Absolute fracture-risk prediction by a combination of calcaneal quantitative ultrasound and bone mineral density

Are there associations between hip geometry and bone quality? An analysis on 3074 adults from a general population

INTRODUCTION

Patients with reduced bone mineral density and altered hip geometry are susceptible for hip pathologies. Knowledge on associations between bone properties and hip geometric parameters might facilitate identification of patients at risk for hip pathologies. The aim of the present study was to identify associations of bone properties assessed by quantitative ultrasound (QUS) at the heel and hip geometric parameters like center-edge angle (CE), neck-shaft angle (NSA) and alpha angle.

MATERIALS AND METHODS

Hip geometric parameters (CE, NSA and alpha angle) of 3074 participants from the population-based Study of Health in Pomerania were assessed on magnetic resonance imaging. QUS was performed on both calcanei providing broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness-index. Based on the stiffness-index the individual osteoporotic fracture risk (low, moderate or high) was determined. Associations between QUS-based and hip geometric parameters were calculated in linear regression models adjusted for age, sex, body height and weight. Interactions of QUS markers with age and sex on hip geometric parameters were tested.

RESULTS

Significant inverse associations between BUA (β = - 0.068), SOS (β = - 0.024) as well as stiffness-index (β = - 0.056) and CE were present, while fracture risk was positively associated with CE (β for high = 1.28 and moderate = 2.54 vs. low fracture risk). Interactions between BUA and sex as well as between SOS and age were detected in the models for CE. Furthermore, there was an inverse relation between fracture risk and NSA that was restricted to the moderate risk (β for moderate vs. low fracture risk = - 0.60). There were no significant associations between QUS parameters and alpha angle.

CONCLUSIONS

In the general population, several associations between QUS-based bone properties or fracture risk and hip geometry are present. Less dysplastic hips had a lower stiffness-index and a higher fracture risk, whereas more valgus hips had a lower fracture risk.

Adherence to the dietary approaches to stop hypertension and bone health in the Chinese elderly

INTRODUCTION

Many studies have demonstrated the relationship between diet and bone health, but research on the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and bone health across populations is rare. The purpose of this study was to examine associations between the DASH dietary pattern and bone health outcomes in Chinese elders, to verify whether higher adherence to the DASH was associated with better bone health in elderly populations.

MATERIALS AND METHODS

A total of 839 Chinese adults aged 50 years and above participated in this cross-sectional study. Bone mineral density (BMD) at calcaneus was measured via ultrasonic bone densitometer. A semiquantitative food frequency questionnaire (FFQ) was used to assess the usual dietary intake in the past 12 months. The DASH score was calculated based on energy-adjusted intakes of nine dietary components, including whole grains, beans, vegetables, fruits, dairy, red meat, total fat, sodium, and sugar-sweetened beverages.

RESULTS

In postmenopausal women, DASH score was significantly and positively correlated with BMD T-score after controlling potential covariates (β: 0.027 ± 0.012, P = 0.031) in multivariable linear regression models. In binary logistic regression analysis, male participants in the highest tertile of DASH score had lower risk of osteoporosis than those in the lowest tertile (odds ratio = 0.499; 95% confidence interval, 0.262-0.951; P = 0.035) after adjusting potential covariates.

CONCLUSION

Adherence to the DASH dietary pattern was associated with better bone health in Chinese elderly adults.

Quantitative Ultrasound and Bone Health in Elderly People, a Systematic Review

Reduced bone mineral density (BMD), osteoporosis, and their associated fractures are one of the main musculoskeletal disorders of the elderly. Quickness in diagnosis could prevent associated complications in these people. This study aimed to perform a systematic review (SR) to analyze and synthesize current research on whether a calcaneal quantitative ultrasound (QUS) can estimate BMD and predict fracture risk in elderly people compared to dual-energy x-ray absorptiometry (DXA), following the PRISMA guidelines. A search was conducted in the main open-access health science databases: PubMed and Web of Science (WOS). DXA is the gold standard for the diagnosis of osteoporosis. Despite controversial results, it can be concluded that the calcaneal QUS tool may be a promising method to evaluate BMD in elderly people, facilitating its prevention and diagnosis. However, further studies are needed to validate the use of calcaneal QUS.

Hormonal contraceptive use, bone density and biochemical markers of bone metabolism in British Army recruits

INTRODUCTION

Hormonal contraceptive use might impair bone health and increase the risk of stress fracture by decreasing endogenous oestrogen production, a central regulator of bone metabolism. This cross-sectional study investigated bone density and biochemical markers of bone metabolism in women taking hormonal contraceptives on entry to basic military training.

METHODS

Forty-five female British Army recruits had biochemical markers of bone metabolism, areal bone mineral density (aBMD) and tibial speed of sound (tSOS) measured at the start of basic military training. Participants were compared by their method of hormonal contraception: no hormonal contraception (NONE), combined contraceptive pill (CP) or depot-medroxyprogesterone acetate (DMPA) (20±2.8 years, 1.64±0.63 m, 61.7±6.2 kg).

