Prediction of fracture risk in postmenopausal white women with peripheral bone densitometry: evidence from the National Osteoporosis Risk Assessment

Evaluation of bone fragility in cognitively or physically impaired elderly care home patients using radiofrequency echographic multi-spectrometry

Dual-energy X-ray absorptiometry (DXA) is the standard for bone mineral density (BMD) assessment but is often inaccessible to cognitively or physically impaired care home patients. Radiofrequency echographic multi-spectrometry (REMS), a portable and radiation-free alternative, enables effective BMD evaluation in this vulnerable and underserved population. This cross-sectional study assessed BMD using REMS in 260 patients aged ≥ 70 years (39 males, 221 females; mean age 82.29 years) between April 2023 and July 2024. Osteoporosis diagnosis was based on T-scores <  - 2.5 SD or history of fragility fractures, with severe osteoporosis defined by WHO criteria and high fracture risk by lumbar T-scores <  - 3.3 SD. Care home patients had significantly lower BMD and T-scores than outpatients, with 56.3% diagnosed with severe osteoporosis and 71.8% exhibiting lumbar T-scores <  - 3.3 SD. Despite high fracture risks, only 12.7% of care home patients received treatment. These trends were consistent across all age groups, revealing a high prevalence and severity of osteoporosis in care home residents. REMS has unveiled a substantial treatment gap in this population, emphasizing the critical need for improved osteoporosis management and proactive interventions to reduce fracture risks among care home patients worldwide.

TBS as a complementary tool for assessing vertebral fractures and spinal deformity in children and adolescents with osteogenesis imperfecta

This study evaluated trabecular bone score (TBS) for assessing vertebral fractures and spinal deformity in children and adolescents with osteogenesis imperfecta (OI). TBS showed superior performance in identifying vertebral fractures compared to areal bone mineral density (aBMD), especially in patients without densitometric osteoporosis, suggesting its potential for monitoring vertebral fractures and spinal deformity risk.

BACKGROUND

TBS, derived from a textural greyscale analysis of lumbar spine dual-energy X-ray absorptiometry (DXA) images, offers a non-invasive and indirect evaluation of bone microarchitecture. This method potentially enhances the assessment of skeletal phenotypes beyond the scope of aBMD. We aim to explore the utility of TBS in assessing vertebral fractures and spinal deformity in children and adolescents with OI.

METHODS

In this cross-sectional study, 153 children and adolescents with OI were enrolled. DXA was used to measure TBS and aBMD, and their Z-scores were calculated based on reference values for BMD and TBS in normal children and adolescents with the same age and sex. Lateral thoracolumbar films were used to evaluate vertebral fractures and calculate the spine deformity index (SDI). The accuracy of TBS and aBMD for identifying vertebral compression fractures (VCFs) was assessed using area under the curve (AUC).

RESULTS

TBS Z-score was negatively correlated with the age of children with OI (r =  - 0.435, P < 0.001) and was positively correlated to aBMD Z-score at the lumbar spine and femoral neck (both P < 0.01), even after adjusting for confounding factors. TBS Z-score was as effective as lumbar spine aBMD Z-score in discriminating VCFs (AUC, 0.667 vs 0.666, P > 0.05). Notably, in patients without densitometric osteoporosis, TBS Z-score demonstrated superior discriminative power for VCFs compared to lumbar spine aBMD Z-score (AUC, 0.719 vs 0.545, P < 0.05). In this population, only the TBS Z-score (r =  - 0.358, P < 0.05), rather than the lumbar spine aBMD Z-score, was negatively correlated with the SDI.

CONCLUSION

TBS has a close correlation with bone mineral density in children and adolescents with OI. In patients without densitometric osteoporosis, the Z-score of TBS is more effective than that of bone mineral density in assessing VCFs and spinal deformity, highlighting the potential of TBS in evaluating the risk of VCFs and monitoring the progression of spinal deformity.

Bone Health for Gynaecologists

Osteoporosis, the most common bone disorder, profoundly impacts women's health, especially during postmenopausal phases. Characterised by diminished bone mineral density (BMD), it increases the risk of fractures, affecting mobility, quality of life, and potentially mortality. The present review analyses the intricate interactions among physiological alterations, diseases, and medications that lead to bone mineral density reduction in women. It underscores the importance of gynaecologists in the prevention, diagnosis, and management of osteoporosis via early risk assessment, suitable hormone treatment, and lifestyle modifications. Essential considerations encompass the categorisation of osteoporosis into primary (age-related) and secondary (attributable to diseases or pharmacological treatments) types, with particular emphasis on predisposing conditions such as premature menopause, hormone deficits, and cancer therapies. The significance of diagnostic instruments such as DXA and novel methodologies like trabecular bone score and quantitative ultrasonography is emphasised for precise evaluation and surveillance. The review also addresses nutritional methods, physical exercise, and pharmaceutical interventions, including hormone replacement therapy (HRT), selective oestrogen receptor modulators (SERMs), and other anti-resorptive drugs, to preserve bone health. This review highlights the important role of gynaecologists in maintaining women's bone health, promoting a proactive strategy to avert osteoporosis-related complications and enhance long-term results.

Choose your mother wisely: the familial resemblance of bone adaptation

This study demonstrates how complex bone microarchitectural features can be summarized to describe bone adaptations seen with aging in women, which are consistent with the stages of osteoporosis. Additionally, we showed familial resemblance in these bone microarchitectural traits between mothers and daughters that can be used to predict bone adaptations.

INTRODUCTION

Patient-specific characterization of bone quality can reduce complex microarchitectural features to common combinations of bone characteristics, known as bone phenotypes. This study investigated whether there is a general trend in bone phenotype change over time seen with aging in females and whether there is a familial resemblance to phenotype membership between mothers and daughters.

METHODS

Bone phenotype membership was calculated on biological mother and daughter pairs (Participants = 101), scanned using high resolution peripheral quantitative computed tomography, to the three pre-defined phenotypes (healthy, low volume, and low density). The trajectory of bone phenotype with age was explored using all participant's data. Linear regression models were used to assess the familial resemblance of phenotyping in the mother-daughter pairs.

RESULTS

When stratified for age, the trajectory of the phenotype membership transitioned from healthy (20-40 years), to low volume (40-60 years), to low density (60-80 years), which similarly aligns with the stages of osteoporosis observed in females. Familial resemblance (½h2) was observed in the healthy phenotype (β = 0.432, p < 0.01). Predictive modelling showed a significant association in phenotype membership between mothers and daughters in the healthy (R2 = 0.347, p = 0.04) and low volume (R2 = 0.416, p < 0.01) phenotypes, adjusted for age, height, and weight.

CONCLUSION

Our results suggest that phenotype membership in females changes with age in a pattern that is consistent with the stages of osteoporosis. Additionally, we showed familial resemblance in bone phenotype, which can be used to predict bone adaptations between mothers and daughters that are associated with bone loss with aging.

Contribution of bone turnover markers (BTMs) and vitamin D to bone health in Iranian elderly women

Purpose

While only a few postmenopausal women exhibit biochemical signs of hypovitaminosis D, it has been shown that vitamin D insufficiency has detrimental effects on the overall skeleton mineralization, bone turnover rate, and may be a significant risk factor for osteoporosis and fracture. We evaluated the concurrent effect of Vitamin D levels and biochemical markers of bone turnover on bone health of postmenopausal women.

Methods

The present study was conducted within the framework of the Bushehr Elderly Health (BEH) program, a population-based prospective cohort study being conducted in Bushehr, a southern province of Iran. In summary, 400 persons from participants of the second stage were selected; serum bone turnover markers (bone-specific alkaline phosphatase (bALP), amino-terminal procollagen propeptides of type I collagen (P1NP), osteocalcin (OC), tartrate-resistant acid phosphatase isoenzyme 5b (TRAP)) and vitamin D were measured. Vitamin D deficiency was defined as serum 25(OH) D below 20 ng/ml, and Bone health was considered in terms of Osteoporosis and degraded bone microarchitecture.

Results

The number of partially or significantly degraded microstructure based on TBS was higher than the number of osteoporotic women based on BMD. Women with higher CTX levels were more prone to being degraded microarchitecture. Although we couldn't find any association between vitamin D deficiency and bone health, when we considered the vitamin D levels in univariable modelling, the effect of it was significant.

Conclusions

In this study, only CTX was found to be significantly correlated with TBS while BMD was associated with CTX, OC, and TRAP.

DXA beyond bone mineral density and the REMS technique: new insights for current radiologists practice

Osteoporosis is the most prevalent skeletal disorder, a condition that is associated with significant social and healthcare burden. In the elderly, osteoporosis is commonly associated with sarcopenia, further increasing the risk of fracture. Several imaging techniques are available for a non-invasive evaluation of osteoporosis and sarcopenia. This review focuses on dual-energy X-ray absorptiometry (DXA), as this technique offers the possibility to evaluate bone mineral density and body composition parameters with good precision and accuracy. DXA is also able to evaluate the amount of aortic calcification for cardiovascular risk estimation. Additionally, new DXA-based parameters have been developed in recent years to further refine fracture risk estimation, such as the Trabecular Bone Score and the Bone Strain Index. Finally, we describe the recent advances of a newly developed ultrasound-based technology known as Radiofrequency Echographic Multi-Spectrometry, which represent the latest non-ionizing approach for osteoporosis evaluation at central sites.

