The ability of calcaneal and multisite quantitative ultrasound variables in the identification of osteoporosis in women and men

Advancing Osteoporosis Assessment Through a Numerical Study Utilizing Ultrasonic Waves in Femur Bone Evaluation

OBJECTIVE

Osteoporosis, a musculoskeletal condition characterized by bone density loss, significantly heightens the risk of fractures. Early detection of this condition is paramount in both its prevention and effective treatment. Traditionally, osteoporosis diagnosis relies heavily on dual X-ray absorptiometry. However, this research demonstrates an initiative by utilizing quantitative ultrasound as a cost-effective, noninvasive alternative, particularly advantageous in certain scenarios.

METHODS

By applying the finite element method, we simulate ultrasound propagation within intricate femur head models, incorporating both healthy and osteoporotic conditions. Through meticulous analysis, we unveil novel speed-based and amplitude-based indices derived from ultrasound signals, offering insights of high resolution into bone evaluation.

RESULTS

Our findings illuminate a paradigm shift: as osteoporosis advances, there is a discernible decrease in speed of sound values, while ultrasound amplitude exhibits intriguing fluctuations, dependent on intricate tissue interactions such as diverse acoustic impedance at tissues' interface and echo reflections within the bone models.

CONCLUSIONS

The approach used in this study promises to reshape osteoporosis assessment, paving the way to revolutionize prevention and treatment strategies. The associated results of our study also could open up new avenues for investigating ultrasound propagation in three-dimensional bone models.

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.

Intrarater and Interrater Reliability of Quantitative Ultrasound Speed of Sound by Trained Raters at the Distal Radius in Postmenopausal Women

BACKGROUND AND PURPOSE

Quantitative ultrasound (QUS) performed at the distal radius shows potential as an effective tool for evaluating fracture risk, especially in postmenopausal women, but the reliability of this tool has not been reported in this patient population. This study investigated the within-day intrarater and interrater reliability of trained raters performing QUS measures at the distal radius of postmenopausal community-dwelling women.

METHODS

Eighteen women between the ages of 56 and 87 years were recruited from senior centers in the Greenville area of South Carolina and consented to participate. A QUS bone sonometer was used in this study; the trained raters performed 3 repeated speed of sound (SOS) measures at the nondominant radius of each participant on the same day. Intraclass correlation coefficients (ICCs) were calculated (model 3,1 for intrarater and 2,3 for interrater reliability) to determine the reliability within and between raters. In addition, we calculated the standard error of measurement (SEM) and the minimal detectable change at 95% confidence interval (MDC 95 ).

RESULTS

The within-day intrarater reliability was excellent for both physical therapist raters (ICC (3,1) ranging from 0.93 to 0.91). The SEM and MDC for the within-day intrarater reliability measures were small for both raters (SEM = 36.79-38.75 or 0.92%-0.97% of the pooled mean; MDC 95  = 101.99-107.40). The interrater reliability for SOS measurements using radial QUS was good with an ICC (2,3) of 0.77 (95% CI, 0.36-0.92) for 3 averaged measures. The SEM and MDC were larger for the interrater reliability measures (SEM = 62.79 or 1.57% of the pooled mean; MDC 95  = 174.05).

CONCLUSIONS

Quantitative ultrasound SOS measurement at the distal radius showed excellent within-day intrarater and good interrater (when 3 measures were averaged) reliability in community-dwelling postmenopausal women. The SEM and MDC 95 were also low for interrater reliability when a mean of 3 trials was used. This study is the first to demonstrate that this particular QUS device at the radius may be a reliable fracture risk screening tool for postmenopausal women.

Bone mineral density parameters and related nutritional factors in vegans, lacto-ovo-vegetarians, and omnivores: a cross-sectional study

Introduction

The growing prevalence of vegetarianism determines the need for comprehensive study of the impact of these diets on health and particularly on bone metabolism. We hypothesized that significant dietary differences between vegans, lacto-ovo-vegetarians, and omnivores also cause significant differences in their nutrient status, which may affect bone health.