RESULTS

aBMD was not different between groups (p≥0.204), but tSOS was higher in NONE (3%, p=0.014) when compared with DMPA users. Beta C-terminal telopeptide was higher in NONE (45%, p=0.037) and DMPA users (90%, p=0.003) compared with CP users. Procollagen type 1 N-terminal propeptide was higher in DMPA users compared with NONE (43%, p=0.045) and CP users (127%, p=0.001), and higher in NONE compared with CP users (59%, p=0.014). Bone alkaline phosphatase was higher in DMPA users compared with CP users (56%, p=0.044).

CONCLUSIONS

DMPA use was associated with increased bone turnover and decreased cortical bone integrity of the tibia. Lower cortical bone integrity in DMPA users was possibly mediated by increased intracortical remodelling, but trabecular bone was not affected by contraceptive use.

Diagnostic value of calcaneal quantitative ultrasound in the evaluation of osteoporosis in middle-aged and elderly patients

To study the correlation between calcaneal quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA), and analyze the diagnostic value of calcaneal QUS in the evaluation of middle-aged and elderly osteoporosis.We assessed bone mineral density (BMD) at the femoral neck and intertrochanteric of left hip and lumbar spine (L1-L4) sites with DXA and QUS parameters of the right and left calcanei in a cohort of 82 patients over the age of 50 years. Using DXA parameters as the gold standard for the diagnosis of osteoporosis, the correlation coefficient between BMD and QUS parameters was calculated. Receiver operating characteristic curve was generated and areas under the curves were evaluated. Cut-off values for QUS were defined.In men, there was a moderate correlation between calcaneal QUS and proximal femoral BMD (P < .05), but no significant correlation between calcaneal QUS and lumbar BMD (P > .05). In women, calcaneal QUS were moderately correlated with lumbar spine and proximal femoral BMD (P < .05). Using DXA as the gold standard, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of calcaneal QUS in the diagnosis of osteoporosis were 90.2%, 89.2%, 100%, 100%, and 50.0%, respectively. According to the receiver operating characteristic curve, when the QUS T-score of calcaneum was -1.8, the area under the curve was 0.888, the sensitivity was 73.21%, and the specificity was 92.31% (P < .05). When the QUS T-score of calcaneum was -2.35, the sensitivity was 37.2% and the specificity was 100%.Calcaneal QUS can be used to predict proximal femoral BMD in middle-aged and elderly people, as well as lumbar BMD in women. As a screening method for osteoporosis, calcaneal QUS has good specificity, so it can be recommended to use it as a pre-screening tool to reduce the number of DXA screening. When the QUS T-score of calcaneum is -1.8, it has the greatest diagnostic efficiency for osteoporosis; when the QUS T-score of calcaneum is ≤-2.35, it can be diagnosed as 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.

Blood lipid levels in patients with osteopenia and osteoporosis:a systematic review and meta-analysis

INTRODUCTION

Considering the controversial relationship between blood lipid levels and osteopenia and osteoporosis (OP), we performed this meta-analysis.

MATERIALS AND METHODS

Using specific keywords and related words, we searched PubMed, Embase, and Cochrane Library databases. The Newcastle-Ottawa Scale form was used to evaluate the quality of the literature. According to the inclusion and exclusion criteria, we systematically screened the literature to extract relevant information and data. ReVman 5.3 and Stata 13.0 software were used for statistical analysis. Results were expressed as the mean difference (MD) and 95% confidence interval (95% CI). The heterogeneity test was conducted according to I² and Q tests. Egger's test was used to quantitatively evaluate publication bias.

RESULTS

This analysis involved 12 studies (12,395 subjects). The quality of the literature was acceptable. Among subjects who were not taking lipid-lowering drugs, total cholesterol (TC) (MD = 0.11 mmol/L, 95%CI: - 0.03, 0.25; I² = 21%; P = 0.36), triglycerides (TG) (MD =  - 0.01 mmol/L, 95%CI: - 0.09, 0.07; I² = 6%; P = 0.34), and low-density lipoprotein cholesterol (LDL-C) (MD = 0.10 mmol/L, 95%CI: 0.00, 0.19; I² = 0%; P = 0.74) in the osteopenia were not significantly increased/decreased. There were no significant differences in LDL-C (MD = 0.02 mmol/L, 95%CI: - 0.09, 0.13; I² = 0%; P = 0.74) in postmenopausal women in osteopenia. TG (MD =  - 0.04 mmol/L, 95%CI: - 0.14,0.07; I² = 49%; P = 0.07) was unchanged in the osteoporosis (OP) group in subjects without taking lipid-lowering drugs. HDL-C was elevated in OP group (MD = 0.05 mmol/L, 95%CI: 0.03, 0.07; I² = 31%; P = 0.15) but not in osteopenia group (MD = 0.01 mmol/L, 95%CI: - 0.01, 0.02; I² = 38%; P = 0.14) in all subjects.

