Stiffness index identifies patients with osteoporotic fractures better than ultrasound velocity or attenuation alone

Does Quantitative Ultrasound at the Calcaneus Predict an Osteoporosis Diagnosis in Postmenopausal Women from the Silesia Osteo Active Study?

The aims of the study were to assess the clinical conformity between quantitative ultrasound (QUS) and densitometry with use of the standard World Health Organization T-score thresholds to determine optimal diagnostic cutoff values for QUS T-scores in different age groups. Three hundred sixty-five postmenopausal Caucasian women were enrolled into the study and divided into two age groups (<65 y and ≥65 y). Skeletal status was assessed using QUS measurements at the calcaneus and bone densitometry at the spine and proximal femur (Hologic Explorer, Bedford, MA, USA). QUS measurement results expressed as the stiffness index (SI) correlated significantly with both femoral neck bone mineral density (r = 0.51, p < 0.0001) and lumbar spine bone mineral density (r = 0.52, p < 0.0001). On the basis of receiver operating characteristic curve analyses, the thresholds for correspondence between QUS T-score values and T-score -2.5SD in dual X-ray absorptiometry (DXA) were established. They ranged between -1.63SD and -1.70SD in relation to femoral neck DXA and between -1.22SD and -1.51SD in relation to lumbar spine DXA, depending on age category. In conclusion, the study described here confirmed that QUS measurements at the calcaneus may provide information comparable to DXA examinations at the femoral neck and lumbar spine in postmenopausal women.

Perfluoroalkyl substances and bone health in young men: a pilot study

PURPOSE

Perfluoroalkyl substances (PFAS) are a class of endocrine-disrupting chemicals. Toxicological studies indicate that PFAS accumulate in bone tissue and could cause alterations in bone metabolism. The primary objective of this study was to examine the association between PFAS exposure and bone status in a cohort of young men resident in a well-defined area with high PFAS environmental pollution.

METHODS

Bone status was assessed in 117 subjects aged 18-21 by quantitative ultrasound (QUS) at the heel. Subjects underwent an accurate medical visit. Socio-demographic characteristics, lifestyle, and medical histories were collected. We also verified the interaction between PFAS and hydroxyapatite by computational modelling. The organic anion-transporting peptide (OATP), the putative transporter of PFAS, was evaluated by qPCR in bone biopsies from femoral heads discarded during arthroplasty in three male subjects.

RESULTS

Exposed subjects showed significantly lower stiffness index, which resulted in lower t-score and higher prevalence of subjects at medium-high risk of fracture (23.6%) compared with controls (9.7%). Data from computational modelling suggested that PFOA exhibits a high affinity for hydroxyapatite, since the estimated change in free energy is in the order of that exhibited by bisphosphonates. Finally, we observed consistent expression of OATP1A2 gene in primary human osteoblasts.

CONCLUSIONS

This is the first study reporting increased osteoporosis risk in young men exposed to PFAS and provide preliminary information on molecular mechanisms that could explain this observation, in agreement with previous studies on animal models and humans. However, these results must be interpreted with caution given the cross-sectional study design and the small number of cases.

The Membrane Transporter OAT7 (SLC22A9) Is Not a Susceptibility Factor for Osteoporosis in Europeans

Bone production, maintenance, and modeling are a well-balanced process involving mineralization by osteoblasts and resorption by osteoclasts. Sex steroid hormones, including their conjugated forms, contribute majorly to maintaining this balance. Recently, variants in the SLC22A9 gene have been associated with osteoporosis in Korean females. We had recently shown that SLC22A9, encoding organic anion transporter 7 (OAT7), is an uptake transporter of estrone sulfate and identified several genetic variants in Europeans leading to functional consequences in vitro. We therefore hypothesized that SLC22A9 genetic variants may contribute to the pathophysiology of osteoporosis in Europeans. To test this hypothesis, we examined the associations of SLC22A9 variants with bone quality, fractures, and bone turnover markers. We genotyped SLC22A9 variants in 5,701 (2,930 female) subjects (age range, 20-93 years) extracted from the population-based Study of Health in Pomerania (SHIP and SHIP-TREND) covered by the Illumina Infinium HumanExome BeadChip version v1.0 (Exome Chip). Descriptive data (e.g., history of fractures), ultrasonography of the calcaneus, as well as serum concentrations of carboxy-terminal telopeptide of type I collagen, amino-terminal propeptide of type I procollagen, and vitamin D were determined. Comprehensive statistical analyses revealed no association between low-frequency and rare SLC22A9 variants and bone quality, fractures, and bone turnover markers. Our results indicate that single genetic SLC22A9 variants do not have a major impact on osteoporosis risk prediction in Europeans, yet findings need to be replicated in larger-scale studies.

Meta-Analysis of Genome-Wide Association Studies Identifies Three Loci Associated With Stiffness Index of the Calcaneus

The stiffness index (SI) from quantitative ultrasound measurements is a good indicator of BMD and may be used to predict the risk of osteoporotic fracture. We conducted a genomewide association study (GWAS) for SI using 7742 individuals from the Taiwan Biobank, followed by a replication study in a Korean population (n = 2955). Approximately 6.1 million SNPs were subjected to association analysis, and SI-associated variants were identified. We further conducted a meta-analysis of Taiwan Biobank significant SNPs with a Korean population-based cohort. Candidate genes were prioritized according to epigenetic annotations, gene ontology, protein-protein interaction, GWAS catalog, and expression quantitative trait loci analyses. Our results revealed seven significant single-nucleotide polymorphisms (SNPs) within three loci: 7q31.31, 17p13.3, and 11q14.2. Conditional analysis showed that three SNPs, rs2536195 (CPED1/WNT16), rs1231207 (SMG6), and rs4944661 (LOC10050636/TMEM135), were the most important signals within these regions. The associations for the three SNPs were confirmed in a UK Biobank estimated BMD GWAS; these three cytobands were replicated successfully after a meta-analysis with a Korean population cohort as well. However, two SNPs were not replicated. After prioritization, we identified two novel genes, RAB15 and FNTB, as strong candidates for association with SI. Our study identified three SI-associated SNPs and two novel SI-related genes. Overall, these results provide further insight into the genetic architecture of osteoporosis. Further studies in larger East Asian populations are needed. © 2019 American Society for Bone and Mineral Research.