Methods

The study assessed dual-energy X-ray absorptiometry parameters in lumbar spine and femoral neck, average nutrient intake, serum nutrient concentrations, serum PTH levels, and urinary pH among 46 vegans, 38 lacto-ovo-vegetarians, and 44 omnivores.

Results

There were no differences in bone mineral density (BMD) between the groups. However, the parathyroid hormone (PTH) levels were still higher in vegans compared to omnivores, despite the same prevalence of hyperparathyroidism in all groups. These findings may probably be explained by the fact that each group had its own "strengths and weaknesses." Thus, vegans and, to a lesser extent, lacto-ovo-vegetarians consumed much more potassium, magnesium, copper, manganese, and vitamins B6, B9, and C. At the same time, the diet of omnivores contained more protein and vitamins D and B12. All the subjects consumed less vitamin D than recommended. More than half of vegans and omnivores had insufficiency or even deficiency of vitamin D in the blood. Low serum concentrations of manganese with its quite adequate intake are also noteworthy: its deficiency was observed in 57% of vegans, 79% of lacto-ovo-vegetarians, and 63% of omnivores.

Discussion

Currently, it is no longer possible to conclude that lacto-ovo-vegetarians have lower BMD than omnivores, as our research supported. Vegans in our study also did not demonstrate lower BMD values, only higher PTH blood concentrations, compared to omnivores, however, a large number of studies, including recent, show the opposite view. In this regard, further large-scale research is required. Vegans and lacto-ovo-vegetarians now have a variety of foods fortified with vitamins D and B12, as well as calcium. There is also a great diversity of ethically sourced dietary supplements. The found low concentrations of manganese require further investigation.

External validation of a deep learning model for predicting bone mineral density on chest radiographs

We developed a new model for predicting bone mineral density on chest radiographs and externally validated it using images captured at facilities other than the development environment. The model performed well and showed potential for clinical use.

PURPOSE

In this study, we performed external validation (EV) of a developed deep learning model for predicting bone mineral density (BMD) of femoral neck on chest radiographs to verify the usefulness of this model in clinical practice.

METHODS

This study included patients who visited any of the collaborating facilities from 2010 to 2020 and underwent chest radiography and dual-energy X-ray absorptiometry (DXA) at the femoral neck in the year before and after their visit. A total of 50,114 chest radiographs were obtained, and BMD was measured using DXA. We developed the model with 47,150 images from 17 facilities and performed EV with 2914 images from three other facilities (EV dataset). We trained the deep learning model via ensemble learning based on chest radiographs, age, and sex to predict BMD using regression. The outcomes were the correlation of the predicted BMD and measured BMD with diagnoses of osteoporosis and osteopenia using the T-score estimated from the predicted BMD.

RESULTS

The mean BMD was 0.64±0.14 g/cm2 in the EV dataset. The BMD predicted by the model averaged 0.61±0.08 g/cm2, with a correlation coefficient of 0.68 (p<0.01) when compared with the BMD measured using DXA. The accuracy, sensitivity, and specificity of the model were 79.0%, 96.6%, and 34.1% for T-score < -1 and 79.7%, 77.1%, and 80.4% for T-score ≤ -2.5, respectively.

CONCLUSION

Our model, which was externally validated using data obtained at facilities other than the development environment, predicted BMD of femoral neck on chest radiographs. The model performed well and showed potential for clinical use.

Comparison between calcaneus quantitative ultrasound and the gold standard DXA in the ability to detect osteoporosis in chronic obstructive pulmonary disease patients

BACKGROUND

Osteoporosis is a prevalent comorbidity in patients with COPD that is usually underrecognized and hence, undertreated. Compared to the gold standard dual-energy X-ray absorptiometry (DXA), calcaneus quantitative ultrasound (QUS) is less expensive, more portable, and more accessible, especially in less developed countries. The aim of this study was to investigate the ability of calcaneus QUS to screen and prescreen for osteoporosis in patients with COPD.

METHODS

This cross-sectional study enrolled 67 males older than 50 years with clinically stable COPD. DXA scans of the lumbar spine (L2-4) and femoral neck were performed. QUS of the right calcaneus (AOS-100) was used to assess the broadband ultrasound attenuation (BUA), speed of sound (SOS), osteo sono-assessment index (OSI), and T-score. When the T-score was ≤  - 2.5, osteoporosis was diagnosed by both DXA and QUS.