CONCLUSION

HDL-C was elevated in patients with OP.

Structural and Metabolic Assessment of Bone

The assessment of bone structure and metabolism should focus on the bone strength. Many factors are involved, and although bone density is an important component, it is not the same as bone strength. Other aspects of bone quality include bone volume, micro-architecture, material composition, and ability to repair damage. This chapter briefly reviews some of the methods that can be used to assess both density and quality of bone. Non-invasive measurements of density or structure include dual X-ray absorptiometry (DXA), quantitative computed tomography, ultrasound, and magnetic resonance imaging. DXA is most widely used and has advantages of safety and accessibility, but there are limitations in the interpretation of the results, and in clinical practice positioning errors are frequently seen. Invasive methods are used primarily for research. Samples of bone can be used to measure structure by histology as well as micro-computed tomography and infra-red spectroscopy or backscattered electron microscopy. Force can be directly applied to bone samples to measure the bones strength. Impact microindentation is a new minimally invasive technique that measures bone hardness. Metabolic assessment includes blood and urine tests that reflect diseases that cause bone loss, particularly problems with mineral metabolism. Tetracycline-labelled bone biopsies are the standard for measuring bone formation. Non-invasive biochemical tests of bone formation and resorption can evaluate a patient's skeletal physiology.

A community-based study of the relationship between calcaneal bone mineral density and systemic parameters of blood glucose and lipids

Osteoporosis (OP) is a disease characterized by decreased bone mineral density (BMD) and an increased risk of osteoporotic fractures. Nutritional factors (including glucose and fats lipids), have been implicated in OP.We hypothesized that the levels of blood glucose and lipids could be biomarkers for predicting the risk of OP. To test this hypothesis, we evaluated the potential relationship between BMD and levels of blood glucose and lipids via a community-based study in China.This was a community-based cross-section analysis, and a total of 8584 cases were investigated. The BMD of the left calcaneus was measured using an ultrasonic bone densitometer. The levels of blood glucose (fasting blood glucose [FBG], 2-h blood glucose [2hBG], and glycosylated hemoglobin [HbAlc]), and lipids (triglyceride [TG], total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], and high-density lipoprotein cholesterol [HDL-C]) were measured and analyzed.In our study population, the levels of FBG, 2hBG, HbAlc, TC, LDL-C and HDL-C were higher in the OP group than in the low bone density and the normal bone density groups, while the levels of HbAlc, TC, and LDL-C in the low bone density group were higher than those in the normal bone density group. In males, the level of blood LDL-C in the low bone density group was higher than that in the normal bone density group. In postmenopausal subjects, the levels of FBG, 2hBG and HbA1C were higher than those in the normal bone density groups, and the level of HbA1C in the low bone density group was higher than that in the normal bone density group. Pearson linear trend analysis demonstrated that BMD was positively associated with TC and LDL-C in males and negatively associated with FBG, 2hBG and HbA1C in postmenopausal females. Moreover, logistic analysis showed that BMD was correlated with TC in premenopausal females and HbA1C in postmenopausal females.OP is generally associated with abnormal levels of blood glucose and/or lipids; nevertheless, the relationship between OP and abnormal levels of blood glucose and/or lipids is complicate and different subpopulations may have different susceptibilities. Therefore, further detailed studies are warranted.

Bone mineral density as a dose-response predictor for osteoporosis: a propensity score analysis of longitudinal incident study (KCIS no. 39)

BACKGROUND

Osteoporosis is a global disease burden for aging society. The role of quantitative ultrasound (QUS) in the prediction for osteoporosis in a dose-response manner is hardly addressed.

AIM

We aimed to show the dose-response of QUS measurement in the prediction for osteoporosis by a community-based study.

DESIGN

A prospective cohort study.

METHODS

Participants were recruited between 2000 and 2004. Demographic data and heel QUS measurement were collected at baseline. Diagnosis of osteoporosis was ascertained by the follow-up of this cohort over time. In order to reduce the imbalance of baseline characteristics in the observational study, we applied propensity score by using proportional odds regression analysis to match the quintiles of QUS T-score.

RESULTS

A total of 44 957 subjects composed of 17 678 men (39.3%) and 27 279 women (69.7%) were recruited. After adjustments for propensity score, an increase in one unit of QUB T-score led to 7% reduction in the risk for osteoporosis [adjusted odds ratio (OR) = 0.93, 95% confidence interval (CI): 0.89-0.96, P < 0.0001]. Higher quintile of QUS T-score yielded a lower risk of osteoporosis with a gradient relationship [OR: 0.82 (95%CI: 0.72-0.92); OR: 0.81 (95%CI: 0.71-0.91); OR: 0.77 (95%CI: 0.68-0.87) and OR: 0.76 (95%CI: 0.67-0.86)] from the second to highest quintile opposed to first quintile (P < 0.0001). The cumulative incidence of osteoporosis was higher in the lower quintile during follow-up (log-rank test, P < 0.001).

