probability of osteoporotic fractures in Korean women.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

Skeletal site-dependent response of bone mineral density and quantitative ultrasound parameters following a 12-month dietary intervention using dairy products fortified with calcium and vitamin D: the Postmenopausal Health Study

The aim of the current study was to examine whether calcium supplementation could prevent bone loss in postmenopausal women or more favourable outcomes could be obtained via the consumption of dairy products fortified with calcium and vitamin D3. For this purpose changes in bone mineral density (BMD) at different skeletal sites, assessed by dual-energy X-ray absorptiometry, as well as in quantitative ultrasound (QUS) parameters of the calcaneus over 12 months were estimated. A population of 101 postmenopausal women (55–65 years old) was randomized into a dairy group (DG: n 39), receiving approximately 1200 mg calcium/d and 7·5 μg vitamin D3/d through fortified dairy products; a calcium-supplemented group (CaG: n 26) provided with a calcium supplement of 600 mg/d; and a control group (CG: n 36). Over the intervention period the DG was found to have more favourable changes in pelvis (P = 0·040), total spine (P < 0·001) and total body BMD (P < 0·001) than the other groups. A significant increase was also observed for DG in lumbar spine BMD (2·0 %; 95 % CI 0·5, 3·5) although it did not differentiate significantly compared to the other groups. No significant differences were observed with respect to the changes in QUS parameters. The current study revealed that recommended intakes of vitamin D3 and calcium via fortified dairy products for 12 months can induce favourable changes in pelvis, total spine and total body BMD in postmenopausal women but not in QUS parameters. No such favourable changes were observed via supplementation of calcium alone.

Prevalência do risco para fraturas estimado pela ultra-sonometria óssea de calcâneo em uma população de mulheres brasileiras na pós-menopausa

Observa-se uma forte tendência de envelhecimento da população mundial levando a um aumento da prevalência de doenças como a osteoporose e fraturas. O objetivo deste estudo foi determinar a prevalência de risco para fraturas estimado pela ultra-sonometria óssea de calcâneo em uma população de mulheres na pós-menopausa, residentes na Ilha de Paquetá, Rio de Janeiro, Brasil. Realizamos medidas antropométricas e ultra-sonometria óssea de calcâneo com aparelho Sonost 2000 em 385 mulheres pós-menopausadas. Observamos que 59,22% da amostra apresentava T-score < -1, sendo que 16,88% tinham T-score < -2,5. Houve variação em todos os parâmetros do exame conforme o aumento da idade, e diferença estatisticamente significativa (p < 0,05) entre os grupos de risco para fratura por idade, tempo de menopausa, peso, IMC e percentual de gordura corpórea. Houve correlação entre velocidade do som e IMC (r = 0,155; p = 0,002). Concluímos que cerca de 60% da população feminina estudada apresenta algum grau de risco para fraturas. As mulheres do grupo de maior risco (T-score < -2,5) eram mais velhas, com maior tempo de menopausa, maior peso e IMC do que as dos outros grupos.

Comparison of the femoral neck bone density, quantitative ultrasound and bone density of the heel between dominant and non-dominant side

Our study was initiated to evaluate whether there are differences between the two sides, depending on hand dominance, in densitometry values and quantitative ultrasound parameters (QUS) of the lower limb. One hundred and six women and 44 men were involved. The hand dominance was determined by interview. The bone mineral density (BMD) of the left and the right femoral necks and the calcanei were measured by dual-energy X-ray absorptiometry (DXA). The QUS examination consisted of measuring the attenuation (BUA), the speed of the ultrasound (SOS) and quantitative ultrasound index (QUI) transversing the left and right calcanei. The density of the neck of femur of the non-dominant side did not differ from that of the dominant side. On the other hand, BMD, BUA and the QUI of the calcaneus were higher on the non-dominant side in both genders (p<0.05 for each parameter). No similar differences were seen for the SOS values. Our study has confirmed the side-to-side differences of the calcaneus in both genders, lower values were found on the dominant side. No similar differences were seen on the femur. The AUC values seemed to be higher on the dominant side, however, these differences were not strictly significant. In the case of peripheral site (heel) measurements, the practical significance of our observations is that they raise the possibility of performing peripheral DXA and QUS examinations of the calcaneus on the dominant side of the patient according to handedness.

