Utility of heel ultrasound bone density in men

Discordance between quantitative ultrasound and dual-energy X-ray absorptiometry in bone mineral density: The Vietnam Osteoporosis Study

Objectives

Calcaneal quantitative ultrasound measurement (QUS) has been considered an alternative to dual-energy X-ray absorptiometry (DXA) based bone mineral density (BMD) for assessing bone health. This study sought to examine the utility of QUS as an osteoporosis screening tool by evaluating the correlation between QUS and DXA.

Methods

The study was a part of the Vietnam Osteoporosis Study that involved 1270 women and 773 men aged 18 years and older. BMD at the femoral neck, total hip and lumbar spine was measured using DXA. Osteoporosis was diagnosed based on the femoral neck T-score using World Health Organization criteria. Broadband ultrasound attenuation (BUA) at the calcaneus was measured by QUS. The concordance between BUA and BMD was analyzed by the linear regression model.

Results

In all individuals, BUA modestly correlated with femoral neck BMD (r = 0.35; P < 0.0001) and lumbar spine BMD (r = 0.34; P < 0.0001) in both men and women. In individuals aged 50 years and older, approximately 16% (n = 92/575) of women and 3.2% (n = 10/314) of men were diagnosed to have osteoporosis. Only 0.9% (n = 5/575) women and 1.0% (n = 3/314) men were classified as "Low BUA". The kappa coefficient of concordance between BMD and BUA classification was 0.09 (95% CI, 0.04 to 0.15) for women and 0.12 (95% CI, 0.03 to 0.22) for men.

Conclusions

In this population-based study, QUS BUA modestly correlated with DXA BMD, suggesting that BUA is not a reliable method for screening of osteoporosis.

A screening model for low bone mass in elderly Japanese men using quantitative ultrasound measurements: Fujiwara-Kyo Study

Screening for low bone mass is important to prevent fragility fractures in men as well as women, although men show a much lower prevalence of osteoporosis than women. The purpose of this study was to establish a screening model for low bone mineral density (BMD) using a quantitative ultrasound parameter and easily obtained objective indices for elderly Japanese men. We examined 1633 men (65-84 yr old) who were subjects of the Fujiwara-Kyo Study. Speed of sound (SOS) at the calcaneus was determined, and BMD was measured by dual-energy X-ray absorptiometry at the lumbar spine (LS), total hip (TH), and femoral neck (FN). Low BMD was defined as >1 standard deviation below the young adult mean, in accordance with World Health Organization criteria. We performed receiver operating characteristic (ROC) analysis to identify a better screening model incorporating SOS and determined the optimal cutoff value using Youden index. Prevalences of low BMD at the 3 skeletal sites were 27.8% (LS), 33.5% (TH), 48.6% (FN), and 43.3% at either LS or TH. The greatest area under the ROC curve (0.806, 95% confidence interval: 0.785-0.828) and smallest Akaike's information criterion were obtained in the multivariate model incorporating SOS, age, height, and weight for predicting low BMD at all skeletal sites. This model predicted low BMD at TH with the sensitivity of 0.726 and specificity of 0.739, whereas a similar model predicted low BMD at LS with much lower validity. We conclude that the multivariate model for TH could be used to screen for low BMD in elderly Japanese men.

Osteoporosis in Long-Term Care Residents with Multiple Sclerosis

OBJECTIVE

To assess the fracture risk of long-term care residents with multiple sclerosis (MS) using ultrasound heel-scan technology and identification of risk factors and areas where intervention by a pharmacist might affect patient outcomes.

DESIGN

Bilateral-heel scans were performed on all patients who consented to take part in the study. A retrospective review of each subject's medical records was performed to identify known risk factors for osteoporosis.

SETTING

A long-term care facility in Omaha, Nebraska.

PARTICIPANTS

All patients with a primary diagnosis of MS residing at the facility were eligible for participation. Of 11 patients identified, 10 consented to participate.

MAIN OUTCOME MEASURES

T-scores of the right and left heel as determined by ultrasound-heel scan were used to determine if study participants met criteria for osteopenia or osteoporosis as set forth by the World Health Organization.

CONCLUSION

Patients in our population who have MS are at high risk for fracture. There are several areas in which pharmacists can intervene to prevent fracture and improve patient outcomes, including administration of heel scans for persons believed to be at risk, recommendation of over-the-counter supplements, and education of both patients and health care practitioners.