The Role of Glucose, Insulin and Body Fat in Assessment of Bone Mineral Density and Trabecular Bone Score in Women with Functional Hypothalamic Amenorrhea

Background: For years, bone mineral density (BMD) has played a key role in assessing bone health, but the trabecular bone score (TBS) is emerging as an equivalent measure. However, BMD alone may not fully measure bone quality or predict osteoporosis risk. To evaluate the usefulness of TBS and BMD in estimating the risk of bone fracture in young women with FHA, this study examined the association between metabolic parameters and bone quality, which was measured using TBS and BMD. Methods: We analyzed the association of metabolic factors with tests assessing bone quality-TBS and BMD. Patients were checked for BMI, measured body fat, and determined serum glucose levels and insulin levels in a 75g glucose load test. Spearman correlation analysis was used. Results: Significant positive correlations were found between BMD and age (p < 0.001) and body fat (p < 0.001), as well as between TBS values and BMI (p < 0.001) and TBS and percent body fat (p < 0.001). Of the variables analyzed in the multivariate analysis, the only independent predictor of higher bone mineral density in the lumbar spine was found to be higher values of the trabecular bone index in the same segment (p < 0.001). Conclusions: The use of TBS provides a simple tool for estimating the risk of bone damage. Ultimately, early screening, diagnosis and treatment of patients with FHA may help prevent osteoporosis and fragility fractures in the long term.

Homogenized finite element analysis of distal tibia sections: Achievements and limitations

High-resolution peripheral quantitative computed tomography (HR-pQCT) based micro-finite element (μFE) analysis allows accurate prediction of stiffness and ultimate load of standardised (∼1 cm) distal radius and tibia sections. An alternative homogenized finite element method (hFE) was recently validated to compute the ultimate load of larger (∼2 cm) distal radius sections that include Colles' fracture sites. Since the mechanical integrity of the weight-bearing distal tibia is gaining clinical interest, it has been shown that the same properties can be used to predict the strength of both distal segments of the radius and the tibia. Despite the capacity of hFE to predict structural properties of distal segments of the radius and the tibia, the limitations of such homogenization scheme remain unclear. Therefore, the objective of this study is to build a complete mechanical data set of the compressive behavior of distal segments of the tibia and to compare quantitatively the structural properties with the hFE predictions. As a further aim, it is intended to verify whether hFE is also able to capture the post-yield strain localisation or fracture zones in such a bone section, despite the absence of strain softening in the constitutive model. Twenty-five fresh-frozen distal parts of tibias of human donors were used in this study. Sections were cut corresponding to an in-house triple-stack protocol HR-pQCT scan, lapped, and scanned using micro computed tomography (μCT). The sections were tested in compression until failure, unloaded and scanned again in μCT. Volumetric bone mineral density (vBMD) and bone mineral content (BMC) were correlated to compression test results. hFE analysis was performed in order to compare computational predictions (stiffness, yield load and plastic deformation field pattern) with the compressive experiment. Namely, strain localization was assessed based on digital volume correlation (DVC) results and qualitatively compared to hFE predictions by comparing mid-slices patterns. Bone mineral content (BMC) showed a good correlation with stiffness (R2 = 0.92) and yield (R2 = 0.88). Structural parameters also showed good agreement between the experiment and hFE for both stiffness (R2 = 0.96, slope = 1.05 with 95 % CI [0.97, 1.14]) and yield (R2 = 0.95, slope = 1.04 [0.94, 1.13]). The qualitative comparison between hFE and DVC strain localization patterns allowed the classification of the samples into 3 categories: bad (15 sections), semi (8), and good agreement (2). The good correlations between BMC or hFE and experiment for structural parameters were similar to those obtained previously for the distal part of the radius. The failure zones determined by hFE corresponded to registration only in 8 % of the cases. We attribute these discrepancies to local elastic/plastic buckling effects that are not captured by the continuum-based FE approach exempt from strain softening. A way to improve strain localization hFE prediction would be to use longer distal segments with intact cortical shells, as done for the radius. To conclude, the used hFE scheme captures the elastic and yield response of the tibia sections reliably but not the subsequent failure process.

East Asians' T-scores for the diagnosis of osteoporosis should be calculated using ethnicity- and gender-specific BMD reference ranges: justifications

The 2013 ISCD consensus recommended a Caucasian female reference database for T-score calculation in men, which says "A uniform Caucasian (non-race adjusted) female reference database should be used to calculate T-scores for men of all ethnic groups." However, this statement was recommended for the US population, and no position was taken with respect to BMD reference data or ethnicity matching outside of the USA. In East Asia, currently, a Japanese BMD reference database is universally adopted in Japan for clinical DXA diagnosis, while both local BMD and Caucasian BMD reference databases are in use in Mainland China, South Korea, Taiwan, and Singapore. In this article, we argue that an ethnicity- and gender-specific BMD database should be used for T-score calculations for East Asians, and we list the justifications why we advocate so. Use of a Caucasian BMD reference database leads to systematically lower T-scores for East Asians and an overestimation of the prevalence of osteoporosis. Using a female BMD reference database to calculate T-scores for male patients leads to higher T-score values and an underestimation of the prevalence of osteoporosis. Epidemiological evidence does not support using a female BMD reference database to calculate T-scores for men. We also note that BMD reference databases collected in Asia should be critically evaluated for their quality.

Insights into the antiosteoporotic mechanism of the soy-derived isoflavone genistein: Modulation of the Wnt/beta-catenin signaling

Bone remodeling is a process that involves osteoblasts, osteoclasts, and osteocytes, and different intracellular signaling, such as the canonical Wnt/β-catenin pathway. Dysregulations of this pathway may also occur during secondary osteoporosis, as in the case of glucocorticoid-induced osteoporosis (GIO), which accelerates osteoblast and osteocyte apoptosis by reducing bone formation, osteoblast differentiation and function, accelerates in turn osteoblast, and osteocyte apoptosis. Genistein is a soy-derived nutrient belonging to the class of isoflavones that reduces bone loss in osteopenic menopausal women, inhibiting bone resorption; however, genistein may also favor bone formation. The aim of this study was to investigate whether estrogen receptor stimulation by genistein might promote osteoblast and osteocyte function during glucocorticoid challenge. Primary osteoblasts, collected from C57BL6/J mice, and MLO-A5 osteocyte cell line were used to reproduce an in vitro model of GIO by adding dexamethasone (1 μM) for 24 h. Cells were then treated with genistein for 24 h and quantitative Polymerase Chain Reaction (qPCR) and western blot were performed to study whether genistein activated the Wnt/β-catenin pathway. Dexamethasone challenge reduced bone formation in primary osteoblasts and bone mineralization in osteocytes; moreover, canonical Wnt/β-catenin pathway was reduced following incubation with dexamethasone in both osteoblasts and osteocytes. Genistein reverted these changes and this effect was mediated by both estrogen receptors α and β. These data suggest that genistein could induce bone remodeling through Wnt/β-catenin pathway activation.

Trabecular bone microstructure analysis on data from a novel twin robotic X-ray device

BACKGROUND

Bone strength is related to both mineral density (BMD) and the bone microstructure. However, only the assessment of BMD is available in clinical routine care today.

PURPOSE

To analyze and study the correlation of trabecular bone microstructure from the imaging data of a prototype Multitom Rax system, using micro-computed tomography (CT) data as the reference method (Skyscan 1176).

MATERIAL AND METHODS

Imaging data from 14 bone samples from the human radius were analyzed regarding six bone structure parameters, i.e. trabecular nodes, separation, spacing, and thickness as well as bone volume (BV/TV) and structural model index (SMI).

RESULTS

All six structure parameters showed strong correlations to micro-CT with Spearman correlation coefficients in the range of 0.83-0.93. BV/TV and SMI had a correlation >0.90. Two of the parameters, namely, separation and number, had mean values in the same range as micro-CT. The other four were either over- or underestimated.

CONCLUSION

The strong correlation between micro-CT and the clinical imaging system, indicates the possibility for analyzing bone microstructure with potential to add value in fracture assessment using the studied device in a clinical workflow.