Calcaneus ultrasonometry and dual-energy X-ray absorptiometry for the evaluation of vertebral fracture risk

The aim of this retrospective, cross-sectional, controlled, non-population-based study was to evaluate the specificity and sensitivity of quantitative ultrasonometry (QUS) of the heel and of dual-energy X-ray absorptiometry (DXA) in the prediction of morphometric vertebral fracture in postmenopausal women and to establish whether the combination of the two devices could improve the capacity to identify the presence of vertebral fracture. Also, we tried to identify the best T-score threshold for high risk of vertebral fracture for both QUS and DXA, highlighting the discrepancies between the two methodologies and between the various sites examined with DXA. From 6,300 patients examined by DXA (total body, lumbar spine, total femur, femoral neck), QUS and DXA vertebral morphometry (MXA), we selected 764 postmenopausal women with nontraumatic vertebral fractures; 770 postmenopausal women with normal morphometry were chosen as a control group. Logistic regression analysis yielded odds ratios (ORs) for bone mineral density (BMD) measurements and QUS that were comparable: BMD-total body 4.16, BMD-lumbar spine 4.80, BMD-total femur 3.77, BMD-femoral neck 3.86, and QUS 4.41, without statistical differences even after correction for different confounding variables (menopausal years, weight, height, body mass index, and age). The ORs obtained from different combinations of QUS and DXA results did not show statistically significant differences compared to those from a single method alone. The sensitivity and specificity of all measurements were determined by area using the receiver operating characteristic curve; these were 0.94 for total body, 0.95 for lumbar spine, 0.86 for total femur, 0.89 for femoral neck, and 0.93 for QUS, without statistical difference. The areas under the curve obtained from the combination of QUS and DXA were higher but without statistical significance compared to QUS alone. In conclusion, both QUS and DXA were able to discriminate women with fracture from women without fracture and independently contributed to determining the association with fracture. The combination of QUS and BMD did not improve the diagnostic ability of either individual technique. We found different diagnostic thresholds for QUS and DXA.

Low femoral bone mineral density and quantitative ultrasound are risk factors for new osteoporotic fracture and total and cardiovascular mortality: a 5-year population-based study of Brazilian elderly women

BACKGROUND

Prospective and cross-sectional studies have confirmed a significant association between bone mineral density (BMD) measurements and fracture risk. However, the relationship among incident fracture risk, mortality, BMD, and quantitative ultrasound is controversial and less studied.

METHODS

At baseline, 275 postmenopausal elderly women were evaluated by clinical questionnaire regarding fracture risk factors and had radiological analysis of the spine, spine and femur dual energy x-ray absorptiometry, and calcaneous quantitative ultrasound measurements. Five years later, 42 (15.3%) women had died, 25 (9.1%) were lost to follow-up, and 208 (75.6%) continued the study. Specific questionnaire items regarding fracture risk were reevaluated, and thoracic and lumbar spine x-rays were taken to identify new fractures. Causes of mortality in this population were also assessed. All reported deaths were confirmed by review of death certificates or hospital records and were classified according to International Classification of Diseases, 10th Revision (ICD-10) code.