Agreement Between Dual-Energy X-Ray Absorptiometry and Quantitative Ultrasound to Evaluate Bone Health in Adolescents: The PRO-BONE Study

PURPOSE

The present study aims to investigate the association between dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) parameters and the intermethods agreement in active males.

METHODS

In this cross-sectional study, bone health (by DXA and calcaneal QUS), physical activity (by accelerometers), and anthropometrics measurements were assessed in 117 active adolescents (12-14 y old). Bivariate correlation coefficients were calculated to assess the relationships between DXA standard regions of interest and QUS parameters. Intraclass correlation coefficients and Bland-Altman plots were used to assess the level of agreement between bone mineral content regions derived from DXA and stiffness index. The measurements were z score transformed for comparison.

RESULTS

Most QUS parameters were positive and significantly correlated with DXA outcomes (stiffness index: r = .43-.52; broadband ultrasound attenuation: r = .50-.58; speed of sound: r = .25-.27) with the hip showing the highest correlations. Moreover, the present study found fair to good intraclass correlation coefficients of agreement (.60-.68) between DXA and QUS to assess bone health. The Bland-Altman analysis showed a limited percentage of outliers (3.2%-8.6%).

CONCLUSION

QUS device could represent an acceptable alternative method to assess bone health in active adolescent males.

Assessment of the effect of strontium, lead, and aluminum in bone on dual-energy x-ray absorptiometry and quantitative ultrasound measurements: A phantom study

PURPOSE

Dual-energy X-ray absorptiometry (DXA) is the gold standard technique to measure areal bone mineral density (aBMD) for the diagnosis of osteoporosis. Because DXA relies on the attenuation of photon to estimate aBMD, deposition of bone-seeking metallic elements such as strontium, lead, and aluminum that differ in atomic numbers from calcium can cause inaccurate estimation of aBMD. Quantitative ultrasound (QUS) is another technique available to assess bone health by measuring broadband ultrasound attenuation (BUA), speed of sound (SOS), and an empirically derived quantity called stiffness index (SI). Because the acoustic properties are not prone to significant change due to changes in microscopic atomic composition of bone, it is hypothesized that QUS is unaffected by the presence of bone-seeking elements in the bone. The objective of this study was to investigate the effect of strontium, lead, and aluminum on DXA-derived aBMD and QUS parameters using bone-mimicking phantoms compatible with both techniques.

METHODS

Bone-mimicking phantoms were produced by homogeneously mixing finely powdered hydroxyapatite compounds that contain varying concentrations of strontium, lead, or aluminum with porcine gelatin solution. Seven strontium-substituted phantoms were produced with varying molar ratio of Sr/(Sr + Ca) ranging from 0% to 2%. Four lead-doped phantoms and four aluminum-doped phantoms were constructed with the respective analyte concentrations ranging from 50 to 200 ppm. An additional 0 ppm phantom was produced to be used as a baseline for the lead and aluminum phantom measurements. All phantoms had uniform volumetric bone mineral density (vBMD) of 200 mg/cm³ , and were assessed using a Hologic Horizon^® DXA device and a Hologic Sahara^® QUS device. Furthermore, theoretical aBMD bias for mol/mol% substitution of calcium with the three bone-seeking elements was calculated.

RESULTS

Strong positive linear relationship was found between aBMD measured by DXA and strontium concentration (P < 0.001, r = 0.995). From the measurement of lead and aluminum phantoms using DXA, no statistically significant relationship was observed between aBMD and the analyte concentrations. For the QUS system, with an exception of BUA and lead concentration that exhibited statistically significant relationship (P < 0.038, r = 0.899), no statistically significant change was observed in all QUS parameters with respect to the clinically relevant concentration of all three elements. The calculated theoretical aBMD bias induced by 1 mol/mol% substitution of calcium with strontium, lead, and aluminum were 10.8%, 4.6%, and -0.7%, respectively.

CONCLUSION

aBMD measured by DXA was prone to overestimation in the presence of strontium, but acoustic parameters measured by QUS are independent of strontium concentration. The deviation in aBMD induced by the clinically relevant concentrations of lead and aluminum under 200 ppm could not be detected using the Hologic Horizon^® DXA device. Furthermore, the SI measured by the QUS system was not affected by lead or aluminum concentrations used in this study.

An Assessment of Osteoporotic Conditions among Users and Non-Users of Warfarin: A Case-Control Study

INTRODUCTION

Warfarin is an oral anticoagulant which is associated with a decrease in Bone Mass Density (BMD).

AIM

The study aimed to explore the prevalence of osteoporosis conditions in Malaysians with chronic warfarin patients using calcaneal quarter of Quantitative Ultrasound (QUS) machine and to investigate whether long-term sodium warfarin therapy that antagonizes vitamin K is affecting the increasing rate of osteoporosis in Penang and to find the risk factors of getting osteoporosis among warfarin users and its non users.

MATERIALS AND METHODS

A case-control study was conducted among 130 patients using warfarin, attending the outpatient clinic at Hospital Pulau Pinang. A convenience sampling method was used to recruit the required sample. Another 140 subjects were selected from the community as a control group (non-users of warfarin).

RESULTS

This study showed that more than three-quarter patients (82%) were at high risk of abnormal BMD. The warfarin users were two times more likely to have a higher osteoporosis risk compared to control group. Moreover, BMD has a negative correlation with age, but has a positive correlation with Body Mass Index (BMI). Patients showed a negative correlation with a higher dose of warfarin intake.

CONCLUSION

This study concluded that osteopenia and osteoporosis are serious problems between users and non-users warfarin in Penang. Therefore, it should be taken into consideration in the Malaysian Health Ministry's agenda.

Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children?

Objectives

The aim of the current study was to assess whether calcaneal broadband ultrasound attenuation (BUA) can predict whole body and regional dual-energy x-ray absorptiometry (DXA)-derived bone mass in healthy, Australian children and adolescents at different stages of maturity.

Methods

A total of 389 boys and girls across a wide age range (four to 18 years) volunteered to participate. The estimated age of peak height velocity (APHV) was used to classify children into pre-, peri-, and post-APHV groups. BUA was measured at the non-dominant heel with quantitative ultrasonometry (QUS) (Lunar Achilles Insight, GE), while bone mineral density (BMD) and bone mineral content (BMC) were examined at the femoral neck, lumbar spine and whole body (DXA, XR-800, Norland). Associations between BUA and DXA-derived measures were examined with Pearson correlations and linear regression. Participants were additionally ranked in quartiles for QUS and DXA measures in order to determine agreement in rankings.