CONCLUSION

QUS is an independent predictor for osteoporosis in a dose-response manner using a large population-based cohort. Due to the lower cost and portability of QUS measurement, the pre-screening for osteoporosis by QUS can be considered in the area with limited resources can be a feasible and alternative method.

Bone quality in young adults with intellectual disability involved in adapted competitive football

The objective of this study was to analyse bone quality parameters of football players with intellectual disability (ID) participating in adapted competitive football. Sixty-seven male football players with ID were studied: 22 with Down syndrome (DS) and 45 without DS. The average age was 26 years (range: 16 ̶ 50 years). A group of 25 age-matched sedentary individuals with ID (11 DS and 14 non-DS) and another group of 20 healthy participants of the same age group not involved in competitive football were comparatively analysed. There were no differences in the bone quality parameters when the healthy sedentary individuals were compared with both the sedentary and the football players with ID. However, the speed of sound (SOS), T-score, and estimated bone mineral density (BMD) were of higher values in the football players with ID than in the sedentary ID group (p < 0.05). On comparing the football players with non-DS ID with the sedentary non-DS individuals, significant differences were noted in SOS (p < 0.01), T-scores (p < 0.01), and estimated BMD (p < 0.01). Four of the 45 non-DS (8.9%) and none of the football players with DS had T-scores less than -1.5. Two of the 14 sedentary non-DS participants (14.3%) had T-scores indicating osteoporosis. In summary, the ID population actively involved in football showed higher values of bone mass parameters than their sedentary ID and healthy peers. The participants with non-DS ID showed a higher prevalence of osteoporosis than the football players with DS. Participation in sports seems to prevent bone loss in individuals with ID.

Screening to Prevent Osteoporotic Fractures: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Osteoporotic fractures cause significant morbidity and mortality.

OBJECTIVE

To update the evidence on screening and treatment to prevent osteoporotic fractures for the US Preventive Services Task Force.

DATA SOURCES

PubMed, the Cochrane Library, EMBASE, and trial registries (November 1, 2009, through October 1, 2016) and surveillance of the literature (through March 23, 2018); bibliographies from articles.

STUDY SELECTION

Adults 40 years and older; screening cohorts without prevalent low-trauma fractures or treatment cohorts with increased fracture risk; studies assessing screening, bone measurement tests or clinical risk assessments, pharmacologic treatment.

DATA EXTRACTION AND SYNTHESIS

Dual, independent review of titles/abstracts and full-text articles; study quality rating; random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Incident fractures and related morbidity and mortality, diagnostic and predictive accuracy, harms of screening or treatment.

RESULTS

One hundred sixty-eight fair- or good-quality articles were included. One randomized clinical trial (RCT) (n = 12 483) comparing screening with no screening reported fewer hip fractures (2.6% vs 3.5%; hazard ratio [HR], 0.72 [95% CI, 0.59-0.89]) but no other statistically significant benefits or harms. The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve [AUC], 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar. For women, bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk of vertebral fractures (9 trials [n = 23 690]; relative risks [RRs] from 0.32-0.64). Bisphosphonates (8 RCTs [n = 16 438]; pooled RR, 0.84 [95% CI, 0.76-0.92]) and denosumab (1 RCT [n = 7868]; RR, 0.80 [95% CI, 0.67-0.95]) were associated with a lower risk of nonvertebral fractures. Denosumab reduced the risk of hip fracture (1 RCT [n = 7868]; RR, 0.60 [95% CI, 0.37-0.97]), but bisphosphonates did not have a statistically significant association (3 RCTs [n = 8988]; pooled RR, 0.70 [95% CI, 0.44-1.11]). Evidence was limited for men: zoledronic acid reduced the risk of radiographic vertebral fractures (1 RCT [n = 1199]; RR, 0.33 [95% CI, 0.16-0.70]); no studies demonstrated reductions in clinical or hip fractures. Bisphosphonates were not consistently associated with reported harms other than deep vein thrombosis (raloxifene vs placebo; 3 RCTs [n = 5839]; RR, 2.14 [95% CI, 0.99-4.66]).

CONCLUSIONS AND RELEVANCE

In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good.

Measuring improvement in fracture risk prediction for a new risk factor: a simulation

Objective

Improvements in clinical risk prediction models for osteoporosis-related fracture can be evaluated using area under the receiver operating characteristic (AUROC) curve and calibration, as well as reclassification statistics such as the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) statistics. Our objective was to compare the performance of these measures for assessing improvements to an existing fracture risk prediction model. We simulated the effect of a new, randomly-generated risk factor on prediction of major osteoporotic fracture (MOF) for the internationally-validated FRAX^® model in a cohort from the Manitoba Bone Mineral Density (BMD) Registry.