RESULTS

After adjustments for age, weight, body mass index, smoking status, previous fracture, physical activity, drug use, and presence of chronic diseases, each 1 standard deviation (SD) reduction in stiffness index (SI) at baseline was significantly associated with future fracture (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.30-3.83) and total mortality 5 years later (HR = 1.57; 95% CI, 1.10-2.47). Femoral neck and trochanter BMD values at baseline were also related to new fracture (HR = 2.01; 95% CI, 1.27-3.18 and HR = 1.62; 95% CI, 1.08-2.42, respectively) and total mortality (HR = 1.44; 95% CI, 1.06-2.22 and HR = 1.59; 95% CI, 1.07-2.36, respectively). Cardiovascular mortality was associated with decreased baseline femur BMD (HR = 1.28; 95% CI, 1.08-2.26) and lower SI values (HR = 1.54; 95% CI, 1.08-2.79).

CONCLUSIONS

Our results demonstrate that low femoral BMD and low SI are able to predict fracture risk and are related to non-cause-specific and cardiovascular mortality, independently of other factors associated with osteoporosis, death, or aging.

Prevalence of low trauma fractures in long-term kidney transplant patients with preserved renal function

We evaluated the prevalence of low bone mineral density (BMD) and osteoporotic fractures in kidney transplantation (KT) patients and determined risk factors associated with osteoporotic fractures. The study was conducted on 191 patients (94 men and 97 women) with first KT for 3 years or more presenting stable and preserved renal function (serum creatinine levels lower than 2.5 mg/dl). KT patients were on immunosuppressive therapy and the cumulative doses of these drugs were also evaluated. BMD was determined by dual-energy X-ray absorptiometry at multiple sites (spine, femur and total body). Quantitative ultrasound of the calcaneus (broadband ultrasound attenuation, speed of sound, and stiffness index, SI) was also performed. Twenty-four percent (46) of all patients had either vertebral (29/46) or appendicular (17/46) fractures. We found osteoporosis and osteopenia in 8.5-13.4 and 30.9-35.1% of KT patients, respectively. Women had more fractures than men. In women, prevalent fractures were associated with diabetes mellitus [OR = 11.5, 95% CI (2.4-55.7)], time since menopause [OR = 3.7, 95% CI (1.2-11.9)], femoral neck BMD [OR = 1.99, 95% CI (1.4-2.8)], cumulative dose of steroids [OR = 1.1, 95% CI (1.02-1.12)] and low SI [OR = 1.1, 95% CI (1.0-1.2)]. In men, fractures were associated with lower lumbar spine BMD [OR = 1.75, 95% CI (1.1-2.7)], lower SI [OR = 1.1, 95% CI (1.03-1.13)], duration of dialysis [OR = 1.3, 95% CI (1.13-2.7)], and lower body mass index [OR = 1.24, 95% CI (1.1-1.4). Our results demonstrate high prevalence of low BMD and osteoporotic fractures in patients receiving a successful kidney transplant and indicate the need for specific intervention to prevent osteoporosis in this population.

Contralateral differences in quantitative ultrasound of the heel: the importance of side in clinical practice

Quantitative ultrasound (QUS) of the heel is becoming increasingly popular for the assessment of skeletal status, although there appears to be a general lack of agreement regarding which side to measure. The purpose of the present study was to evaluate possible side differences (right versus left) in heel QUS within the general population, including children (10-15 years old, n=406), adults (26-33 years old, n=339), and elderly subjects (60-75 years old, n=455) of both genders (818 females and 382 males), and to examine the impact of these differences on prevalence estimates of osteoporosis and individual fracture risk assessment. All participants had both their heels measured twice with the Sahara device, which measures broadband ultrasound attenuation (BUA) and speed of sound (SOS) through the os calcis; a composite parameter, that is, quantitative ultrasound index (QUI) and an estimate of heel BMD (eBMD) were also derived. Significant side differences were detected for BUA and SOS (P<0.05), but not for QUI or eBMD. Contralateral differences were rather small in absolute terms, but were in the order of 12.6% for BUA, 0.72% for SOS, 7.9% for QUI, and 9.9% for eBMD, when expressed as percentage of the mean values for the two heels. Bilateral differences appeared to vary across age and gender. Significant correlations between QUS indices of the right and left heel were observed (r=0.75-0.85; P<0.001), which seemed to be stronger among the elderly and among male individuals. Prevalence rates of osteopenia and osteoporosis were not significantly different when estimated from eBMD T-scores for the one or the other foot (chi(2)=1.781, df=2, P=0.410). However, cross-classification analysis revealed that only 84% of the subjects classified into each risk category by the two calcanei were actually the same persons. In conclusion, results from the present study strongly suggest that QUS measurements of opposite heels may not be equivalent with respect to the evaluation of bone status and classification of individual fracture risk assessment, although the degree of discrepancy appears to be related to the primary outcome of interest.