Osteoporosis in men

With the aging of the population, there is a growing recognition that osteoporosis and fractures in men are a significant public health problem, and both hip and vertebral fractures are associated with increased morbidity and mortality in men. Osteoporosis in men is a heterogeneous clinical entity: whereas most men experience bone loss with aging, some men develop osteoporosis at a relatively young age, often for unexplained reasons (idiopathic osteoporosis). Declining sex steroid levels and other hormonal changes likely contribute to age-related bone loss, as do impairments in osteoblast number and/or activity. Secondary causes of osteoporosis also play a significant role in pathogenesis. Although there is ongoing controversy regarding whether osteoporosis in men should be diagnosed based on female- or male-specific reference ranges (because some evidence indicates that the risk of fracture is similar in women and men for a given level of bone mineral density), a diagnosis of osteoporosis in men is generally made based on male-specific reference ranges. Treatment consists both of nonpharmacological (lifestyle factors, calcium and vitamin D supplementation) and pharmacological (most commonly bisphosphonates or PTH) approaches, with efficacy similar to that seen in women. Increasing awareness of osteoporosis in men among physicians and the lay public is critical for the prevention of fractures in our aging male population.

Quantitative ultrasound variables of the heel in Finnish men aged 18-20 yr: predictors, relationship to bone mineral content, and changes during military service

INTRODUCTION

Determinants of BUA and SOS and their changes during military service-associated physical training were studied in 196 army recruits and 50 control men, aged 18-20 years.

METHODS

Heel ultrasound measurement, DXA, muscle strength test, Cooper's running test and genetic analyses were performed. Lifestyle factors were recorded. Sex steroids and bone turnover markers were determined. Heel ultrasound was repeated after six months.

RESULTS

Exercise was the most significant determinant of both BUA (p<0.0001) and SOS (p<0.0001). There were 10% and 1.3% differences in BUA (p=0.006) and SOS (p=0.0001), respectively, between men belonging to the lowest and highest quartiles of exercise index. Weight associated with BUA (p=0.005) and height with SOS (p=0.03). BUA and SOS correlated with BMC and BMD (p<0.0001) but explained only up to 21% of their variance. Over six months SOS increased more in recruits than in control men (p=0.0043), the increase being higher, the lower muscle strength at baseline (r =-0.27, p=0.0028).

CONCLUSION

Exercise is the most important determinant of ultrasonographic variables in men, aged 18-20 years. Physical loading during military training increases SOS.

Epidemiology and pathophysiology of osteoporosis in men

Osteoporosis in men is an unrecognized but growing problem as the number of men who live to old age increases. The 10-year fracture risk at age 50 quadruples by age 80, and in general the incidence rate of osteoporotic fracture in men is about half that of women. Of note, the mortality and morbidity after hip fracture are much greater in men. There are many men whose osteoporosis is the result of specific causes such as oral glucocorticoid therapy, hypogonadism, or androgen withdrawal therapy for prostate cancer. In addition there are several interesting syndromes of osteoporosis in middle-aged men; these men usually present with vertebral fractures. As knowledge about the prevalence and etiology of osteoporosis in men increases, it will be recognized and treated in more men, in hopes of preventing fracture.

Utility of screening tools for the prediction of low bone mass in African American men

INTRODUCTION

Osteoporosis remains under-diagnosed, particularly in African American men, despite the availability of reliable diagnostic tests. In women, several screening tools, including heel ultrasound and clinical assessment tools, reliably predict low bone mass, however the usefulness of these screening tools in African American men is unknown. The aim of this study was to determine the utility of screening tools, namely heel ultrasound, the osteoporosis self-assessment tool (OST), weight-based criterion (WBC) and body mass index (BMI), in screening for low bone mass in African American men.

MATERIALS AND METHODS

African American men 35 years of age and older were invited to participate. The OST risk index is a score based on age and weight [(weight in kilograms--age in years)x0.2]. Bone mineral density (BMD) of the heel was measured by heel ultrasound, and BMD of both the lumbar spine and hip were determined by dual energy X-ray absorptometry (DXA). One hundred and twenty-eight men fulfilled the inclusion criteria for our study.