Results

For the whole sample, BUA predicted 29% of the study population variance in whole body BMC and BMD, 23% to 24% of the study population variance in lumbar spine BMC and BMD, and 21% to 24% of the variance in femoral neck BMC and BMD (p < 0.001). BUA predictions were strongest for the most mature participants (pre-APHV R² = 0.03 to 0.19; peri-APHV R² = 0.05 to 0.17; post-APHV R² = 0.18 to 0.28) and marginally stronger for girls (R² = 0.25-0.32, p < 0.001) than for boys (R² = 0.21-0.27, p < 0.001). Agreement in quartile rankings between QUS and DXA measures of bone mass was generally poor (27.3% to 38.2%).

Conclusion

Calcaneal BUA has a weak to moderate relationship with DXA measurements of bone mass in children, and has a tendency to misclassify children on the basis of quartile rankings.

Cite this article: B. K. Weeks, R. Hirsch, R. C. Nogueira, B. R. Beck. Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children? Bone Joint Res 2016;5:538–543. DOI: 10.1302/2046-3758.511.BJR-2016-0116.R1.

Comparison of combined low-dose hormone therapy vs. tibolone in the prevention of bone loss

OBJECTIVES

To compare the effects on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry at the lumbar spine, the femoral neck and the total hip following 2 years of treatment with a low-dose combined hormone therapy (HT) comprised of 1 mg estradiol and 0.5 mg norethisterone acetate (E2/NETA) versus 2.5 mg tibolone in postmenopausal women. Additionally, quantitative ultrasonometry (QUS) of the os calcaneus and of the phalanges was performed.

METHODS

Changes in BMD, QUS and side-effects were assessed at baseline, 6, 12 and 24 months in 50 postmenopausal women who received either E2/NETA (n = 26) or tibolone (n = 24) for 2 years.

RESULTS

Compared to women on tibolone, women receiving E2/NETA showed a significant increase in BMD from baseline to 12 and 24 months at the lumbar spine (3.07%, 3.86%; p < 0.01 vs. 1.13%, 2.23%; p < 0.05), and at the total hip (1.33%, 1.69%; p < 0.01 vs. 0.76%, 0.70%) and at the femoral neck from baseline to 24 months (1.10%; p < 0.05). QUS indices only showed a significant change with the ultrasound bone profile index with E2/NETA at 6 months (-2.32%; p < 0.001).

CONCLUSIONS

Low-dose E2/NETA showed a significantly higher increase in BMD compared to tibolone. QUS measurement was not considered to comprise beneficial effects in monitoring drug-induced bone changes.

Measurements of bone mineral density and stiffness index in young Saudi females

Objective:

To examine the ability to use Quantitative Ultrasonography (QUS) densitometer for screening of osteoporosis and osteopenia by comparing QUS values obtained at the calcaneus region to bone mineral density (BMD) values measured at the spine and the neck of the femur using Dual Energy X-ray Absorbemetry (DXA).

Methods:

QUS (in the calcaneus region) and DXA (the spine and the neck of femur respectively) measurements were performed in 101 females.

Results:

The precision of the QUS parameters varied from 1.77-1.78, whereas the reliability ranged from 92.2%-98.6%. For the QUS parameters variability between subjects was greater than that within subjects. Positive correlation were found between stiffness index (SI) and BMD_spine and BMD_N.femur (r= 0.29 & r=0.25 respectively, P < 0.05) and a strong positive correlation between T-score_calcaneus and both T-score_Spine and T-score_N.femur (r= 0.5 & r=0.58 respectively, P < 0.01).

Conclusions:

QUS is a reliable technique to be used in combination with DXA for the investigation of osteopenia and osteoporosis.

Quantitative ultrasound criteria for risk stratification in clinical practice: a comparative assessment

This study aimed to compare two different classifications of the risk of fracture/osteoporosis (OP) based on quantitative ultrasound (QUS). Analyses were based on data from the Epidemiological Study on the Prevalence of Osteoporosis, a cross-sectional study conducted in 2000 aimed at assessing the risk of OP in a representative sample of the Italian population. Subjects were classified into 5 groups considering the cross-classification found in previous studies; logistic regression models were defined separately for women and men to study the fracture risk attributable to groups defined by the cross-classification, adjusting for traditional risk factors. Eight-thousand six-hundred eighty-one subjects were considered in the analyses. Logistic regression models revealed that the two classifications seem to be able to identify a common core of individuals at low and at high risk of fractures, and the importance of a multidimensional assessment in older patients to evaluate clinical risk factors together with a simple, inexpensive, radiation-free device such as QUS.

A population-based study examining calcaneus quantitative ultrasound and its optimal cut-points to discriminate osteoporotic fractures among 9352 Chinese women and men

CONTEXT

No generally accepted thresholds for quantitative ultrasound (QUS) parameters to screen individuals at high risk of osteoporotic fractures have been defined.

OBJECTIVE

We sought to define appropriate cutoff points for osteoporotic fractures of calcaneus ultrasound according to participants' prevalent osteoporotic fractures.

DESIGN AND SETTING

This was a cross-sectional, population-based study conducted in Shanghai, China.

PARTICIPANTS

A total of 9352 Chinese women and men aged 40 and older were studied.

MAIN OUTCOME MEASURES

We measured calcaneus QUS (Achilles Express, GE Lunar) values and their relationships with osteoporotic fractures.

RESULTS

A prevalence of 14.9 and 12.2% of osteoporotic fractures was found in the women and men (P<0.001), respectively. Subjects with osteoporotic fractures had significantly lower QUS values than those without (P<0.001). One sd decline in the stiffness index (SI)-derived T-score was associated with a high risk of nonvertebral fracture [odds ratio (OR)=1.50; 95% confidence interval (CI), 1.39-1.62; P<0.001], clinical vertebral fracture (OR=1.49; 95% CI, 1.18-1.90; P<0.01), and multi-fractures (OR=1.98; 95% CI, 1.63-2.40; P<0.001). The receiver operating characteristic analysis showed that QUS could differentiate osteoporotic fractures in postmenopausal women and men, but not in premenopausal women. The optimal cutoff points for the SI-derived T-score to detect a high risk of nonvertebral fractures, clinical vertebral fractures, and multi-fractures were -1.25, -1.55, and -1.80 in postmenopausal women, respectively, and -1.30, -1.90, and -2.00 in males, respectively.