Risk assessment tools for osteoporosis and fractures in 2022

Osteoporosis is one of the frequently encountered non-communicable diseases in the world today. Several hundred million people have osteoporosis, with many more at risk. The clinical feature is a fragility fracture (FF), which results in major reductions in the quality and quantity of life, coupled with a huge financial burden. In recognition of the growing importance, the World Health Organisation established a working group 30 years ago tasked with providing a comprehensive report to understand and assess the risk of osteoporosis in postmenopausal women. Dual-energy X-ray absorptiometry (DXA) is the most widely endorsed technology for assessing the risk of fracture or diagnosing osteoporosis before a fracture occurs, but others are available. In clinical practice, important distinctions are essential to optimise the use of risk assessments. Traditional tools lack specificity and were designed for populations to identify groups at higher risk using a 'one-size-fits-all' approach. Much has changed, though the purpose of risk assessment tools remains the same. In 2022, many tools are available to aid the identification of those most at risk, either likely to have osteoporosis or suffer the clinical consequence. Modern technology, enhanced imaging, proteomics, machine learning, artificial intelligence, and big data science will greatly advance a more personalised risk assessment into the future. Clinicians today need to understand not only which tool is most effective and efficient for use in their practice, but also which tool to use for which patient and for what purpose. A greater understanding of the process of risk assessment, deciding who should be screened, and how to assess fracture risk and prognosis in older men and women more comprehensively will greatly reduce the burden of osteoporosis for patients, society, and healthcare systems worldwide. In this paper, we review the current status of risk assessment, screening and best practice for osteoporosis, summarise areas of uncertainty, and make some suggestions for future developments, including a more personalised approach for individuals.

Estimation of Thickness and Speed of Sound for Transverse Cortical Bone Imaging Using Phase Aberration Correction Methods: An In Silico and Ex Vivo Validation Study

Delay-and-sum (DAS) beamforming of backscattered echoes is used for conventional ultrasound imaging. Although DAS beamforming is well suited for imaging in soft tissues, refraction, scattering, and absorption, porous mineralized tissues cause phase aberrations of reflected echoes and subsequent image degradation. The recently developed refraction corrected multi-focus technique uses subsequent focusing of waves at variable depths, the tracking of travel times of waves reflected from outer and inner cortical bone interfaces, the estimation of the shift needed to focus from one interface to another to determine cortical thickness (Ct.Th), and the speed of sound propagating in a radial bone direction (Ct.ν11). The method was validated previously in silico and ex vivo on plate shaped samples. The aim of this study was to correct phase aberration caused by bone geometry (i.e., curvature and tilt with respect to the transducer array) and intracortical pores for the multi-focus approach. The phase aberration correction methods are based on time delay estimation via bone geometry differences to flat bone plates and via the autocorrelation and cross correlation of the reflected ultrasound waves from the endosteal bone interface. We evaluate the multi-focus approach by incorporating the phase aberration correction methods by numerical simulation and one experiment on a human tibia bone, and analyze the precision and accuracy of measuring Ct.Th and Ct.ν11. Site-matched reference values of the cortical thickness of the human tibia bone were obtained from high-resolution peripheral computed tomography. The phase aberration correction methods resulted in a more precise (coefficient of variation of 5.7%) and accurate (root mean square error of 6.3%) estimation of Ct.Th, and a more precise (9.8%) and accurate (3.4%) Ct.ν11 estimation, than without any phase aberration correction. The developed multi-focus method including phase aberration corrections provides local estimations of both cortical thickness and sound velocity and is proposed as a biomarker of cortical bone quality with high clinical potential for the prevention of osteoporotic fractures.

Prescreening for osteoporosis with forearm bone densitometry in health examination population

BACKGROUND

Early detection and timely prophylaxis can retard the progression of osteoporosis. The purpose of this study was to determine the validity of peripheral Dual Energy X-ray Absorptiometry (DXA) test for osteoporosis screening. We examined peripheral bone mineral density (BMD) using AKDX-09 W-I DXA densitometer. Firstly, we acquired BMD data from manufacturer-supplied density-gradient phantoms and 30 volunteers to investigate its accuracy and precision, then we measured BMD for 150 volunteers using both AKDX (left forearm) and Hologic Discovery Wi (left forearm, left hip and L1 - L4 vertebrae) simultaneously. Correlation relationship of BMD results acquired from two instruments was assessed by simple linear regression analysis, the Receiver Operating Characteristic (ROC) curves and Areas Under the Curves (AUCs) were evaluated for the diagnostic value of left forearm BMD measured by AKDX in detecting osteoporosis.

RESULTS

In vitro precision errors of AKDX BMD were 0.40, 0.20, 0.19%, respectively, on low-, medium-, and high-density phantom; in vivo precision was 1.65%. Positive correlation was observed between BMD measured by AKDX and Hologic at the forearm (r = 0.670), L1-L4 (r = 0.430, femoral neck (r = 0.449), and total hip (r = 0.559). With Hologic measured T-score as the gold standard, the sensitivity of AKDX T-score < - 1 for identifying suboptimal bone health was 63.0 and 76.1%, respectively, at the distal one-third radius and at any site, and the specificity was 73.9 and 90.0%, respectively; the AUCs were 0.708 and 0.879. The sensitivity of AKDX T-score ≤ - 2.5 for identifying osteoporosis at the distal one-third radius and at any site was 76.9 and70.4%, respectively, and the specificity was 80.4 and 78.0%, respectively; the AUCs were 0.823 and 0.778.

CONCLUSIONS

Peripheral DXA appears to be a reliable tool for prescreening for osteoporosis.

Outcomes post fragility fracture among members of an integrated healthcare organization

This study highlights an unmet need in osteoporosis management, suggesting that beyond bone mineral density and fracture history, gender, fracture type, and age should be considered for fracture risk assessment. Following fragility fracture, men, patients with a spine or hip fracture, and those aged ≥ 65 have a higher disease burden.

INTRODUCTION

The objective of this study was to characterize osteoporosis-related fracture incidence and identify predictors of subsequent fractures and mortality.

METHODS

This retrospective cohort study, conducted within Kaiser Permanente Southern California, included patients aged ≥ 50 years with qualifying fractures from 1/1/2007 to 12/31/2016, identified from diagnosis/procedure codes. Rates for fracture incidence, mortality, and resource utilization in the year post-fracture are reported. Associations between index fracture types and demographic/clinical characteristics, and mortality, subsequent fracture, and rehospitalization outcomes were estimated.

RESULTS

Of 63,755 eligible patients, 66.7% were ≥ 65 years and 69.1% female. Index fractures included nonhip/nonspine (64.4%), hip (25.3%), and spine (10.3%). Age-adjusted subsequent fracture rate/100 person-years was higher for those with an index spine (14.5) versus hip fracture (6.3). Hospitalization rate/100 person-years was highest for patients ≥ 65 (31.8) and for spine fractures (43.5). Men (vs women) had higher age-adjusted rates of hospitalization (19.4; 17.7), emergency room visits (73.8; 66.3), and use of rehabilitation services (31.7; 27.2). The 30-day age-adjusted mortality rate/100 person-years was 46.7, 32.4, and 15.5 for spine, hip, and nonspine/nonhip fractures. The 1-year age-adjusted mortality rate/100 person-years was 14.7 for spine and 15.6 for hip fractures. In multivariable analyses, spine and hip fractures (vs nonhip/nonspine fractures) were significant predictors of 1-year mortality, all-cause and osteoporosis-related hospitalization, and nursing home use (all P-values < 0.0001).

CONCLUSION

Morbidity is high in the year following a fragility fracture and men, patients with a spine or hip fracture, and those aged ≥ 65 have a greater disease burden.

Usefulness of the trabecular bone score in maintenance dialysis patients : A single center observational study

Background

The number of dialysis patients is steadily increasing. Associated comorbidities include impaired bone and mineral metabolism, termed chronic kidney disease-mineral and bone disorder (CKD-MBD), leading to a high fracture risk, increased morbidity and mortality and impaired quality of life. While the bone density is assessed with dual-energy X‑ray absorptiometry (DXA), the trabecular bone score (TBS) captures the image texture as a potential index of skeletal microarchitecture. The aim of this study was to evaluate the clinical relevance of DXA and TBS in dialysis patients with and without prevalent fractures.

Methods

Bone disorders were evaluated in 82 dialysis patients (37% female) at the University Hospital of Graz, Austria, by DXA including the assessment of the TBS based on a patient interview and the local routine patient database software. The patient cohort was stratified by having sustained a fragility fracture in the past or not. Descriptive statistics, t‑tests for continuous variables and χ²-tests for nominal variables including results of DXA and TBS were performed to compare these groups considering the dialysis modality and duration as well as the number of kidney transplantations.

Results

Of the 82 patients, 32 (39%) had a positive history of fractures. There was a significant association between dialysis duration and fracture prevalence (p < 0.05) as well as musculoskeletal pain (p < 0.01). No significant correlation between DXA/TBS parameters and musculoskeletal pain could be established. The DXA scores did not correlate with fracture prevalence with the exception of DXA radius measurements; however, fracture prevalence significantly correlated inversely with TBS (p < 0.001).

Conclusion

The use of DXA has a limited role in fracture prediction in dialysis patients; however, the TBS seems to add information as an additional tool for fracture risk estimation in this patient population.

Predicting the trabecular bone apparent stiffness tensor with spherical convolutional neural networks

The apparent stiffness tensor is relevant for characterizing trabecular bone quality. Previous studies have used morphology-stiffness relationships for estimating the apparent stiffness tensor. In this paper, we propose to train spherical convolutional neural networks (SphCNNs) to estimate this tensor. Information of the edges, trabecular thickness, and spacing are summarized in functions on the unitary sphere used as inputs for the SphCNNs. The concomitant dimensionality reduction makes it possible to train neural networks on relatively small datasets. The predicted tensors were compared to the stiffness tensors computed by using the micro-finite element method (μFE), which was considered as the gold standard, and models based on fourth-order fabric tensors. Combining edges and trabecular thickness yields significant improvements in the accuracy compared to the methods based on fourth-order fabric tensors. From the results, SphCNNs are promising for replacing the more expensive μFE stiffness estimations.