Results

The study cohort was comprised of 31,999 women 50+ years of age; 9.9% sustained at least one MOF in a mean follow-up of 8.4 years. The original prediction model had good discriminative performance, with AUROC = 0.706 and calibration (ratio of observed to predicted risk) of 0.990. The addition of the simulated risk factor resulted in improvements in NRI and IDI for most investigated conditions, while AUROC decreased and changes in calibration were negative. Reclassification measures may give different information than discrimination and calibration about the performance of new clinical risk factors.

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.

Advances in imaging approaches to fracture risk evaluation

Fragility fractures are a growing problem worldwide, and current methods for diagnosing osteoporosis do not always identify individuals who require treatment to prevent a fracture and may misidentify those not a risk. Traditionally, fracture risk is assessed using dual-energy X-ray absorptiometry, which provides measurements of areal bone mineral density at sites prone to fracture. Recent advances in imaging show promise in adding new information that could improve the prediction of fracture risk in the clinic. As reviewed herein, advances in quantitative computed tomography (QCT) predict hip and vertebral body strength; high-resolution HR-peripheral QCT (HR-pQCT) and micromagnetic resonance imaging assess the microarchitecture of trabecular bone; quantitative ultrasound measures the modulus or tissue stiffness of cortical bone; and quantitative ultrashort echo-time MRI methods quantify the concentrations of bound water and pore water in cortical bone, which reflect a variety of mechanical properties of bone. Each of these technologies provides unique characteristics of bone and may improve fracture risk diagnoses and reduce prevalence of fractures by helping to guide treatment decisions.

Effects of age, sex, and ethnicity on bone health status of the elderly in Kuala Lumpur, Malaysia

Background

Osteoporosis is a significant health problem in the developing countries and its prevalence data are important for the estimation of health care burden and policy making. This study aimed to determine the age-related changes in bone health and the prevalence of osteoporosis in males and females aged 50 years or above living in Kuala Lumpur, Malaysia.

Methods

A cross-sectional study was conducted between December 2014 and December 2015. Subjects answered a demographic questionnaire and underwent body anthropometric and bone health measurement. Assessment of bone health was performed using a quantitative ultrasound device that generated speed of sound, broadband ultrasound attenuation, stiffness index, and T-score based on stiffness index value as bone health indices.

Results

The prevalence of osteoporosis was 10.6% in males and 8.0% in females. Significant age-related decline of bone health indices (speed of sound, broadband ultrasound attenuation, stiffness index, and T-score) and a concurrent increase in the prevalence of osteoporosis and osteopenia were observed in females (P<0.05) but not in males (P>0.05). Ethnic differences in bone health indices and prevalence of osteoporosis/osteopenia were not observed (P>0.05).

Conclusion

A significant proportion of males and females age 50 years or above have suboptimal bone health. Preventive measures such as early screening should be implemented to retard the progression of osteoporosis.

Correlation between Parameters of Calcaneal Quantitative Ultrasound and Hip Structural Analysis in Osteoporotic Fracture Patients

Background

Calcaneal quantitative ultrasound (QUS), which is used in the evaluation of osteoporosis, is believed to be intimately associated with the characteristics of the proximal femur. However, the specific associations of calcaneal QUS with characteristics of the hip sub-regions remain unclear.

Design

A cross-sectional assessment of 53 osteoporotic patients was performed for the skeletal status of the heel and hip.

Methods

We prospectively enrolled 53 female osteoporotic patients with femoral fractures. Calcaneal QUS, dual energy X-ray absorptiometry (DXA), and hip structural analysis (HSA) were performed for each patient. Femoral heads were obtained during the surgery, and principal compressive trabeculae (PCT) were extracted by a three-dimensional printing technique-assisted method. Pearson’s correlation between QUS measurement with DXA, HSA-derived parameters and Young’s modulus were calculated in order to evaluate the specific association of QUS with the parameters for the hip sub-regions, including the femoral neck, trochanteric and Ward’s areas, and the femoral shaft, respectively.

Results

Significant correlations were found between estimated BMD (Est.BMD) and BMD of different sub-regions of proximal femur. However, the correlation coefficient of trochanteric area (r = 0.356, p = 0.009) was higher than that of the neck area (r = 0.297, p = 0.031) and total proximal femur (r = 0.291, p = 0.034). Furthermore, the quantitative ultrasound index (QUI) was significantly correlated with the HSA-derived parameters of the trochanteric area (r value: 0.315–0.356, all p<0.05) as well as with the Young’s modulus of PCT from the femoral head (r = 0.589, p<0.001).

Conclusion

The calcaneal bone had an intimate association with the trochanteric cancellous bone. To a certain extent, the parameters of the calcaneal QUS can reflect the characteristics of the trochanteric area of the proximal hip, although not specifically reflective of those of the femoral neck or shaft.