CONCLUSIONS

As a screening tool, the SI-derived T-score obtained from the Achilles QUS device for a postmenopausal woman or man that is less than -1.25 and -1.30, respectively, may indicate an increased risk of osteoporotic fractures and should be further evaluated by central DXA.

Calcaneal quantitative ultrasound value for middle-aged and elderly Malaysian Chinese men and its association with age and body anthropometry

Quantitative ultrasound (QUS) is a relatively easy, reliable, and safe method for bone status assessment, but reference data for Asian males remain scarce. Our study aimed to determine the values for one QUS parameter, the speed of sound (SOS) at the calcaneus, in Malaysian Chinese men and to determine the association between the SOS and several demographic characteristics, such as age, weight, height, and body mass index. Three hundred forty-eight Malaysian Chinese men aged 40 yr and older were recruited, and their calcaneal QUS value was determined using the CM-200 densitometer (Furuno Electric, Nishinomiya City, Japan). The results indicated a significant correlation between SOS and age, and multiple stepwise regression analysis indicated that age and height were important predictors of SOS. A significant reduction in SOS value was observed when men 60 yr and older were compared with men aged 40-49 yr. Compared with the reference data for Japanese males, Chinese men in Malaysia showed higher SOS values across all the age groups studied. In conclusion, there is an age-related decrease in SOS values in Malaysian Chinese men, and the SOS values established in this study can be used as a reference for future studies.

Bone Status in Activity-Restricted Pregnant Women Assessed Using Calcaneal Quantitative Ultrasound

Objective:

Pregnancy-induced bone loss may be further exacerbated by activity restriction (AR). The authors compared the bone status of AR hospitalized (≥7 days) pregnant women in the third trimester to ambulatory (AM) women at the same gestational age, using a prospective cross-sectional design.

Method:

AR was quantified in AR women by daily step counts using a pedometer for 7 consecutive days. Bone status was evaluated in the left and right calcaneus bones of both AR ( n = 13) and AM ( n = 20) women using quantitative ultrasound (QUS).

Results:

AR women took an average of 1,504 ± 1,377 steps/day. Speed of sound scores (1,543.05 ± 41.97 m/s vs. 1,569.60 ± 46.12 m/s) and broadband ultrasound attenuation (BUA) scores (107.93 ± 9.59 dB/MHz vs. 114.69 ± 17.06 dB/MHz) were not different between the AR and AM groups, respectively ( p > .05). However, bone stiffness index (SI) scores (84.0 ± 16.2 vs. 95.8 ± 22.1, respectively, p < .05) were different between groups, indicating a greater relative risk of future fracture in the AR women.

Conclusion:

Increased fracture risk appears to be a negative side effect incurred through an average of 16 days of hospitalized AR in late pregnancy. Further investigations using a larger sample size are necessary to evaluate the effect of antepartum AR on bone status in the postpartum period to determine if bone status is further attenuated by breastfeeding or if recovery occurs with resumption of ambulation and return of menses and to assess future risk in these women as they age. Prenatal care providers should be made aware of these risks.

Association between alcohol consumption and bone strength in Korean adults: the Korean Genomic Rural Cohort Study

Previous studies have reported an inconsistent relationship between alcohol consumption and bone health. A growing body of research has shown that chronic alcoholism leads to osteopenia and increased incidence of skeletal fractures, but some studies have concluded that alcohol consumption may be associated with higher bone mineral density in elderly populations. However, most studies showing a significant relationship between alcohol consumption and bone status have been in Western countries; and subjects have usually been postmenopausal women. The purpose of the present study was to investigate the association of alcohol consumption with bone strength in Korean adults. Data were from the Korean Genomic Rural Cohort Study, which is an ongoing population-based study of adults aged 40 to 70 years from 5 regions. A total of 7713 participants (3368 men, 4345 women) were surveyed about their annual consumption of alcohol such as soju, beer, makkolli, wine, and whisky. Bone strength was measured by stiffness index using the calcaneal quantitative ultrasound method. Overall, the annual age-specific decrease rate in the stiffness index of women was 2.7 times higher than that of men (0.463% for women, 0.169% for men).After adjustment for eligible covariates, the association between alcohol consumption and risk of reduced bone strength showed a J-shaped curve for both men and women. Compared with nondrinkers, the relative risk of reduced bone strength was 0.52 (95% confidence interval, 0.33-0.83) in men who drank 4 to 5 cups of soju for an amount of 29.626 to 49.375 g of alcohol per day and 0.61 (95% confidence interval, 0.38-0.86) in men who drank 6 to 7 cups of soju for an amount of 49.376 to 69.125 g of alcohol per day. We found no significant relationship between alcohol consumption and bone strength in any other group of men. For women, results suggested that the risk of reduced bone strength was lower in the moderate-consumption group; but no significant relationship was found between alcohol consumption at any level and bone strength. Among Korean adults, alcohol consumption has a J-shaped relationship with risk of reduced bone strength.

The influence of chemotherapy on bone mineral density, quantitative ultrasonometry and bone turnover in pre-menopausal women with breast cancer

INTRODUCTION

The effects of doxorubicin/cyclophosphamide (A/C; 6 cycles) chemotherapy on bone mineral density (BMD), quantitative ultrasonography (QUS) and bone turnover markers in pre-menopausal women with oestrogen receptor-negative breast cancer (BC) were compared with age-matched controls.

METHODS

Among 106 women (BC=53, controls=53), BMD (spine and hip), QUS (calcaneus and phalanges) and bone marker levels were measured at baseline, 6 and 12 months. Correlations between parameters were determined by Spearman's rho.

RESULTS

All BC patients became amenorrhoeic after chemotherapy and remained so for the duration of treatment. BC patients had significant bone loss at all sites (P.005) and significant increases in bone turnover (P.05). There were significant correlations between BMD, QUS and bone markers (P.05).

CONCLUSIONS

Results confirm A/C's deleterious influence on bone health in pre-menopausal women with BC and established QUS's utility for monitoring bone effects. Large-scale longitudinal studies are needed to further understand and prevent bone changes following chemotherapy.