RESULTS

The population prevalence of osteopenia and osteoporosis were 39% and 7%, respectively. Using a heel ultrasound T-score cut-off value of -1 or less, we predicted low bone mass (T-score of -2 or less at the hip) with a sensitivity of 83%, a specificity of 71% and an area under the curve (AUC) of 0.80. Using an OST cut-off value of 4, we predicted low bone mass with a sensitivity of 83%, a specificity of 57% and an AUC of 0.83. The OST risk index ranged from 18.1 to -6.1, based on which we categorized risk as: low, 5 or greater; moderate, 0-4; high, -1 or less. Of the men with a high-risk OST score, 87% had either osteopenia or osteoporosis based on World Health Organization (WHO) criteria. Using the WBC alone with a cut-off value of 85 kg, we predicted low bone mass with a sensitivity of 74%, a specificity of 50% and an AUC of 0.70. A BMI cut-off value of 30 or greater yielded a sensitivity of 83%, a specificity of 43% and an AUC of 0.70 for the diagnosis of low bone mass.

DISCUSSION

The prevalence of osteopenia and osteoporosis were unexpectedly high in outpatient African American male veterans, who are considered to be at low risk for low bone mass. Heel ultrasound was able to predict low bone mass with sufficiently high sensitivity and specificity for use as a screening tool. Surprisingly, WBC and BMI proved ineffective in predicting low bone mass with adequate sensitivity and specificity. The OST, a clinical formula based on weight and age, appeared to be an easy and reliable screening tool for identifying men at high risk for low bone mass.

Comparison of questionnaire and quantitative ultrasound techniques as screening tools for DXA

The aim of the study is to assess the sensitivity and specificity of different techniques and their ability to act as screening tools in relation to dual energy X-ray absorptiometry (DXA) in a group of 208 postmenopausal women. In this study we examined eight screening systems for the diagnosis of osteoporosis, the osteoporosis self-assessment tool (OST), the osteoporosis risk assessment instrument (ORAI), the osteoporosis index of risk (OSIRIS), a risk index derived using data from the study of osteoporotic fractures (SOFSURF), the simple calculated osteoporosis risk estimation (SCORE), patient body weight (pBW), along with two ultrasound based systems, the Sunlight Omnisense (Sunlight Medical, Rehovot, Israel) and the CUBA Clinical (McCue plc, Winchester, UK). The sensitivity and specificity of the different techniques in relation to DXA were plotted as receiver-operating characteristic (ROC) curves at three different levels (DXA T-score -2.5 osteoporosis, -2 and -1 osteopenia). The areas under the curves (AUC) were calculated and showed broadband ultrasound attenuation (BUA) at the calcaneus to provide consistently the highest AUC (0.77-0.81). The velocity of sound (VOS) of the calcaneus (AUC=0.72-0.76) was equally good, but was out-performed by some of the questionnaire systems (AUC=0.66-0.79). Both the questionnaire systems and the CUBA Clinical out-perform the Sunlight Omnisense (AUC=0.58-0.7), which showed comparable performance with body weight (AUC=0.66-0.69). The results show that QUS is capable of selecting patients with low bone density as measured by DXA. A patient displaying a low QUS value should be followed up with a DXA scan to confirm the diagnosis.

The ability of peripheral quantitative ultrasound to identify patients with low bone mineral density in the hip or spine

This study aims to assess the sensitivity and specificity of two commercially available quantitative ultrasound (QUS) scanners (CUBA Clinical, Sunlight Omnisense), to differentiate patients with osteoporosis (OP) or osteopenia at the spine and hip confirmed by dual-energy x-ray absorptiometry (DXA) and to investigate the optimum cut-off values to maximize the effectiveness of the screening technique. Participants (n = 268) received DXA scans on their lumbar spine (L1-L4) and hip, with paired QUS scans on their distal radius, proximal phalanx, midshaft tibia and calcaneus. Scanners were evaluated by using receiver-operating characteristics curves and their area under the curve (AUC) values. Measurement of the calcaneus by the CUBA Clinical showed a superior ability to predict DXA, with AUC values between 0.75 to 0.83 in comparison with AUC values of 0.60 to 0.70 for the Sunlight Omnisense. Cut-off values varied according to the technique used and the accuracy of the screening required. Assessment of the calcaneus was the best QUS technique for the prediction of low bone density at the axial skeleton as diagnosed by DXA.

Osteoporosis risk and low bone mineral density in women with physical disabilities

OBJECTIVES

To describe the results of bone mineral density (BMD) screening in women with different physical disabilities and to identify their risk factors for osteoporosis and use of strategies to prevent osteoporosis.

DESIGN

A cross-sectional descriptive study.

SETTING

Community.

PARTICIPANTS

Convenience sample of 429 community-residing women with different disabilities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Peripheral BMD screening of the os calcis, using dual-energy x-ray absorptiometry. A self-administered survey addressed osteoporosis risk factors, use of osteoporosis prevention strategies, and previous recommendations for BMD screening or testing.