Diagnostic value of osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) in detecting high-risk populations for osteoporosis among elderly Chinese men

This study aims to evaluate an osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) and their combination in detecting populations at high risk for osteoporosis, and to determine the best cutoff value for the diagnosis of osteoporosis among elderly Chinese men. A group of Chinese men, aged ≥ 60 years, recruited from the health checkup population of Zhongshan Hospital, Fudan University, were included. The OSTA index was calculated from age and weight. Bone mineral density (BMD) at left hip (femoral neck, internal, and total hip) and lumbar spine (L1-L4, L-Total) was measured with dual-energy X-ray absorptiometry (DXA), and calcaneal BMD was measured with QUS. Receiver operating characteristic analysis was used to determine the best cutoff values, sensitivity, and specificity. The area under the curve (AUC) between the different screening tools was compared. Our study included 472 men with mean age of 78.0 years. The prevalence of osteoporosis was 27.7%.The best cutoff for OSTA was -3.5 for predicting men with osteoporosis at any site; this yielded a sensitivity and specificity of 47.3% and 76.8%, respectively. The AUC for OSTA was 0.676. The optimal cutoff for QUS-T score was -1.25, with a sensitivity of 80.4% and specificity of 59.7%. The AUC for QUS-T score was 0.762. Combining QUS with OSTA improved the specificity to 92.9% but reduced sensitivity to 36.1%. A new variable derived from a combination of OSTA and the QUS-T score gave a better performance, with sensitivity of 70.1% and specificity of 72.1%; the AUC for this variable was 0.771, which was greater than OSTA but not different from QUS alone. In conclusion, OSTA and QUS, respectively, and their combination may help find populations at high risk for osteoporosis, which could be an alternative method for diagnosing osteoporosis, especially in areas where DXA measurement is not accessible.

Measurement properties of radial and tibial speed of sound for screening bone fragility in 10- to 12-year-old boys and girls

The objective of this study was to analyze measurement properties of the radial and tibial speed of sound (SoS) evaluated by quantitative ultrasound (QUS) for screening bone fragility. Bone fragility was defined as low whole body less head bone mineral density (WBLH BMD) measured by DXA (first tertile, 95% CI -1.1 to -0.9) and as past fractures evaluated by questionnaire. The sample included 319 nonobese boys and girls, ages 10-12 yr. All bone variables were standardized. The results revealed concordance coefficient correlations between WBLH BMD and radial and tibial SoS of 0.129 and 0.038, respectively. The regression lines between DXA and QUS variables were different from the identity lines. Cross-classification analysis by Kappa statistic showed that only 34% and 36% of the 113 participants categorized in the first tertile of WBLH BMD were also categorized in the first tertile of tibial and radial SoS, correspondingly. Logistic regression with gender and maturity adjustments demonstrates that radial SoS was the single significant variable in predicting OR for identifying participants with past fractures. In conclusion, the radial QUS revealed itself to be a valuable tool for screening bone fragility in youth of 10-12 yr, despite the absence of agreement with DXA WBLH BMD.

Bone quality in older adults with intellectual disabilities

Although osteoporosis is a progressive bone disease leading to increased risk of fracture, it has rarely been investigated on a large scale in older people with intellectual disabilities (ID). In this study, 768 persons with ID (aged ≥ 50 years) were measured with quantitative ultrasound to determine the prevalence of low bone quality. The association of low bone quality with patient characteristics, mobility, physical activity, body mass index (BMI), prior fractures, anticonvulsant drug use, intake of calcium, and vitamin D3 levels was also investigated. The prevalence of low bone quality was 43.9%. Low bone quality was positively associated with female gender, age, more severe level of ID, mobility impairment, and anticonvulsant drug use, and negatively with BMI. In clinical practice, people with ID who are at risk for low bone quality should periodically be screened for osteoporosis and be given advice about nutritional supplements and appropriate lifestyle.

Bone mineral density after bariatric surgery. A systematic review

PURPOSE

Bone regulation system may be affected after bariatric surgeries, but procedures impact differently to bone mineral density (BMD) and measures restraining bone loss are frequently neglected until clinical consequences become manifest. This is a systematic review aimed to elucidate whether BMD loss is comparable after different bariatric surgeries.

MATERIALS AND METHODS

A search of morbid obese adults, undergone to bariatric surgery, with BMD measured by dual-energy X-ray absorptiometry at baseline and after surgery studies was performed in several databases. Studies were assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement and COCHRANE Risk of Bias tool. The random model was selected for meta-analysis; heterogeneity was analyzed with T(2), inconsistency (I(2) > 50%) and Chi(2) (p < 0.10). Level of evidence and strength of recommendations were summarized using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE System).