Quantitative ultrasonometry of the phalanges during pregnancy: a longitudinal study

OBJECTIVE

The aim of this study was to determine prospectively the change in results of bone ultrasonometry measurement during pregnancy in healthy German women. Study design Quantitative ultrasonometry (QUS) of the phalanges was performed in 60 healthy, pregnant women. Measurements of amplitude-dependent bone propagation velocity (speed of sound; AdSOS) and the bone transmission time (BTT) were performed during the three trimesters of pregnancy in 60 patients.

RESULTS

During pregnancy, a significant increase in body weight and body mass index (p < or = 0.001) were observed. In accordance with bone ultrasonometry, a significant reduction in AdSOS was found in each trimester; AdSOS was significantly lower in the second and third trimesters compared with the first (p < or = 0.001). The BTT values also decreased significantly in the second and third trimesters compared with the first (p < or = 0.001). No significant influence was found of possible risk factors such as family risk of osteoporosis, previous pregnancies, age at menarche and prior use of oral contraceptives on QUS measurement results.

CONCLUSIONS

During normal pregnancy, we found a significant reduction of quantitative ultrasonometry variables AdSOS and BTT in healthy pregnant women. This decrease had a large influence on the t score and Z score of QUS in our study and demonstrates therefore a possible clinical relevance. The decrease was independent of osteoporosis-related risk factors and the increase in body weight. More large-scale, prospective studies are needed to increase our knowledge about the mechanism of bone turnover during pregnancy and lactation.

Quantitative Ultrasonography of Calcaneal Bone Mass and Its Relationship to Calcium Consumption Among Impoverished Hispanic Women

Perimenopausal Hispanic women need to be able to build and sustain peak bone mass, but this may be affected by their low socioeconomic status. This feasibility research study provided descriptive information on the relationship between calcium consumption and bone mass measured with sonography at the calcaneus. Little research exists to examine bone health with this specific age or ethnic group of women. This research found a strong positive correlation between the amount of self-reported calcium food consumed and the bone stiffness index recorded using quantitative sonography. The translational impact of this project will inform the development of culturally relevant patient education for Hispanic women of low socioeconomic status to encourage the development of peak bone mass.

Reference data for quantitative ultrasound values of calcaneus in 2927 healthy Chinese men

Quantitative ultrasound (QUS) is a bone densitometry technique that is rapidly gaining popularity for the assessment of bone status. However, few QUS data are available for men, especially in China. In the present study, a random stratified sample of 2927 Chinese men (10-90 years) was recruited, and bone status was established using measurements by Achilles ultrasonometer. The peak stiffness index (SI) value for Chinese men was 103.0 +/- 20.8, which presented in the age group of 20-24 years. Pearson correlation analysis showed that there was significant correlation between SI and age (P < 0.001), and multivariate regression analysis indicated that weight was also an important factor for SI. In addition, in comparison with the normal data of Italian and Japanese males, the SI value for Chinese males in each age group was lower than those of Italians but higher than Japanese, except for the 20-29 years age group. The descending velocity of curves for Chinese men was lower than that of Italian and Japanese men. In conclusion, QUS values of the calcaneus provided by the present study may be used as normal reference values for Chinese men.

Digital X-ray radiogrammetry better identifies osteoarthritis patients with a low bone mineral density than quantitative ultrasound

This study assessed the ability of quantitative ultrasound (QUS) and digital X-ray radiogrammetry (DXR) to identify osteopenia and osteoporosis in patients with knee osteoarthritis (OA). One hundred and sixty-one patients with painful knee OA (81 men, 80 women; age 62.6+/-9.2 years, range 40-82 years) were included in this cross-sectional study and underwent dual-energy X-ray absorptiometry (DXA) of both hips and the lumbar spine, QUS of the phalanges and calcanei of both hands and heels, and DXR using radiographs of both hands. Unpaired t-test, Mann-Whitney U test, ROC analysis and Spearman's rank correlation were used for comparisons and correlation of methods. Using DXA as the reference standard, we defined a low bone mineral density (BMD) as a T-score < or =-1.0 at the lumbar spine or proximal femur. In contrast to phalangeal or calcaneal QUS, DXR was able to discriminate patients with a low BMD at the lumbar spine (p<0.0001) or hips (p<0.0001). ROC analysis showed that DXR had an acceptable predictive power in identifying OA patients a low hip BMD (sensitivity 70%, specificity 71%). Therefore, DXR used as a screening tool could help in identifying patients with knee OA for DXA.

Assessment of low quantitative ultrasound values of calcaneus in Chinese mainland women

Calcaneus quantitative ultrasound (QUS) assessment is a safe and reliable method for evaluating skeletal status. Until now, considerable data have been accumulated on the distribution of QUS in Caucasian populations, whereas such data are still insufficient in Asian populations, especially in Chinese mainland. The present study aimed to obtain the distribution characteristic of calcaneus QUS in healthy Chinese women, and to further investigate the distribution of low bone mass by QUS stiffness index (SI). This study included 2,498 healthy Chinese females aged 10-87 yr. The QUS exhibited a characteristic mild rise and then fall pattern with increasing age. Age, body height, and weight were significant influencing factors on SI, especially age and weight. The prevalence of osteoporosis detected using instrument-derived T-score or internal T-score was different from that calculated according to calcaneus bone mass density (BMD) previously reported. Furthermore, between instrument-derived T-scores and internal T-scores, there were also significant differences. We concluded that the World Health Organization criteria from BMD may not be appropriate for QUS, and the instrument-derived T-score may also not be appropriate for the studied population. The results will be useful for predicting fracture risk of Chinese women and determining diagnostic criteria of osteoporosis by QUS.

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.