•

Characteristic stiffness tensors are derived from trabecular bone micro-CT samples.

•

Previous approximation methods fall short on heterogeneous data-sets.

•

The gradient, trabecular thickness and spacing are mapped to a spherical domain.

•

Spherical convolutional neural networks are used for the prediction.

•

The prediction error is significantly reduced compared to the state-of-the-art.

Thyroid-stimulating hormone is associated with trabecular bone score and 5-year incident fracture risk in euthyroid postmenopausal women: the OsteoLaus cohort

Thyroid-stimulating hormone (TSH) excess or deficiency influences bone density and fracture risk. Nevertheless, does TSH in the reference range influence bone health? In euthyroid postmenopausal women, TSH levels in the reference range were positively associated with trabecular bone score and negatively with incident fractures, without affecting BMD.

PURPOSE

Subclinical hyperthyroidism is associated with low bone mineral density (BMD) and increased fracture risk. In healthy postmenopausal women, association between thyroid-stimulating hormone (TSH) in the normal range and BMD is contradictory. Trabecular bone score (TBS), an index of bone micro-architecture, is often decreased in secondary osteoporosis (OP). The aim was to determine the association between thyroid hormones (TSH, fT4) and BMD, TBS, and the incident 5-year OP fractures, in euthyroid post-menopausal women.

METHODS

We assessed 1475 women of the CoLaus/OsteoLaus cohort. We evaluated BMD at lumbar spine, femoral neck and total hip, lumbar spine TBS, and vertebral fracture with DXA. Incident major OP fractures were evaluated 5 years later by questionnaire and DXA. Women with anti-osteoporotic, antidiabetic, thyroid-modifying, hormone replacement, or systemic corticoid treatment were excluded.

RESULTS

Five hundred thirty-three women (age 68.4 ± 7.3 years, BMI 25.9 ± 4.6 kg/m2, TSH 2.03 ± 0.87 mU/l, fT4 15.51 ± 1.85 pmol/l) met the inclusion criteria. There was no significant association between TSH or fT4 and BMD measures at any site. A positive association was found between TSH and TBS (β = 0.138, p < 0.01), even after adjusting for age, BMI, and duration of menopause (β = 0.086, p < 0.05). After a 5-year follow-up, women with incident major OP fractures had lower TSH levels (1.77 ± 0.13 vs. 2.05 ± 0.04 mU/l, p < 0.05) than women without fractures, while no difference was found for fT4.

CONCLUSION

In euthyroid postmenopausal women, TSH levels were positively associated with TBS and negatively with incident fractures, without affecting BMD. Further studies are needed to evaluate the influence of thyroid hormones on TBS.

Application and prospect of trabecular bone score in differentiated thyroid cancer patients receiving thyrotropin suppression therapy

Thyroid-stimulating hormone (TSH) suppression therapy is one of the common treatments for most patients with differentiated thyroid cancer (DTC). Unfortunately, its detrimental effects on bone health are receiving increasing attention. It may increase the risk of osteoporosis and osteoporotic fractures. The trabecular bone score (TBS) is a relatively new gray-scale texture measurement parameter that reflects bone microarchitecture and bone strength and has been shown to independently predict fracture risk. We reviewed for the first time the scientific literature on the use of TBS in DTC patients on TSH suppression therapy and aim to analyze and compare the utility of TBS with bone mass strength (BMD) in the management of skeletal health and prediction of fracture risk. We screened a total of seven relevant publications, four of which were for postmenopausal female patients and three for all female patients. Overall, postmenopausal female patients with DTC had lower TBS and a significant reduction in TBS after receiving TSH suppression therapy, but their BMD did not appear to change significantly. In addition, TBS was also found to be an independent predictor of osteoporotic fracture risk in postmenopausal women with DTC receiving TSH suppression therapy. However, due to limitations in the number of studies and study populations, this evidence is not sufficient to fully demonstrate the adverse effects of TSH suppression therapy on patients' TBS or BMD and the efficacy of TBS, and subsequent larger and more case-cohort studies are needed to further investigate the relationship and application of TBS to TSH suppression therapy in terms of skeletal health impairment and fracture risk in DTC patients.

Considerations for understanding protein measurements: Identification of formation, degradation and more pathological relevant epitopes

OBJECTIVES

There is a need for precision medicine and an unspoken promise of an optimal approach for identification of the right patients for value-based medicine based on big data. However, there may be a misconception that measurement of proteins is more valuable than measurement of fewer selected biomarkers. In population-based research, variation may be somewhat eliminated by quantity. However, this fascination of numbers may limit the attention to and understanding of the single. This review highlights that protein measurements (with collagens as examples) may mean different things depending on the targeted epitope - formation or degradation of tissues, and even signaling potential of proteins.

DESIGN AND METHODS

PubMed was searched for collagen, neo-epitope, biomarkers.

RESULTS

Ample examples of assays with specific epitopes, either pathological such as HbA1c, or domain specific such as pro-peptides, which total protein arrays would not have identified were evident.

CONCLUSIONS

We suggest that big data may be considered as the funnel of data points, in which most important parameters will be selected. If the technical precision is low or the biological accuracy is limited, and we include suboptimal quality of biomarkers, disguised as big data, we may not be able to fulfill the promise of helping patients searching for the optimal treatment. Alternatively, if the technical precision of the total protein quantification is high, but we miss the functional domains with the most considerable biological meaning, we miss the most important and valuable information of a given protein. This review highlights that measurements of the same protein in different ways may provide completely different meanings. We need to understand the pathological importance of each epitope quantified to maximize protein measurements.

Association of Vitamin D Gene Polymorphisms and Bone Mineral Density in Healthy young Saudi Females

BACKGROUND

Osteoporosis is a systemic skeletal disease characterized by low bone mineral density. Vitamin D metabolism may play a pivotal role in its pathophysiology.

OBJECTIVES

To determine the association between Vitamin D receptor gene polymorphisms and bone density, as well as its relation to biochemical markers of bone turnover, in a healthy Saudi female population.

METHODS

A cross-sectional study was carried out at Taibah University, Madinah Region, Kingdom of Saudi Arabia. After receiving informed consent, blood samples from 300 subjects were collected to measure calcium, phosphorus, alkaline phosphatase, parathyroid hormone osteocalcin, and 1,25-OHD and perform genetic analysis of SNPs in vitamin D receptors (VDR) rs2228570, rs731236, and rs11568820.

RESULTS

There were significant differences between the CC, CT, and TT alleles of VDR rs2228570. Carrying the TT allele was associated with increased risks of decreased bone density and the presence of osteopenia with lower vitamin D3 levels (p≤0.001). The VDR rs731236 gene showed that CC allele carriers had significant risk of osteopenia. The AA genotype of rs11568820 showed lower levels of physical activity, bone mineral density, Z scores, serum osteocalcin, phosphorus, and parathyroid hormones.

CONCLUSION

The presence of the TT allele of the SNP rs2228570 of the VDR gene and the SNP rs731236 of the CC genotype was associated with the presence of osteopenia and decreased bone mineral density alongside malfunctions of vitamin D.

TSH suppressive therapy and bone

Thyroid hormones stimulate bone turnover in adults by increasing osteoclastic bone resorption. TSH suppressive therapy is usually applied in patients with differentiated thyroid cancer (DTC) to improve the disease outcome. Over the last decades several authors have closely monitored the potential harm suffered by the skeletal system. Several studies and meta-analyses have shown that chronic TSH suppressive therapy is safe in premenopausal women and men. Conversely, in postmenopausal women TSH suppressive therapy is associated with a decrease of bone mineral density, deterioration of bone architecture (quantitative CT, QCT; trabecular bone score, TBS), and, possibly, an increased risk of fractures. The TSH receptor is expressed in bone cells and the results of experimental studies in TSH receptor knockout mice and humans on whether low TSH levels, as opposed to solely high thyroid hormone levels, might contribute to bone loss in endogenous or exogenous thyrotoxicosis remain controversial. Recent guidelines on the use of TSH suppressive therapy in patients with DTC give value not only to its benefit on the outcome of the disease, but also to the risks associated with exogenous thyrotoxicosis, namely menopause, osteopenia or osteoporosis, age >60 years, and history of atrial fibrillation. Bone health (BMD and/or preferably TBS) should be evaluated in postmenopausal women under chronic TSH suppressive therapy or in those patients planning to be treated for several years. Antiresorptive therapy could also be considered in selected cases (increased risk of fracture or significant decline of BMD/TBS during therapy) to prevent bone loss.