RESULTS

Twelve studies met the selection criteria. After one year, reduction in total BMD in patients with mixed surgical procedures was significant: -0.03 g/cm(2) (CI 95% 0.00 to -0.06, p < 0.05). BMD was reduced by -0.12 g/cm(2) (CI 95% -0.10 to -0.15, p < 0.001) in the hip, -0.07 g/cm(2) (CI 95% -0.03 to -0.11, p < 0.001) in the column, and -0.03 g/cm(2) (IC 95% -0.02 to -0.04, p < 0.001) in the forearm, but not in restrictive surgeries. Studies included showed high heterogeneity and low quality of evidence.

CONCLUSIONS

Patients undergone to mixed bariatric surgery had significant higher BMD deterioration as demonstrated in this review, suggesting that more attention for preventing fractures is required.

Analysis of apparent integrated backscatter coefficient and backscattered spectral centroid shift in Calcaneus in vivo for the ultrasonic evaluation of osteoporosis

The purposes of our study were to evaluate the correlation among apparent integrated backscatter coefficient (AIB), spectral centroid shift (SCS) of ultrasonic backscatter signals and bone mineral density (BMD) and to examine the effectiveness of ultrasound variables as predictors of osteoporosis. A total of 1011 persons aged 21-80 y old were included. All study participants underwent BMD measurements of the lumbar spine (LSBMD) and the femoral neck (FNBMD). The participants also underwent calcaneal measurements to determine AIB and SCS with central frequencies of 3.5 (one transducer) and 5.0 MHz (the other transducer). AIB decreased with age and was positively correlated with BMD, while SCS increased with age and was negatively correlated with BMD. The correlation coefficient of SCS with LSBMD and FNBMD at 3.5 MHz was -0.72 and -0.70, respectively. The correlation coefficient at 5.0 MHz was -0.75 and -0.74, respectively. The correlation coefficient of AIB with LSBMD and FNBMD at 3.5 MHz was 0.65 and 0.63. The correlation coefficient at 5.0 MHz was 0.59 and 0.55, respectively. The correlation between SCS and BMD was significantly better than the correlation between AIB and BMD. Using receiver operating characteristic analysis, a significant difference was found between the areas under the curve for SCS and AIB at 3.5 MHz (0.781 vs. 0.715, respectively, p < 0.05), as well as at 5.0 MHz (0.782 vs. 0.709, respectively, p < 0.05). The optimum T-score threshold for SCS was -1.3 for both transducers. The sensitivity and specificity of SCS at 3.5 MHz and 5.0 MHz for the optimum threshold were 64%, 85%, 63% and 86%, respectively. In conclusion, the correlations among the ultrasound parameters and BMDs are strong. SCS performs better than AIB in differentiating patients with osteoporosis. Ultrasound variables may be taken into consideration as predictors of osteoporosis in the future considering its portability.

Polyalanine repeat polymorphism in RUNX2 is associated with site-specific fracture in post-menopausal females

Runt related transcription factor 2 (RUNX2) is a key regulator of osteoblast differentiation. Several variations within the RUNX2 gene have been found to be associated with significant changes in BMD, which is a major risk factor for fracture. In this study we report that an 18 bp deletion within the polyalanine tract (17A>11A) of RUNX2 is significantly associated with fracture. Carriers of the 11A allele were found to be nearly twice as likely to have sustained fracture. Within the fracture category, there was a significant tendency of 11A carriers to present with fractures of distal radius and bones of intramembranous origin compared to bones of endochondral origin (p = 0.0001). In a population of random subjects, the 11A allele was associated with decreased levels of serum collagen cross links (CTx, p = 0.01), suggesting decreased bone turnover. The transactivation function of the 11A allele showed a minor quantitative decrease. Interestingly, we found no effect of the 11A allele on BMD at multiple skeletal sites. These findings suggest that the 11A allele is a biologically relevant polymorphism that influences serum CTx and confers enhanced fracture risk in a site-selective manner related to intramembranous bone ossification.

Multisite quantitative ultrasound for the prediction of fractures over 5 years of follow-up: the Canadian Multicentre Osteoporosis Study

This study assessed the ability of multisite quantitative ultrasound (mQUS) to predict fracture over a 5-year follow-up. Participants were a subset of the Canadian Multicentre Osteoporosis Study. mQUS-assessed speed of sound (SOS in m/s) at three sites (distal radius, tibia, and phalanx) and extensive questionnaires were completed, after which participants were followed for 5 years and incident fractures recorded. Two survival analyses were completed for each site--a univariate analysis and an adjusted multivariate analysis controlling for age, antiresorptive use, femoral neck bone mineral density, number of diseases, previous fractures, body mass index (BMI), parental history of hip fracture, current smoking, current alcoholic drinks >3 per day, current use of glucocorticoids, and rheumatoid arthritis diagnosis (variables from the FRAX 10-year fracture risk assessment tool). The unit of change for regression analyses was one standard deviation for all measurement sites, specific to site and sex. Separate analyses were completed for all clinical fractures, nonvertebral fractures, and hip fractures by sex. There were 2633 women and 1108 men included, and they experienced 204 incident fractures over 5 years (5.5% fractured). Univariate models revealed statistically significant (p < 0.05) predictive ability of mQUS for all three measurement sites for women alone for all three fracture types (one standard deviation decrease in SOS was associated with a 52% to 130% increase in the risk of fracture), but not for the men's group. The adjusted model found that measures at the distal radius and tibia in the women's group could significantly (p < 0.05) predict all clinical fractures and nonvertebral fractures within the next 5 years (one standard deviation decrease in SOS was associated with a 25% to 31% increase in the risk of fracture). mQUS provided significant 5-year clinical fracture prediction in women, independent of bone mineral density and other significant risk factors for fracture, when measured at the distal radius and tibia sites.