An osteoporosis screening tool for Chinese men

Several osteoporosis risk instruments have been proposed to select women for bone densitometry, but no validated instruments are currently available for men. This study aims to address this deficiency by developing and validating a Male Osteoporosis Screening Tool (MOST) for Chinese men. Two thousand ambulatory men, aged 65 and above, were recruited from the general community in Hong Kong, and a cohort of 1,970 men with valid total hip and lumbar spine dual-energy X-ray absorptiometry (DXA) measurements was included in the current analysis. A 60% random sample was selected as the training sample for developing the screening tool, and the remaining 40% constituted the validation sample. Logistic regression and receiver operating characteristic (ROC) analysis were used to identify the simplest combination of risk factors to be included in the screening tool for predicting osteoporosis at the femoral neck, total hip, or lumbar spine. Body weight and quantitative ultrasound index (QUI) were found to contribute significantly to the area under the ROC curve (AUC), yielding an AUC of 0.823 in the training sample. The resulting MOST had a sensitivity of 94% and a specificity of 46% when using a cutoff score of 3. MOST had an AUC of 0.839 in the validation sample. The risk of osteoporosis was 1% among those with MOST scores < or = 2, but 72% among those with MOST scores > 7. Using a cutoff of 3, the negative predictive value was 97.5% which suggests that the 42% with MOST scores < or = 3 may be accurately screened out as being without osteoporosis, thus saving two fifths of our DXA resources. The positive predictive value was 72% when using a cutoff of 7, implying that MOST cannot replace DXA for case-finding purposes. Nevertheless, for resource allocation and patient satisfaction, it is prudent and economical to offer DXA screening first to the 6% with MOST scores > 7.

Quantitative ultrasound and bone mineral density: discriminatory ability in patients with rheumatoid arthritis and controls with and without vertebral deformities

BACKGROUND

Quantitative ultrasound (QUS) is a reliable tool for discriminating between subjects with and without vertebral deformities in postmenopausal osteoporosis. Less is known about osteoporosis caused by inflammatory diseases or corticosteroid use.

OBJECTIVES

(1). To compare in patients with rheumatoid arthritis the ability of QUS and dual energy x ray absorptiometry (DXA) to discriminate between those with and without vertebral deformities; (2). to explore whether the results are similar in population based controls.

METHODS

Standardised lateral radiographs of the spine were obtained from 210 patients with rheumatoid arthritis aged over 50 years and 210 individually matched controls. Vertebral deformities were assessed morphometrically and semiquantitatively. All participants underwent bone measurements by DXA (Lunar Expert) and QUS (Lunar Achilles+). Receiver operating curve (ROC) analysis was used to compare the discriminating ability of BMD and QUS measurements in patients and controls with and without vertebral deformities. Analyses were repeated in patients stratified according to corticosteroid use.

RESULTS

For all bone measurements except lumbar spine in the rheumatoid arthritis group, BMD discriminated significantly between the patients with and without vertebral deformities, and the results were similar to those obtained in controls. Among current corticosteroid users, neither QUS nor DXA could discriminate between subjects with and without vertebral deformities.

CONCLUSIONS

These findings support QUS as an alternative tool for identifying patients at risk of having vertebral deformities in rheumatoid arthritis, although results should be interpreted with caution in current users of corticosteroids.

Quantitative ultrasound (QUS) of bone in the management of postmenopausal women

OBJECTIVES

Postmenopausal osteoporosis is becoming a major problem for healthcare institutions as it has a growing social and economic impact. The incidence of osteoporotic fractures is constantly increasing due to the increase in life expectancy. The gynaecologist plays an important role in establishing a "biological zero" in each perimenopausal patient, and controlling the rate of bone loss during postmenopausal period.

RESULTS

Dual energy X-ray absorptiometry (DXA) has been widely used for the diagnosis and management of osteoporosis and represents a strong risk factor for fractures, but it presents several limitations with regards to diagnosis, treatment follow-up and differential diagnosis of secondary osteoporosis. In these last years quantitative ultrasound (QUS) technique has been introduced for the evaluation of bone status in postmenopausal women and several in vitro and clinical studies have demonstrated the reliability of the examination in terms of: reproducibility, evaluation of fracture risk, treatment follow-up, differential diagnosis. QUS has proven to be equally capable in the prediction of future osteoporosis related fractures in comparison to DXA. Large-scale cross-sectional and longitudinal studies have demonstrated the applicability of QUS in screening the female population during the climacteric period. QUS technique seems to be very efficient in identifying "fast losers", identifying subjects at risk for osteoporosis requiring second-level investigation (DXA, X-ray), diagnosing secondary osteoporosis.

CONCLUSION

If QUS is used in a systematic and rational manner in clinical practice, it is a valid technique for the prevention of osteoporosis in postmenopausal women.

Oestrogen receptor alpha genotype, and interactions between vitamin D receptor and transforming growth factor-beta1 genotypes are associated with quantitative calcaneal ultrasound in postmenopausal women

OBJECTIVE

Quantitative ultrasound (QUS) of bone is a new radiation-free, low-cost method that measures both bone mass and quality. We investigated associations between QUS parameters and polymorphisms of vitamin D receptor (VDR), oestrogen receptor alpha (ERalpha) and transforming growth factor-beta1 (TGF-beta1) genes in postmenopausal women residing in a community.

DESIGN

QUS and anthropometric characteristics were measured in postmenopausal women, and compared with regard to the VDR, ERalpha and TGF-beta1 genotypes.

PATIENTS

Among the 552 women who participated in the population-based Chung-Up osteoporosis prevalence study, 206 postmenopausal women, aged 60-69 years, were included.

MEASUREMENTS

Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured at the left calcaneus using QUS measurement of bone, and a stiffness index (SI) was calculated. We determined the BsmI and FokI polymorphisms of VDR gene and the XbaI and PvuII polymorphisms of ERalpha gene using the polymerase chain reaction-restriction fragment length polymorphism method, and Tau29 --> C polymorphism of TGF-beta1 gene using an allele-specific polymerase chain reaction assay.

RESULTS

The XbaI polymorphism of ERalpha gene was significantly associated with SI (T-score) and BUA (P = 0.040 and P = 0.024, respectively). There were no significant differences in any QUS parameters among the genotypes of VDR and TGF-beta1. However, significant genetic interactions between the VDR and TGF-beta1 genotypes, were noted (P = 0.017 for SI and P = 0.028 for BUA between the BsmI and Tau29 --> C polymorphisms; P = 0.038 for SI and P = 0.035 for BUA between the FokI and T29 --> C polymorphisms). The combined genotypes between the BsmI and T29 --> C polymorphisms or between the FokI and T29 --> C polymorphisms, were significantly associated with the QUS parameters.

CONCLUSIONS

This study indicates that the XbaI polymorphism of ERalpha gene may influence the Quantitative ultrasound parameters in postmenopausal women, and suggests the need for further investigations about the interactions between the VDR and TGF-beta1 genes.