Low Predictive Value of FRAX Adjusted by Trabecular Bone Score for Osteoporotic Fractures in Korean Women: A Community-Based Cohort Study

BACKGROUND

The value of the Fracture Risk Assessment Tool (FRAX) and the trabecular bone score (TBS) for assessing osteoporotic fracture risk has not been fully elucidated in Koreans. We conducted this study to clarify the predictive value of FRAX adjusted by TBS for osteoporotic fractures in Korean women.

METHODS

After screening 7,192 eligible subjects from the Ansung cohort, 1,165 women aged 45 to 76 years with available bone mineral density (BMD) and TBS data were enrolled in this study. We assessed their clinical risk factors for osteoporotic fractures and evaluated the predictive value of FRAX with or without BMD and TBS.

RESULTS

During the mean follow-up period of 7.5 years, 99 (8.5%) women suffered major osteoporotic fractures (MOFs) and 28 (2.4%) experienced hip fractures. FRAX without BMD, BMD-adjusted FRAX, and TBS-adjusted FRAX were significantly associated with the risk of MOFs (hazard ratio [HR] per percent increase, 1.08; 95% confidence interval [CI], 1.03 to 1.14; HR, 1.09; 95% CI, 1.03 to 1.15; and HR, 1.07; 95% CI, 1.02 to 1.13, respectively). However, BMD-adjusted FRAX and TBS-adjusted FRAX did not predict MOFs better than FRAX without BMD based on the Harrell's C statistic. FRAX probabilities showed limited value for predicting hip fractures. The cut-off values of FRAX without BMD, FRAX with BMD, and FRAX with BMD adjusted by TBS for predicting MOFs were 7.2%, 5.0%, and 6.7%, respectively.

CONCLUSION

FRAX with BMD and TBS adjustment did not show better predictive value for osteoporotic fractures in this study than FRAX without adjustment. Moreover, the cut-off values of FRAX probabilities for treatment might be lower in Korean women than in other countries.

Postmenopausal women with osteoporosis consume high amounts of vegetables but insufficient dairy products and calcium to benefit from their virtues: the CoLaus/OsteoLaus cohort

We evaluated the associations between nutrients, dietary patterns or compliance to dietary guidelines and bone health among postmenopausal women from the CoLaus/OsteoLaus cohort. Postmenopausal women with osteoporosis consume a high amount of vegetables but insufficient amount of dairy products and calcium to benefit from their adherence to dietary guidelines.

INTRODUCTION

Diet plays a significant role in the prevention of osteoporosis (OP). We evaluated the associations between nutrients, dietary patterns or compliance (expressed in odds of meeting) to dietary Swiss guidelines and bone health (T score < - 2.5 SD, TBS < 1230) among postmenopausal women.

METHODS

One thousand two hundred fifteen women (64.3 ± 7.5 years) from the CoLaus/OsteoLaus cohort (Lausanne, Switzerland) had their dietary intake assessed using a validated food frequency questionnaire. Bone mineral density (BMD), trabecular bone score (TBS) and vertebral fractures were evaluated with DXA. OP risk factors, calcium supplements (> 500 mg) and prevalent major OP fractures were assessed by questionnaire.

RESULTS

One hundred eighty of 1195 women had OP according to BMD, 87/1185 a low TBS and 141/1215 prevalent major OP fractures. In multivariate analysis (adjusted for total energy intake, age, antiosteoporotic treatment, educational level, BMI, sedentary status and diabetes), OP women consumed more vegetable proteins (21.3 ± 0.4 vs 19.6 ± 0.2 g/day), more fibres (18.2 ± 0.5 vs 16.5 ± 0.2 g/day), less animal proteins (40.0 ± 1.1 vs 42.8 ± 0.4 g/day), less calcium (928 ± 30 vs 1010 ± 12 mg/day) and less dairy products (175 ± 12 vs 215 ± 5 g/day), all p ≤ 0.02. According to guidelines, OP women had a tendency to higher compliance for vegetables (OR (95% CI) 1.50 (0.99-2.26)) and a lower compliance for dairy (OR (95% CI) 0.44 (0.22-0.86)) than those without OP. Women taking calcium supplements consumed significantly higher amounts of dairy products. No association was found between TBS values or prevalent OP fractures and any dietary components.

CONCLUSION

Postmenopausal women with OP consume a high amount of vegetables but insufficient amount of dairy products and calcium. TBS does not seem to be influenced by diet.

Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis

Areal bone mineral density (aBMD) is currently the gold standard for the diagnosis of osteoporosis, however, it has its own pitfalls. Trabecular bone score (TBS), a novel tool in the evaluation of osteoporosis is an indirect indicator of bone microarchitecture. It is a textural index that evaluates pixel gray-level variations in the lumbar spine DXA (dual energy X-ray absorptiometry) image. Both cross-sectional and longitudinal studies have demonstrated that TBS may independently predict fragility fractures. TBS can also be used to adjust FRAX probabilities of fracture, though data available till date doesn't support any additional benefit. TBS also shows an improving trend with anti-osteoporotic treatment; however, the least significant change (LSC) is high that it takes more than 2 years for the change to manifest. TBS is also used in the evaluation of bone strength in cases of secondary osteoporosis. Though TBS predicts fracture risk independently in both genders, with the currently available data, it cannot be recommended as a standalone tool for decision regarding treatment of osteoporosis. TBS can be used as a tool to complement BMD in assessment of bone health. Additional studies are needed to assess its utility in clinical practice.

Recovery patterns over 4 years after distal radius fracture: Descriptive changes in fracture-specific pain/disability, fall risk factors, bone mineral density, and general health status

STUDY DESIGN

Descriptive/Longitudinal cohort.

INTRODUCTION

Distal radius fracture (DRF) is a common fall related fragility fracture that is known to be an early and independent predictor of secondary osteoporotic (OP) fractures. Changes in falls risk status, bone status and general health has not been evaluated prospectively in a population that has sustained a DRF.

PURPOSE OF THE STUDY

The purpose of our study was to describe the status of fracture-specific pain/disability, fall risk factors such as physical activity (PA) and fear of falling (FOF), bone mineral density (BMD) and general health status (HS) in people with a DRF and how these variables change over four years with respect to sex, age, incidence of secondary falls and secondary OP fractures.

METHODS

Patients (n = 94) self-reported their fracture-specific pain and disability (Patient-Rated Wrist Evaluation), PA (Rapid Assessment of Physical Activity), FOF (Modified Fall Efficacy Scale), HS (12-item Short Form Health Survey) and completed dual-energy X-ray absorptiometry scan based BMD assessment (lumbar spine and total hip) at baseline (1-2 weeks post-fracture), six months and four years after DRF. Descriptive statistics and general linear models were used to describe changes in recovery patterns over four years.

RESULTS

There was significant (p<0.001) improvement in fracture-specific pain/disability (60 points), FOF (1 point) and physical HS (11 points) between baseline and 4 year follow-up. There were no significant changes in PA and BMD. When stratified with respect to age, sex, presence of subsequent falls and OP fractures, there were no significant differences in fracture-specific pain/disability, PA, FOF, and BMD at baseline, six months or four years after DRF. The physical HS was significantly (p<0.05) less/poorer among those with secondary falls (lower by 2-6 points) and fractures (lower by 5-6 points) compared to those without. Similarly, mental HS was significantly (p<0.05) poorer among people with secondary falls (lower by 2-6 points) and in 50-64 year age group (lower by 3-5 points) than those without secondary falls and in 65-80 year age group, respectively.

CONCLUSION

Post DRF, the majority of the improvement in fracture-specific pain/disability, FOF and HS was completed at six months and very small changes were observed between the six month and four year follow-up.

LEVEL OF EVIDENCE

NA.

Impact of reference point selection on DXA-based measurement of forearm bone mineral density

Few studies have systematically evaluated the technical aspects of forearm bone mineral density (BMD) measurement. We found that BMD remained stable regardless of the reference point; however, the ROI identified was not always consistent. Our study highlights the importance of using the same reference point for serial measurements of forearm BMD.

BACKGROUND

Forearm fractures are clinically important outcomes from the perspective of morbidity, health care costs, and interruption of work. BMD of the forearm, as derived by dual-energy x-ray absorptiometry (DXA), is a better predictor of fracture at the forearm compared with BMD measured at other sites. However, very few studies have evaluated the technical aspects of selecting the ROI for forearm BMD measurement. This study aimed to compare the BMD values measured at the 1/3 radius site using three different reference points: the ulnar styloid process, the radial endplate, and the bifurcation of the ulna and radius.

METHODOLOGY

Healthy Chinese patients participating in the control group of an ongoing study at Zhejiang Provincial People's Hospital were recruited for this study. For each patient, a DXA scan (GE Lunar Prodigy) of the forearm was performed and BMD values were separately calculated using each of the three reference points to identify the ROI. Pearson correlation coefficients were calculated to examine the correlation between the BMD measures derived from each reference point. The F test and independent t test were applied for more robust analysis of the differences in the variances and means.