Missense polymorphisms of the WNT16 gene are associated with bone mass, hip geometry and fractures

Two missense polymorphisms of WNT16 were associated with hip bone mineral density (BMD), the buckling ratio of the femoral neck, calcaneal ultrasound and hip fractures in individuals under 80 years of age. These results confirm the association of the WNT16 gene with bone mass and osteoporotic fractures.

INTRODUCTION

Osteoporosis has a strong genetic component. Wnt ligands stimulate the differentiation of osteoblast precursors and play a major role in skeletal homeostasis. Therefore, the aim of this study was to explore the association of allelic variants of the WNT16 gene with BMD, other structural parameters of bone and osteoporotic hip fractures.

METHODS

Six single nucleotide polymorphisms were analysed in 1,083 Caucasian individuals over 49 years of age.

RESULTS

Two missense polymorphisms (rs2908004 and rs2707466) were associated with femoral neck BMD, with average differences across genotypes of 35 mg/cm(2) (p = 0.00037 and 0.0015, respectively). Likewise, the polymorphisms were associated with calcaneal quantitative ultrasound parameters (p = 0.00004 and 0.0014, respectively) and the buckling ratio, an index of cortical instability of the femoral neck (p = 0.0007 and 0.0029, respectively). Although there were no significant differences in the genotype frequency distributions between 294 patients with hip fractures and 670 controls, among the subgroup under 80 years of age, TT genotypes were underrepresented in patients with fractures (odds ratio 0.50; CI 0.27-0.94).

CONCLUSION

Common missense polymorphisms of the WNT16 gene are associated with BMD at the hip, calcaneal ultrasound and the buckling ratio of the femoral neck, as well as with hip fractures in individuals under 80 years of age. Overall, these results confirm the association of the WNT16 locus with BMD identified in genome-wide association studies and support its role in determining the risk of osteoporotic fractures.

Calcaneal quantitative ultrasound as a determinant of bone health status: what properties of bone does it reflect?

Quantitative ultrasound (QUS) has emerged as a convenient and popular screening tool for osteoporosis. This review aimed to provide basic information on the principle of QUS measurement and discuss the properties of bone reflected by QUS indices. QUS employed high frequency sound waves generated by the device to determine bone health status in humans. In vitro studies showed that QUS indices were significantly associated with bone mineral density (BMD), bone microarchitecture and mechanical parameters. In humans, QUS indices were found to be associated with BMD as well. In addition, QUS could discriminate subjects with and without fracture history and predict risk for future fracture. In conclusion, QUS is able to reflect bone quality and should be used in the screening of osteoporosis, especially in developing countries where dual-X-ray absorptiometry devices are less accessible to the general population.

Glutamine repeat variants in human RUNX2 associated with decreased femoral neck BMD, broadband ultrasound attenuation and target gene transactivation

RUNX2 is an essential transcription factor required for skeletal development and cartilage formation. Haploinsufficiency of RUNX2 leads to cleidocranial displaysia (CCD) a skeletal disorder characterised by gross dysgenesis of bones particularly those derived from intramembranous bone formation. A notable feature of the RUNX2 protein is the polyglutamine and polyalanine (23Q/17A) domain coded by a repeat sequence. Since none of the known mutations causing CCD characterised to date map in the glutamine repeat region, we hypothesised that Q-repeat mutations may be related to a more subtle bone phenotype. We screened subjects derived from four normal populations for Q-repeat variants. A total of 22 subjects were identified who were heterozygous for a wild type allele and a Q-repeat variant allele: (15Q, 16Q, 18Q and 30Q). Although not every subject had data for all measures, Q-repeat variants had a significant deficit in BMD with an average decrease of 0.7SD measured over 12 BMD-related parameters (p = 0.005). Femoral neck BMD was measured in all subjects (-0.6SD, p = 0.0007). The transactivation function of RUNX2 was determined for 16Q and 30Q alleles using a reporter gene assay. 16Q and 30Q alleles displayed significantly lower transactivation function compared to wild type (23Q). Our analysis has identified novel Q-repeat mutations that occur at a collective frequency of about 0.4%. These mutations significantly alter BMD and display impaired transactivation function, introducing a new class of functionally relevant RUNX2 mutants.