Comparison of three bone ultrasounds for the discrimination of subjects with and without osteoporotic fractures among 7562 elderly women

Bone ultrasound measures (QUSs) can assess fracture risk in the elderly. We compared three QUSs and their association with nonvertebral fracture history in 7562 Swiss women 70-80 years of age. The association between nonvertebral fracture was higher for heel than phalangeal QUS.

INTRODUCTION

Because of the high morbidity and mortality associated with osteoporotic fractures, it is essential to detect subjects at risk for such fractures with screening methods. Because quantitative bone ultrasound (QUS) discriminated subjects with osteoporotic fractures from controls in several cross-sectional studies and predicted fractures in prospective studies, QUS could be more practical than DXA for screening.

MATERIAL AND METHODS

This cross-sectional and retrospective multicenter (10 centers) study was performed to compare three QUSs (two heel ultrasounds: Achilles+ [GE-Lunar] and Sahara [Hologic]; the phalanges: ultrasound DBM sonic 1200 [IGEA]) for determining by logistic regression nonvertebral fracture odds ratio (OR) in a sample of 7562 Swiss women, 75.3 +/- 3.1 years of age. The two heel QUSs measured the broadband ultrasound attenuation (BUA) and the speed of sound (SOS). In addition, Achilles+ calculated the stiffness index (SI) and the Sahara calculated the quantitative ultrasound index (QUI) from BUA and SOS. The DBM sonic 1200 measured the amplitude-dependent SOS (AD-SOS).

RESULTS

Eighty-six women had a history of a traumatic hip fracture after the age of 50, 1594 had a history of forearm fracture, and 2016 had other nonvertebral fractures. No fracture history was reported by 3866 women. Discrimination for hip fracture was higher than for the other nonvertebral fractures. The two heel QUSs had a significantly higher discrimination power than the QUSs of the phalanges, with standardized ORs, adjusted for age and body mass index, ranging from 2.1 to 2.7 (95% CI = 1.6, 3.5) compared with 1.4 (95% CI = 1.1, 1.7) for the AD-SOS of DBM sonic 1200.

CONCLUSION

This study showed a high association between heel QUS and hip fracture history in elderly Swiss women. This could justify integration of QUS among screening strategies for identifying elderly women at risk for osteoporotic fractures.

Performance of quantitative ultrasound in the discrimination of prevalent osteoporotic fractures in a bone metabolic unit

There is a growing interest in ultrasound evaluation of bone status as an alternative to the measurement with dual X-ray absorptiometry (DXA), due to its low cost, portability, and nonionizing radiation. The aim of our study was to investigate the relation among DXA, QUS, clinical, anthropometric, and lifestyle factors, and to determine QUS cutoff values in order to discriminate fractures in patients referred to the Bone Metabolic Unit at an Endocrinology Service. We studied 300 patients (281 females and 19 males; age 58 +/- 11 years) referred for evaluation of osteoporosis. In all cases we determined basic anthropometric parameters, a clinical history including previous osteoporotic fractures and risk factors for osteoporosis, and QUS parameters in calcaneus (Hologic Sahara), and BMD in lumbar spine (LS) and femoral neck (FN), by DXA (Hologic QDR 1000). Using the WHO densitometric criteria, 37, 46.7, and 16.3% of our population were osteoporotic, osteopenic, and normal, respectively. A QUI T-score </=-1.5 SD provided a sensitivity of 68.9% and a specificity of 64.7% for osteoporotic fracture discrimination and a sensitivity of 64.9% and a specificity of 74.1% for osteoporosis defined by WHO criteria using DXA. In the logistic regression, the presence of family history of fragility fractures (OR: 3.03; CI 95%: 1.3-7.03), a DXA T-score </=-2.5 (OR: 3.58; CI 95%: 1.66-7.73), and a QUI T-score </=-1.5 (OR: 2.56; CI 95%: 1.15-5.69) were independently associated with prevalent osteoporotic fractures. In conclusion, calcaneus ultrasound appears as a useful technique for the routine clinical practice, as its performance is similar to DXA for the discrimination of subjects with osteoporotic fracture.

The ability of quantitative ultrasound at the calcaneus to identify postmenopausal women with different types of nontraumatic fractures

The aim of the cross-sectional study was to determine if ultrasound (US) measurements of the calcaneus have the ability to predict the risk for fractures and to discriminate between postmenopausal women with and without different types of nontraumatic fractures. All women (n = 1,129, age range 40 to 87 years) were divided into group 1, created by 656 women with 956 nontraumatic past fractures, and group 2, consisting of 473 women without fractures. Group 1 was divided into subgroups: with hip fractures, with vertebral (nonhip) fractures, with wrist (nonhip and nonspine) fractures and with other (nonhip, nonspine and nonwrist) fractures. The speed of sound (SOS; m/s) and broadband ultrasound attenuation (BUA; dB/MHz) were measured with the Achilles system (Lunar), which also calculates stiffness index (SI; %). US values were significantly lower in group 1 (1,481.4 +/- 20.2 m/s, 98.7 +/- 9.4 dB/MHz, 61.1 +/- 11.0%; p < 0.000001) and in subgroups (p < 0.000001), and these women had a higher mean age and longer postmenopausal period than women without fractures (1508.2 +/- 26.5 m/s, 107.7 +/- 9.9 dB/MHz, 74.2 +/- 13.0%). Women with hip fractures had the lowest US values (1464.6 +/- 18.6 m/s, 89.9 +/- 8.7 dB/MHz, 50.6 +/- 10.5%), women with vertebral fractures had intermediate values (1473.6 +/- 17.4 m/s, 94.8 +/- 8.9 dB/MHz, 56.4 +/- 10.0%), and women with wrist (1,484.3 +/- 19.8 m/s, 99.9 +/- 9.3 dB/MHz, 62.7 +/- 10.7%) and other fractures (1,483.3 +/- 21.0 m/s, 100.4 +/- 8.6 dB/MHz, 62.7 +/- 10.6%) had the highest values. The US values differed significantly between subgroups with fractures (p < 0.05), with no significant differences between women with wrist and other fractures. ROC analysis showed SOS to have the best sensitivity and specificity in detecting fracture cases. All US parameters revealed the greatest areas under the ROC curve (AUCs) for hip fracture (0.92 to 0.93) in comparison to smaller AUCs for vertebral fractures (ranging from 0.84 to 0.87), and the smallest AUCs for wrist and other fractures (ranging from 0.72 to 0.77 and 0.72 to 0.78, respectively). Generally, the SOS measurement presented greater odds ratio (OR) than BUA and SI: 4.1 (3.09 to 5.43) for any fracture, 11.66 (3.09 to 43.96) for hip fracture, 6.51 (3.61 to 11.73) for vertebral fracture, 3.32 (2.41 to 4.58) for wrist fracture and 4.2 (2.7 to 6.54) for other fracture. The present study demonstrates the ability of calcaneal QUS to discriminate between healthy individuals and subjects with different types of nontraumatic fractures. Calcaneal US parameters show the best sensitivity and specificity in discriminating the hip fracture patients from the controls. Generally, the SOS parameter is a better discriminator than SI and BUA and estimates the highest OR for fractures.