RESULTS

Based on World Health Organization criteria, 30.5% and 22.6% of the total sample had BMD values indicative of osteopenia and osteoporosis, respectively. The number of self-reported osteoporosis risk factors ranged from 0 to 10 (mean, 4.5+/-1.7). Subjects reported using few strategies to reduce their osteoporosis risks. One quarter of the women reported previous BMD screening or testing; about one third reported receiving recommendations for testing or screening by a health care provider.

CONCLUSIONS

More than half of the sample had low BMD, and it was present in premenopausal as well as menopausal women. Despite low BMD and the presence of osteoporosis risk factors, less than a third of the women previously had BMD testing or screening or recommendations for such testing. Because low BMD is common in women with disabilities, greater attention must be directed toward their risk for osteoporosis and osteoporotic fractures. Prevention strategies to reduce osteoporosis risk should be considered, although their efficacy is not yet known in populations with disabilities.

Osteoporosis: Point-of-Care Testing

OBJECTIVE

To review the literature concerning the utility of point-of-care (POC) testing devices for the diagnosis and management of osteoporosis.

DATA SOURCES

Articles were identified from a MEDLINE search (1993–June 2003). Additional references were obtained from cross-referencing the bibliographies of selected articles.

STUDY SELECTION AND DATA EXTRACTION

After evaluation of clinical trials and select review articles, articles comparing peripheral dual-energy absorptiometry (pDXA) or quantitative ultrasound (QUS) with central DXA (cDXA) measurements were emphasized in this analysis.

DATA SYNTHESIS

Sensitivity for detecting osteoporosis by QUS or pDXA varies widely (range 35–75%). Using adjusted T-score cutoffs increases sensitivity to 85–95%, at the price of reducing device specificity to 23–49%. Many states require a radiology technician to perform pDXA tests.

CONCLUSIONS

POC testing with peripheral devices should only be considered in areas with limited access to cDXA or for women who initially refuse cDXA testing. T scores of −1.0 or less with POC testing typically require further evaluation via cDXA. Many states require pDXAs to be performed by certified radiology technologists, making QUS use more feasible for pharmacists. POC testing should not be used for assessing response to osteoporosis therapy.

Management of Bone Loss in Men With Prostate Cancer

PURPOSE

Bone loss is increasingly recognized as a common occurrence in men receiving androgen deprivation therapy (ADT) for prostate cancer. Skeletal metabolism and osteoporosis in men, assessment of bone mineral density (BMD), effects of ADT on BMD, management strategies and potential therapies for osteopenia or osteoporosis in men with prostate cancer are reviewed.

MATERIALS AND METHODS

Relevant literature is reviewed concerning bone loss and osteoporosis in men with and without prostate cancer, techniques of assessing BMD, data on bone loss and fracture risk and management strategies.

RESULTS

The incidence of osteoporotic fractures usually increases a decade later in men than in women. ADT causes significant loss of BMD, which may hasten the development of osteoporosis. Men who are treated with hormonal therapy for an increasing prostate specific antigen and who may live for many years should have baseline BMD assessments. Osteopenia or osteoporosis should be treated to minimize the risk of osteoporotic fracture. Treatment with zoledronic acid seems appropriate since it has been shown to increase BMD in men treated with ADT and to reduce the rate of skeletal related events in men with early hormone refractory prostate cancer with metastatic disease.

CONCLUSIONS

Monitoring BMD is warranted in men contemplating or receiving ADT but prophylactic therapy to prevent bone loss currently is not recommended. Men with evidence of significant bone loss who are receiving ADT should be treated. Zoledronic acid is a logical choice based on available data.

Performance of the Osteoporosis Self-assessment Screening Tool for osteoporosis in American men

OBJECTIVE

To determine whether the Osteoporosis Self-assessment Tool (OST) can predict central bone mineral density in men, as defined by dual energy x-ray absorptiometry (DXA).

PATIENTS AND METHODS

We applied the OST index to men in pulmonary (evaluated January-May 2001) and rheumatology (evaluated November 2001-March 2002) clinics at a veterans hospital. The calculated OST risk index is based on weight and age.

RESULTS

In 181 men, we arbitrarily defined osteoporosis as a DXA T score of -25 or less in the spine, total hip, or femoral neck. The mean age and weight of the men were 64.3 years and 91.2 kg; 15.6% had osteoporosis by DXA. The OST index ranged from -5 to 19, from which we categorized risk as follows: low, 4 or greater; moderate,-1 to 3; and high, -2 or less. Only 2.0% of men with a low-risk OST index had osteoporosis, whereas 27.0% with a moderate risk and 72.7% with a high risk had osteoporosis. Using an OST cutoff score of 3, we predicted osteoporosis with a sensitivity of 93% and a specificity of 66%. When patients were studied by age in decades, race, or current glucocorticoid use, the predictive value of the OST was maintained.