Older women track and field athletes have enhanced calcaneal stiffness

Vigorous weight-bearing exercise is recommended to women as a method of osteoporosis prevention. This study examined older women athletes to see if they indeed were less likely to develop osteoporosis than those in the general population, and to investigate which factors could have contributed to these results. One hundred and thirty-nine women 40-88 years old, all competitors in a USA National Masters Track and Field Championships, volunteered for the study. Masters refers to competitors > or =40 years old. Their calcaneal stiffness (SI) was measured by a Lunar Achilles+ ultrasonometer. Subjects were also measured for height and weight, and completed a questionnaire on exercise history, diet, lifestyle factors, medical and menopausal issues, and use of hormone replacement therapy (HRT). The women, mean age 57.3 years, had an overall average SI of 99.5 (T-score = 0.04) which is equivalent to that of a 20-year-old woman and 20.8% higher than expected for women of their age. Their median SI remained not different from expected peak bone SI until the age of 70. For analysis, this cohort of women was divided into two groups: premenopausal and postmenopausal athletes. The SI of both groups was correlated with the earliest age at which they had first participated in sports or exercises that impart moderate to high strain rates to the lower limbs and with current participation in high impact track and field events. Variables correlated with SI in the general population, such as weight, HRT, previous fracture, hysterectomy, and current menopausal status, did not predict SI in this cohort. In conclusion, women competing in Masters track and field at the national level had calcaneal stiffness substantially higher than expected for women of their age in the general population, and their participation in vigorous sports and activities, either currently or at a younger age, was predictive of this association.

Interobserver reproducibility of criteria for vertebral body exclusion

We studied reproducibility of the ISCD vertebral exclusion criteria among four interpreters. Surprisingly, agreement among interpreters was only moderate, because of differences in threshold for diagnosing focal structural defects and choice of which vertebra among a pair discordant for T-score, area, or BMC to exclude. Our results suggest that reproducibility may be improved by specifically addressing the sources of interobserver disagreement.

INTRODUCTION

Although DXA is widely used to measure vertebral BMD, its interpretation is subject to multiple confounders including osteoarthritis, aortic calcification, and scoliosis. In an attempt to standardize interpretation and minimize the impact of artifacts, the International Society for Clinical Densitometry (ISCD) established criteria for vertebral exclusion, including the presence of a focal structural defect (FSD), discrepancy of >1 SD in T-score between adjacent vertebrae, and a lack of increase in BMC or area from L1 to L4. Whereas the efforts of the ISCD represent an important advance in BMD interpretation, the interobserver reproducibility with application of these criteria is unknown. We hypothesized that there would be substantial agreement among four interpreters regarding application of the exclusion criteria and the final lumbar spine T-score.

MATERIALS AND METHODS

Each interpreter read a set of 200 lumbar DXA scans obtained on male veterans, applying the ISCD vertebral body exclusion criteria.

RESULTS

Surprisingly, agreement among interpreters was only moderate. Differences in interpretation resulted from differing thresholds for recognition of FSD and the choice of excluding the upper or lower vertebral body for the criteria requiring comparison between adjacent vertebrae.

CONCLUSIONS

Despite their apparent simplicity, the ISCD vertebral exclusion criteria are difficult to apply consistently. In principle, appropriate refinement of the exclusion criteria may significantly improve interobserver agreement.