RESULTS

Sixty-eight healthy Chinese volunteers agreed to participate in this study. The root mean square standard deviation (RMS-SD) percentages of BMD values measured at the 1/3 radius site were 2.19%, 2.23%, and 2.20% when using the ulnar styloid process, radial endplate, and the bifurcation of the ulna and radius as the reference points, respectively. Pearson's correlation coefficients for all pairwise comparisons among these three groups were greater than 0.99. F tests and independent t tests showed p values ranging from 0.92 to 0.99. However, we observed that among 10% of patients, choosing an ROI at the ulnar styloid process led to an inability to accurately determine the BMD at the ultra-distal radius.

CONCLUSIONS

Given equal ability to determine BMD at the 1/3 radius accurately, the radial endplate or the bifurcation of the ulna and radius should be preferentially selected as the reference point for routine forearm BMD measurements in order to avoid situations in which the ultra-distal radius BMD cannot be determined.

Effect of the "Building Osteo Neatly Exercise" program on quantitative ultrasound parameters and plantar pressure distribution for college-aged females

[Purpose] We investigated the effects of a specifically designed exercise program that focused on the arches of the foot and the forefoot (the "Building Osteo Neatly Exercise" program) in college-aged females. [Participants and Methods] Forty college-aged females were divided randomly into experimental and control groups. The experimental group underwent the Building Osteo Neatly Exercise program for 60 min once a week for 4 months. In both groups, the plantar pressure distribution and quantitative ultrasound parameters of the calcaneus (speed of sound and bone area ratio) were evaluated at the beginning and end of the study. The plantar pressure distribution during walking was measured using a pressure plate to evaluate the deviation from the ideal values for the following: contact time, contact duration, peak pressure time, and foot pressure, all measured in the rear foot (the external and internal sides), medial forefoot including (the hallux and second and third toes), and lateral forefoot (the fourth and fifth toes). [Results] After completing the program, the speed of sound and bone area ratio had increased significantly in the experimental group and were significantly higher than those in the control group. The experimental group showed significant improvements in the deviations from the ideal values in contact time and contact duration in the medial forefoot, all four parameters in the lateral forefoot, and pressure in the rear foot. [Conclusion] College-aged females who participated in the Building Osteo Neatly Exercise program once weekly for 4 months exhibited significant improvements in bone strength in the calcaneus and in foot function, as shown by the plantar pressure distribution. Further studies are needed to examine the outcomes of the Building Osteo Neatly Exercise program in an elderly population.

Association between Inflammatory Potential of Diet and Bone-Mineral Density in Korean Postmenopausal Women: Data from Fourth and Fifth Korea National Health and Nutrition Examination Surveys

Post menopause is considered a critical period for bone-mass loss. Impaired bone metabolism during this phase can increase the risk of fractures in old age. Inflammation is a risk factor for bone health, and diet is a potential source of inflammation. However, few studies have examined the association between the dietary inflammatory index (DII®) and bone-mineral density (BMD) in postmenopausal women in Korea. The objective of this study was to determine, by means of a Korean cross-sectional investigation, whether higher DII scores are associated with decreased BMD in postmenopausal women. To that end, the raw data from the fourth and fifth Korea National Health and Nutrition Examination Surveys (KNHANES, 2009-2011) for 2778 postmenopausal women aged over 50 years were analyzed. The subjects' BMD were measured by dual-energy x-ray absorptiometry, and their DII® scores were calculated from a single 24-h dietary recall. Further, the participants were classified into three groups according to DII® score. Women with more pro-inflammatory diets (i.e., those in the highest tertile of DII®) had significantly lower BMD in the femoral neck as compared with women in the lowest tertile (p for trend <0.05) after adjustment for age, body-mass index (BMI), household income, education status, smoking habits, physical activity, total calcium intake, female-hormone use, age at menopause, and blood vitamin D levels. Multiple logistic regression analyses revealed that the odds ratio (OR) of total femur osteopenia/osteoporosis was higher in women in the highest tertile of DII® than in those in the lowest (OR 1.27, 95% CI 1.00-1.62, p for trend < 0.05). This study established that more pro-inflammatory diets might be associated with lower BMD in postmenopausal Korean women.

Emerging Technologies in Osteoporosis Diagnosis

Osteoporosis is a disease defined by diminished bone mass, often resulting in debilitating fragility fractures. As hand surgeons who care for patients with fractures of the distal radius and proximal humerus often related to osteoporosis, it is critical to understand the diagnostic modalities used in the workup of decreased bone density. Although the current reference standard for diagnosing osteoporosis is dual x-ray absorptiometry, this technique has notable drawbacks such as the inability to provide a 3-dimensional image or information about bone microstructure. These limitations result in underdiagnosis of osteoporosis. Other emerging imaging technologies such as quantitative computed tomography, high-resolution peripheral quantitative computed tomography, and quantitative ultrasound offer distinct advantages over dual x-ray absorptiometry. Among these advantages are the production of 3-dimensional images, information about cortical and trabecular microstructure, and reduced radiation exposure. It is essential for hand surgeons to be aware of these evolving diagnostic modalities and the benefits that they offer to provide the best care for patients with osteoporosis.

Improvement of region of interest extraction and scanning method of computer-aided diagnosis system for osteoporosis using panoramic radiographs

OBJECTIVES

Patients undergoing osteoporosis treatment benefit greatly from early detection. We previously developed a computer-aided diagnosis (CAD) system to identify osteoporosis using panoramic radiographs. However, the region of interest (ROI) was relatively small, and the method to select suitable ROIs was labor-intensive. This study aimed to expand the ROI and perform semi-automatized extraction of ROIs. The diagnostic performance and operating time were also assessed.

METHODS

We used panoramic radiographs and skeletal bone mineral density data of 200 postmenopausal women. Using the reference point that we defined by averaging 100 panoramic images as the lower mandibular border under the mental foramen, a 400 × 100-pixel ROI was automatically extracted and divided into four 100 × 100-pixel blocks. Valid blocks were analyzed using program 1, which examined each block separately, and program 2, which divided the blocks into smaller segments and performed scans/analyses across blocks. Diagnostic performance was evaluated using another set of 100 panoramic images.

RESULTS

Most ROIs (97.0%) were correctly extracted. The operation time decreased to 51.4% for program 1 and to 69.3% for program 2. The sensitivity, specificity, and accuracy for identifying osteoporosis were 84.0, 68.0, and 72.0% for program 1 and 92.0, 62.7, and 70.0% for program 2, respectively. Compared with the previous conventional system, program 2 recorded a slightly higher sensitivity, although it occasionally also elicited false positives.

CONCLUSIONS

Patients at risk for osteoporosis can be identified more rapidly using this new CAD system, which may contribute to earlier detection and intervention and improved medical care.

Discrimination of vertebral fragility fracture with lumbar spine bone mineral density measured by quantitative computed tomography

Background/Objective

This study is a case–control study to explore risk and protective factors, including clinical data and bone mineral density (BMD), affecting vertebral body fragility fracture in elderly men and postmenopausal women. In addition, we investigate the effectiveness of lumbar spine BMD by quantitative computed tomography (QCT) in discriminating vertebral fragility fracture.

Methods

In this case–control study, 52 males and 198 females with vertebral fragility fracture were compared with sex- and age-matched healthy controls to analyse the risk factors that may affect vertebral fragility fracture. The L1–L3 vertebral BMDs were measured by QCT. The difference in risk factors between fracture cases and controls were analysed using student t test and Mann–Whitney U test. The correlation between BMD, age, height and weight were analysed using univariate analysis. Multiple logistic regression analysis was used to study statistically significant indexes. The receiver operating characteristic curve was used to calculate the cut-off values for positive and negative predictive values of BMD for vertebral fracture discrimination.

Results

In males, body weight and BMD were significantly different between the fracture group and the control group, whereas BMD was only weakly correlated with age (r = −0.234). In females, only BMD was significantly different between the fracture and control groups. BMD was weakly correlated with height (r = 0.133) and weight (r = 0.120) and was moderately correlated with age (r = −0.387). There was no correlation between BMD and the remaining variables in this study. In both men and women, the BMD (p = 0.000) was the independent protective factor against vertebral fracture. The cut-off values of vertebral BMD for fractures were 64.16 mg/cm³ for males and 55.58 mg/cm³ for females. QCT-measured BMD has a high positive predictive value and negative predictive value for discriminating vertebral fragility fracture across a range of BMD values.

Conclusion

This study suggests that BMD is closely related to vertebral fragility fracture and that QCT is an effective technique to accurately discriminate vertebral fragility fracture.

The translational potential of this article

The spine BMD measured by QCT is closely related to fracture, which may allow clinicians to more accurately discriminate which individuals are likely to experience vertebral fragility fracture.

HIV Infection Is Associated With Abnormal Bone Microarchitecture: Measurement of Trabecular Bone Score in the Women's Interagency HIV Study

OBJECTIVES

We compared skeletal microarchitecture using trabecular bone score (TBS) and evaluated relationships between change in TBS and lumbar spine (LS) bone mineral density (BMD) in women with and without HIV.