Discriminatory ability of quantitative ultrasound parameters and bone mineral density in a population-based sample of postmenopausal women with vertebral fractures: results of the Basel Osteoporosis Study

The discriminatory potential to classify subjects with or without vertebral fractures was tested cross-sectionally with different methods for the measurement of bone status in a population-based sample of postmenopausal women. Quantitative ultrasound (QUS) measurement at the calcaneus (Lunar Achilles, Hologic Sahara), the proximal phalanges (Igea Bone Profiler), and measurement of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA; Lunar Expert) at several anatomic sites was performed in 500 postmenopausal women (aged 65-75 years) randomly selected from the population. In addition, 50 young female subjects (20-40 years old) had QUS measurements and served as controls to express QUS results as T-score values. Radiographs of the lumbar and thoracic spine were performed in the elderly women. Two independent radiologists reviewed the X-rays for the presence of vertebral fractures. Of 486 eligible study participants, no fracture was seen in 396 participants. Single vertebral fractures were observed in 71 subjects; 19 individuals presented multiple fractures. The overall prevalence of vertebral fractures was 18.5%. Participants without vertebral fractures were compared with subjects with vertebral fractures. Normal statistical distributions were found for all bone measurement results. Risk of vertebral fracture in subjects with no and multiple vertebral fracture was estimated using age adjusted odds ratios (ORs) for QUS and dual-energy X-ray absorptiometry (DXA) values. Each SD decrease in bone measurement increased the risk of multiple vertebral fracture by 3.0 (95% CI, 1.6-5.6) for the Achilles stiffness, by 3.8 (95% CI, 1.8-8.2) for the Sahara QUI, 2.1 (95% CI, 1.3-3.4) for the Bone Profiler amplitude-dependent speed of sound (AD-SOS), and 2.1 (95% CI, 1.2-3.9) and 2.4 (95% CI, 1.3-4.3) for DXA lumbar spine and for DXA total hip, respectively. Results of a discriminant analysis showed sensitivities between 84% and 58% and specificities between 72% and 58% for the respective DXA and QUS parameters. Optimum fracture thresholds for QUS measurements derived from this analysis were calculated also. Optimum T-score threshold values for QUS measurements tended to be higher than those for DXA measurements. However, the performance of QUS measurements is at least comparable with DXA measurements in identifying subjects with multiple vertebral fractures randomly selected from the population.

Potential roles for quantitative ultrasound in the management of osteoporosis

OBJECTIVE

To assess the validity of four models for the role of quantitative ultrasound (QUS) in the management of osteoporosis.

DESIGN

Cross-sectional survey and review of literature.

SETTINGS

Nuclear medicine departments of three teaching hospitals in Sydney.

SUBJECTS

1000 women aged 22 to 88 years (mean, 59 years) referred for assessment of osteoporotic fracture risk.

MAIN OUTCOME MEASURES

BMD categories as defined by dual-energy x-ray absorptiometry (DEXA) of the lumbar spine and proximal femur, and QUS category as defined by calcaneal ultrasound stiffness; prevalence of DEXA-defined osteoporosis in the different QUS categories.

RESULTS

In women with QUS Achilles stiffness < or = 70 the prevalence of axial osteoporosis was 51%, whereas in the group with stiffness > 70 the prevalence of axial osteoporosis was 8%. In women 65 years and over the corresponding values were 59% and 17%.

CONCLUSIONS

Of the four possible models for QUS, the use of QUS for the estimation of BMD, or in a "standalone" model, can not be recommended at the current time. The model of QUS as a "prescreening" modality may be acceptable assuming adequate education of clinicians and patients of its limitations, particularly the risk of false negatives. The model of QUS as one factor in a composite risk factor assessment of patients is promising but more data are required.

Quantitative ultrasound and dual X-ray absorptiometry measurements of the calcaneus in patients on maintenance hemodialysis

It has been suggested that quantitative ultrasound measurements (QUS), which reflect mainly bone density, could be influenced by bone micro-architecture. The aim of the study was to assess whether the relationship of QUS to dual X-ray absorptiometry (DXA) would reflect abnormalities of bone structure observed in renal osteodystrophy. QUS and bone mineral density of the calcaneus (BMDc) were measured by DXA in 30 patients on maintenance hemodialysis and 34 age- and gender-matched controls. QUS parameters and BMDc were significantly lower in hemodialysis patients than in controls (speed of sound [SOS] and broadband ultrasound attenuation [BUA], p = 0. 030; stiffness, p = 0.003; BMDc, p = 0.006). Bone measurements were not correlated with serum parathyroid hormone (PTH). The regression lines of SOS, BUA, and stiffness to BMDc were not significantly different from that of the controls. When dividing the patients into two subgroups according to their median PTH (203 pg/mL), the slopes of the regression lines of BUA to BMDc were significantly different between these two subgroups (p = 0.052). The slope of the subgroup with PTH </= 203 pg/mL was significantly different from that of the controls (p = 0.030). In conclusion, QUS of the calcaneus can be used for bone assessment in patients on maintenance hemodialysis. The differences in the slopes of patients with a less pronounced degree of hyperparathyroidism compared with patients with a higher degree of hyperparathyroidism and to controls suggest that BUA of the calcaneus contains information on bone complementary to DXA measured at the same site. The clinical relevance of this finding is presently unclear.