CONCLUSION

The OST is an easy method to predict osteoporosis by DXA.

Osteoporosis in pulmonary clinic patients: does point-of-care screening predict central dual-energy X-ray absorptiometry?

STUDY OBJECTIVES

Patients in a pulmonary clinic have disorders that predispose them to osteoporosis and may use glucocorticoid therapy, which has been associated with low bone mineral density (BMD) and increased fracture risk. Ideally, all patients at risk for osteoporosis would be screened using the best test available, which is central BMD by dual-energy x-ray absorptiometry (DXA). We proposed to stratify the risk for osteoporosis by the use of a simple questionnaire and point-of-care heel ultrasound BMD measurements.

DESIGN

Cross-sectional screening study.

SETTING

Pulmonary clinic in a single Veterans Affairs Medical Center.

PATIENTS

Approximately 200 male and female patients who had not had previous BMD testing were eligible for the study, and 107 gave consent.

INTERVENTIONS

One hundred seven men (white, 71 men; black, 35 men; and Asian, 1 man) underwent heel BMD testing and filled out a questionnaire. Ninety-eight men underwent a central DXA.

RESULTS

Of 98 subjects, 24.5% had a spine, total hip, or femoral neck (FN) T-score of <or= -2.5, which is the generally accepted definition of osteoporosis diagnosed using DXA, and 44.9% had a T-score of <or= -2.0. The best-fit models for predicting FN or total hip BMD included body weight, heel BMD, corticosteroid use for >or= 7 days, and race, which accounted for 52 to 57% of the variance. When a heel ultrasound T-score of -1.0 was tested to predict a central DXA T-score of -2.0, the sensitivity was 61% and the specificity 64%. Adding the questionnaire score and body mass index (BMI) to the heel T-score improved sensitivity but not specificity. Moreover, BMI and age predicted central BMD with similar sensitivity and specificity. Importantly, of 24 patients with a central DXA T-score of <or= -2.5, only 14 were identified by a heel T-score of <or= -1.0.

CONCLUSIONS

Although the findings from a heel ultrasound plus the answers to a questionnaire were reasonably good indicators for predicting the presence of low BMD, little predictability was gained over the use of BMI and age. In a group of pulmonary clinic patients, the prevalence of osteoporosis was clinically significant, and central DXA testing was the preferable technique for identifying patients who were at risk for fracture.

Prevalence of low bone density in institutionalized men with developmental disabilities

This study investigates the prevalence and degree of low bone mineral density (BMD) in a group of 108 institutionalized men with developmental disabilities. Speed of sound (SOS) and broadband attenuation (BUA) of the calcaneus were measured to determine a quantitative ultrasound index (QUI). Comparison was made to the values for this index in a reference population of age-matched and young adult controls. Thirty-four percent of the study participants had QUI values more than 2 standard deviations (SDs) below those of age-matched controls. Fifty-one percent of this population showed QUI values more than 2 SDs below those of the young adult reference group, suggesting a high prevalence of significantly decreased BMD.

Ability of peripheral bone assessments to predict areal bone mineral density at hip in community-dwelling elderly men

We present cross-sectional data on bone mineral density (BMD) and quantitative ultrasound (QUS) indices in an ambulatory elderly male population (n = 235). Dual X-ray absorptiometry (DXA) at the proximal femur was considered the reference assessment site and was compared with DXA at the forearm and heel and to QUS at the heel and midtibia. Correlations and weighted kappa analysis indicate an only moderate concordance of absolute values between peripheral bone assessment and total hip DXA (weighted kappas: 0.31-0.45). Discrepancies are even more important when T-scores and prevalence rates of osteoporosis are considered, owing to factors related to the reference populations used. Predictive value of peripheral measurements for osteoporosis diagnosed on the basis of hip BMD by DXA, as assessed by receiver operator characteristic analysis, was moderate and comparable for all peripheral measurements (area under the curve: 0.708-0.870), with the exception of a clearly lower predictive value for QUS at the tibia. Discrimination of male subjects with a history of at least one fragility fracture was significant for DXA at the proximal femur and QUS at the heel. It is concluded that peripheral measurements cannot be used as a substitute for hip DXA. However, they might be useful to guide patient referral for central DXA.