METHODS

Dual-energy X-ray absorptiometry was performed on 319 women with HIV and 118 without HIV in the Women's Interagency HIV Study at baseline and 2 and 5 years, to measure regional BMD and lean and fat mass. TBS was extracted from LS dual-energy X-ray absorptiometry images and examined continuously and categorically [normal (≥1.35), intermediate (1.20-1.35), or degraded (≤1.20) microarchitecture]. Pearson correlation and linear regression examined associations of TBS with regional BMD at baseline and over time.

RESULTS

Women with HIV were older (43 vs. 37 years), more likely to be postmenopausal (27% vs. 4%), have lower baseline total fat mass, trunk fat, and leg fat than uninfected women, degraded microarchitecture (27% vs. 9%, P = 0.001), and lower baseline mean TBS (1.3 ± 0.1 vs. 1.4 ± 0.1, P < 0.001). After adjusting for age, race, menopause status, and body mass index, TBS remained lower in women with HIV (P < 0.0001). Annual change in TBS correlated with LS BMD change among women with HIV (r = 0.36, P < 0.0001) and without HIV (r = 0.26, P = 0.02); however, mean % annual TBS change did not differ by HIV status (-1.0%/yr ± 2.9% for HIV+ vs. -0.8%/yr ± 1.7% for HIV-, P = 0.42).

CONCLUSIONS

Women with HIV have worse bone microarchitecture than uninfected women, but annual percent change in LS BMD or TBS was similar. Use of TBS as an adjunct to BMD to improve prediction of fragility fractures in women with HIV merits further study.

Comparative assessment of fracture risk among osteoporosis and osteopenia patients: a cross-sectional study

BACKGROUND

Both osteoporosis and osteopenia remain worldwide public health concerns. They both lead to bone fractures, which can lead to disability and burden on those who are afflicted.

OBJECTIVES

To assess and compare fracture risk between these two groups of patients.

PATIENTS AND METHODS

Our cross-sectional study included 82 patients (46 with osteoporosis and 36 with osteopenia) with an average age of 63±9.33 years, who received treatment at the Clinic for Medical Rehabilitation, Clinical Center of Vojvodina in Novi Sad, Serbia. The assessment of the fracture risk was executed by applying the Fracture Assessment Risk (FRAX) index (an algorithm developed by the World Health Organization) based on clinical fracture risks or combination of clinical fracture risks and bone mineral density.

RESULTS

Patients with osteoporosis had significantly higher risk of major fracture compared to patients with osteopenia (p<0.01). Results from FRAX index in osteoporotic patients showed that more than half (58.70%) of patients had a low risk of fracture; less than one-third of patients (30.43%) had an intermediate risk of major osteoporotic fracture, while almost four out of every 10 (39.96%) had a high risk of hip fracture. The majority of patients with osteopenia (63.89%) had a low risk of major osteoporotic fracture, while 36.11% of them had an intermediate risk. The majority of patients with osteopenia (91.67%) had a low risk of hip fracture. Statistically significant differences in relation to specific fracture risks between patients with osteoporosis and osteopenia, in particular, weight (t=-2.250, p=0.027*) and previous fractures (t=2.985, p=0.004**), were established.

CONCLUSION

Osteoporosis patients had a high risk of major osteoporotic fracture, while there was no association between the intermediate level for major osteoporotic fracture and osteo-penia. For patients suffering from an increased fracture risk, especially those who had already been diagnosed with osteoporosis, preventive measures such as designing individual therapeutic programs should be adopted.

The Prevalence of Osteopenia and Osteoporosis Among Malaysian Type 2 Diabetic Patients Using Quantitative Ultrasound Densitometer

Background:

Type 2 Diabetes Mellitus (T2DM) and osteoporosis are both chronic conditions and the relationship between them is complex.

Objective:

The aims of this study were to assess the prevalence of Low Bone Mineral density (LBMD, i.e., osteopenia and osteoporosis), as well as, the difference and associations between Quantitative Ultrasound Scan (QUS) parameters with socio-demographic data and clinical related data among T2DM in Penang, Malaysia.

Method:

An observational, cross-sectional study with a convenient sample of 450 T2DM patients were recruited from the outpatient diabetes clinic at Hospital Pulau Pinang (HPP) to measure Bone Mineral Density (BMD) at the heel bone using QUS. In addition, a self-reported structured questionnaire about the socio-demographic data and osteoporosis risk factors were collected. Moreover, the study included the retrospective collection of clinical data from patients’ medical records.

Results:

The mean value of T-score for normal BMD, osteopenic and osteoporotic patients’ were (-0.41±0.44), (-1.65±0.39) and (-2.76±0.27), respectively. According to QUS measurements, more than three quarters of T2DM patients (82%) were at high risk of abnormal BMD. The results showed that QUS scores were significantly associated with age, gender, menopausal duration, educational level and diabetic related data. Moreover, the QUS parameters and T-scores demonstrated significant negative correlation with age, menopausal duration, diabetic duration and glycaemic control, as well as, a positive correlation with body mass index and waist to hip ratio. The current study revealed that none of the cardiovascular disease risk factors appear to influence the prevalence of low BMD among T2DM Malaysian patients.

Conclusion:

The study findings revealed that the assessment of T2DM patients’ bone health and related factor are essential and future educational programs are crucial to improve osteoporosis management.

TRABECULAR BONE SCORE (TBS) HAS A POOR DISCRIMINATIVE POWER FOR VERTEBRAL FRACTURES IN 153 ROMANIAN PATIENTS WITH PRIMARY HYPERPARATHYROIDISM

CONTEXT

Trabecular Bone Score (TBS) has been recently proposed as a good tool to investigate secondary osteoporosis.

OBJECTIVE

The aim of this study was to assess TBS from spine DXA images in patients with primary hyperparathyroidism (PHPT) and look at its correlates.

SUBJECTS AND METHODS

153 patients, mean age 59.1 ± 12.1 yrs, females and males (10%), mean BMI 26.2 ± 4.8 kg/m2, mean serum calcium and PTH of 11.3 ± 1.2 mg/dL and 232 ± 329 pg/mL, respectively; 89% had osteoporosis/osteopenia by LS DXA and 46% had renal involvement. There were 7.6% patients with vertebral fractures, 13.2% patients with nonvertebral fractures. TBS indices were derived from LS-DXA images and cutoff points used were those previously reported.

RESULTS

Mean TBS was in the partially degraded range (1.258 ± 0.115); 32% of patients had degraded microarchitecture (TBS ≤ 1.20), 51% had partially degraded microarchitecture (TBS > 1.20 and < 1.35) and 17% had normal TBS. TBS was significantly correlated with areal BMD both at the LS (r=0.544; p<0.001) and FN (r = 0.315; p < 0.001), and negatively with age (r= - 0.354; p < 0.001) and years since menopause - YSM (r = - 0.257, p = 0.005). Patients with vertebral fractures had mean values of TBS in the degraded range, significantly lower than those without vertebral fractures (1.173 ± 0.076 vs. 1.263 ± 0.115; p = 0.006). The presence of vertebral fracture was independently associated only with YSM (OR = 1.131, 95% CI = 0.032 - 0.214, p = 0.008) but not with TBS.

CONCLUSIONS

In a cohort of symptomatic PHPT patients, including postmenopausal, premenopausal and male patients, we have shown that TBS was in the partially degraded range, but it was not independently associated with fractures.

Utility of trabecular bone score in the evaluation of osteoporosis

PURPOSE OF REVIEW

Trabecular bone score (TBS) is a lumbar spine dual-energy absorptiometry texture index which provides information on skeletal quality partially independent of bone mineral density (BMD). A body of work has emerged demonstrating the relationship between TBS and fracture risk, with lower TBS values associated with increased risk for osteoporotic fracture in postmenopausal women and older men. TBS is derived from standard DXA images; however, the information provided by TBS is complementary to that provided by BMD. In this article, we review the current state of TBS and its evolving role in the assessment and management of osteoporosis, with particular emphasis on the literature of the previous year.

RECENT FINDINGS

TBS-adjusted The Fracture Risk Assessment tool (FRAX) probabilities enhance fracture risk prediction compared with conventional FRAX predictions. TBS has been found to better categorize fracture risk and assists in FRAX-based treatment decisions, particularly for patients close to an intervention threshold. However, change in lumbar spine TBS while undergoing antiresorptive treatment is not a useful indicator of antifracture effect.

SUMMARY

Lumbar spine TBS is a recently developed image-based software technique for skeletal assessment, complementary to conventional BMD, which has been shown to be clinically useful as a fracture risk prediction tool.

Trabecular bone score (TBS): Method and applications

Trabecular bone score (TBS) is a texture index derived from standard lumbar spine dual energy X-ray absorptiometry (DXA) images and provides information about the underlying bone independent of the bone mineral density (BMD). Several salient observations have emerged. Numerous studies have examined the relationship between TBS and fracture risk and have shown that lower TBS values are associated with increased risk for major osteoporotic fracture in postmenopausal women and older men, with this result being independent of BMD values and other clinical risk factors. Therefore, despite being derived from standard DXA images, the information contained in TBS is independent and complementary to the information provided by BMD and the FRAX® tool. A procedure to generate TBS-adjusted FRAX probabilities has become available with the resultant predicted fracture risks shown to be more accurate than the standard FRAX tool. With these developments, TBS has emerged as a clinical tool for improved fracture risk prediction and guiding decisions regarding treatment initiation, particularly for patients with FRAX probabilities around an intervention threshold. In this article, we review the development, validation, clinical application, and limitations of TBS.

Bone mineral density at distal forearm in men over 40 years of age in Mae Chaem district, Chiang Mai Province, Thailand: a pilot study

OBJECTIVE

To study the prevalence of bone mineral density (BMD) and osteoporosis in the distal forearm among Thai men over 40 years of age in Mae Chaem District, Chiang Mai Province, Thailand.

METHODS

The subjects in this study were 194 Thai men, aged between 40 and 87 years who resided in Mae Chaem District, Chiang Mai Province, Thailand. Self-administered questionnaires were used for receiving the demographic characteristics information. BMD was measured by peripheral dual energy X-ray absorptiometry at the nondominant distal forearm in all men.

RESULTS

The BMD was highest in the age-group 40-49 years and lowest in the age-group 70-87 years. The average T-score at the distal forearm was also highest in the age-group 40-49 years and lowest in the age-group 70-87 years. The BMD decreased as a function of age-group (p < .05). In contrast, the BMD increased as a function of weight (p < .05). Height had weak impact on the BMD in the distal forearm (p > .05). The percentage of osteopenia and osteoporosis are increased as a function of age-group in, while decreased in that of normal bone density.

CONCLUSIONS

We found the prevalence of osteoporosis in men who resided in Mae Chaem District, Chiang Mai Province, Thailand.

Predicting fractures using trabecular patterns on panoramic radiographs

OBJECTIVES

The observer score of the trabecular pattern on panoramic radiographs is known to be a strong predictor of bone fractures. The aim of this study was to enhance the predictive power of panoramic radiographs by means of texture analysis methods.

MATERIAL AND METHODS

The study followed 304 postmenopausal women during 26 years. At the beginning of the study, panoramic radiographs were obtained. One observer assessed the trabecular pattern in the premolar region as dense, sparse, or alternating dense and sparse. In addition, on each radiograph, a region of interest was selected in the molar/premolar region and analyzed with texture analysis procedures. During 26 years of follow-up, 115 women suffered a fracture of the hip, spine, leg, or arm. Logistic regression was applied to test the predictive power of various variables with respect to fractures.

RESULTS

Of all variables, the observer score of the trabecular pattern correlated strongest with the occurrence of fractures. By itself, the score yielded an ROC curve with an area of 0.80 under the curve. Combining the observer score with the texture analysis features increased the area under the ROC curve to 0.85.

CONCLUSIONS

The trabecular pattern on panoramic radiographs provides a strong predictor of fractures, at least for postmenopausal women. The assessment by an observer combined with texture analysis procedures yields a predictive power that parallels best known predictions in literature.

CLINICAL RELEVANCE

This study illustrates that panoramic radiographs are state of the art predictors of postcranial fractures.

The Prevalence of Vitamin D Insufficiency and Deficiency and Their Relationship with Bone Mineral Density and Fracture Risk in Adults Receiving Long-Term Home Parenteral Nutrition

It has been demonstrated that low bone mass and vitamin D deficiency occur in adult patients receiving home parenteral nutrition (HPN). The aim of this study is to determine the prevalence of vitamin D insufficiency and deficiency and its relationship with bone mineral density (BMD) and fracture risk in long-term HPN patients. Methods: A retrospective chart review of all 186 patients in the HPN registry followed by the Northern Alberta Home Parenteral Nutrition Program receiving HPN therapy >6 months with a 25 (OH) D level and BMD reported were studied. Results: The mean age at the initiation of HPN was 53.8 (20–79) years and 23 (37%) were male. The mean HPN duration was 56 (6–323) months and the most common diagnosis was short bowel syndrome. Based on a total of 186 patients, 62 patients were categorized based on serum vitamin D status as follows: 1 (24.2%) sufficient, 31 (50%) insufficient and 16 (25.8%) deficient. Despite an average of 1891 IU/day orally and 181 IU/day intravenously vitamin D, the mean vitamin D level was 25.6 ng/mL (insufficiency) and 26.2 ± 11.9 ng/mL in patients with the highest 10-year fracture risk. Conclusion: Suboptimal vitamin D levels are common among patients on long-term HPN despite nutrient intake that should meet requirements.

Longitudinal Change in Trabecular Bone Score during and after Treatment of Osteoporosis in Postmenopausal Korean Women

BACKGROUND

The aim of this study was to evaluate the longitudinal changes of trabecular bone score (TBS) during and after bisphosphonate (BP) treatment in postmenopausal Korean women with osteoporosis.

METHODS

We analyzed 191 patients who took BP and underwent bone mineral density (BMD) test for the period from January 2010 to December 2015. The mean follow up period during treatment and after treatment was 22.8 months and 18 months, respectively. The TBS and BMD values were evaluated by the percent changes relative to the baseline.

RESULTS

In 191 patients, who treated with BPs, L-spine BMD increased 3.65±0.5% and TBS increased 0.26±0.4% from baseline during first 1 year. At 2 to 4 years, the changes of BMD and TBS from baseline gradually increased up to 9.3±3.25% and 2.69±0.98% and both results showed statistically significant correlation. In 86 patients who stopped BPs, L-spine BMD decreased -0.54±1.07% and TBS increased 0.33±1.96% from baseline during 3 years follow up period.

CONCLUSIONS

Lumbar spine TBS increase over time with BPs treatment although the changes were less than that of BMD. Also, it preserve for years after stopping treatment, as the changes of lumbar spine BMD. The results of BMD and TBS showed significant correlation during treatment but not during drug withdrawal.

Epidemiology of distal radius fractures and factors predicting risk and prognosis

STUDY DESIGN

Literature Review.

INTRODUCTION

For optimal Distal Radius Fracture (DRF) rehabilitation and fracture prevention, it is important to understand the epidemiology and factors predictive of injury, chronic pain, chronic disability, and subsequent fracture.

PURPOSE

To summarize the literature reporting on DRF epidemiology, risk factors, and prognostic factors.

METHODS

Literature synthesis.

RESULTS

Although incidence varies globally, DRFs are common across the lifespan and appear to be on the rise. Risk of DRF is determined by personal factors (age, sex/gender, lifestyle, health condition) and environmental factors (population density, climate). For example, age and sex influence risk such that DRF is most common in boys/young men and older women. The most common causes of DRF in the pediatric and young adult age groups include playing/sporting activities and motor vehicle accidents. In contrast, the most common mechanism of injury in older adults is a low-energy trauma because of a fall from a standing height. Poorer health outcomes are associated with older age, being female, poor bone healing (or having an associated fracture of the ulnar styloid), having a compensated injury, and a lower socioeconomic status.

CONCLUSIONS

Risk stratification according to predictors of chronic pain and disability enable therapists to identify those patients who will benefit from advocacy for more comprehensive assessment, targeted interventions, and tailored educational strategies. The unique opportunity for secondary prevention of osteoporotic fracture after DRF has yet to be realized by treating therapists in the orthopedic community.

LEVEL OF EVIDENCE

V.

The lumbar spine age-related degenerative disease influences the BMD not the TBS: the Osteolaus cohort

We evaluated the influence of degenerative disease and fractured vertebra on lumbar spine bone mineral density (BMD) and trabecular bone score (TBS) in 1500 women aged 50-80 years. TBS was not affected by a degenerative disease. While BMD increases after 62.5 years, TBS continues to decline. TBS should play a leading role in lumbar spine evaluation.

INTRODUCTION

After menopause, lumbar spine (LS) BMD and TBS values decrease. Degenerative disease (DD) increases with age and affect LS BMD. The aim of this study was to measure changes in LS BMD and TBS in women 50 to 80 years old, taking into account the impact of fractured vertebrae and DD.

METHODS

LS BMD, TBS, and vertebral fracture assessment were evaluated in the OsteoLaus cohort (1500 women, 50-80 years old). The exams were analyzed following ISCD guidelines to identify vertebrae with fractures or DD (Vex).

RESULTS

1443 women were enrolled: mean age 66.7 ± 11.7 years, BMI 25.7 ± 4.4. LS BMD and TBS were weakly correlated (r2 = 0.16). The correlation (Vex excluded) between age and BMD was +0.03, between age and TBS -0.34. According to age group, LS BMD was 1.2 to 3.2% higher before excluding Vex (p < 0.001). TBS had an insignificant change of <1% after excluding Vex. LS BMD (Vex) decreased by 4.6% between 52.5 and 62.5 years, and increased by 2.6% between 62.5 and 77.5 years. TBS (Vex excluded) values decreased steadily with age with an overall loss of 8.99% between 52.5 and 77.5 years. Spine TBS, femoral neck, and total hip BMD gradually decreased with age, reaching one SD between the oldest and youngest group.

CONCLUSIONS

TBS is not affected by DD. While BMD increases after 62.5 years, TBS continues to decline. For lumbar spine evaluation, in view of its independence from DD, TBS should play a leading role in the diagnosis in complement to BMD.