RESULTS

Forty-eight patients (71.6%) had DXA T-scores ≤  - 2.5 at either the lumbar spine or femoral neck. All QUS parameters (BUA, SOS, OSI, and T-score) could discriminate DXA-determined osteoporosis (the area under the curve varied from 0.64 to 0.83). The QUS T-score was significantly moderately correlated with the DXA T-score at both the femoral neck (r = 0.55) and lumbar spine (r = 0.52). The sensitivity and specificity of QUS in identifying osteoporosis were 10.4% and 94.7%, respectively. The positive and negative predictive values were 83.3% and 29.5%, respectively. When a QUS T-score of 0.09 was used as the cutoff, the sensitivity exceeded 90%, and 15% of the DXA scans were not warranted.

CONCLUSIONS

The sensitivity and specificity of calcaneus QUS were not sufficient for QUS to be used as an alternative to DXA for osteoporosis screening. However, QUS may be useful for prescreening before DXA to identify COPD patients who have either a high or low likelihood of osteoporosis. Consequently, QUS reduces the need for DXA referral.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of quantitative ultrasonography and dual X-ray absorptiometry for bone status assessment in South African children living with HIV

Children living with HIV (CLHIV) have decreased bone mineral content (BMC) and density (BMD), increasing risk for fracture and future osteoporosis. While DXA is the gold-standard for bone assessments, it lacks availability in resource-constrained settings (RCS). Quantitative ultrasound (QUS) offers an alternative owing to its portability, low cost, ease of handling, and lack of ionizing radiation. While QUS has detected reduced bone quality in CLHIV, the relationship between QUS and DXA in this population remains unexplored. At baseline and 12 months, BMC and BMD of the whole body, lumbar spine, and radius were measured by DXA in a longitudinal cohort of CLHIV in Johannesburg, South Africa. Calcaneal speed of sound (SOS) and broadband ultrasound attenuation (BUA) and radius SOS were obtained by QUS, and calcaneal stiffness index (SI) was calculated. Spearman correlations, with and without HIV stratification, were performed between QUS and DXA measurements at each visit and for absolute difference in measurements between visits. At baseline and 12-months, calcaneal BUA and SI displayed strong positive correlations with DXA, with only modest correlations between radial QUS and DXA at baseline. Longitudinal measures of QUS did not correlate with DXA. At both baseline and 12-months, individuals with DXA whole-body BMD z-score < -1 displayed significantly lower calcaneal BUA and SI. Cross-sectionally, calcaneal QUS correlates strongly with whole body DXA and may represent a viable diagnostic alternative in RCS. Longitudinally, the two methods do not correlate well, possibly reflecting that each method assesses distinct aspects of bone architecture.

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

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

Fragility fracture discriminative ability of radius quantitative ultrasound: a systematic review and meta-analysis

The fragility fracture discriminative ability of radius quantitative ultrasound (QUS) was evaluated in a systematic review of 13 studies, including 16,681 individuals and 1296 fractures. The radial speed of sound (SOS) per standard deviation (SD) decrease contributed to an increased risk of total and hip fracture by 32% and 66% in women. Osteoporotic fracture, as a devastating consequence of osteoporosis, brings severe socio-economic burden. The availability of dual-energy X-ray absorptiometry (DXA), as the gold standard of diagnosis, was quite limited in remote areas. Radius QUS measured by SOS shows potential in fracture discriminative ability where DXA equipment is not available. This study aimed to provide a comprehensive evaluation of the association between radius QUS and fracture risk. A detailed article search was carried out on PubMed, EMBASE, Cochrane Libraries, CNKI, Wan-Fang database, VIP, and SinoMed for studies published between January 1980 and February 2020. We determined the estimated relative risk (RR) for fracture per each radial SOS SD decrease. A meta-analysis of studies was performed under the random-effects model. A total of 16,681 individuals were included in this review. Among the participants, 5892 were male and 10,789 were female. A total of 1296 cases of fragility fracture were included. With each SD decrease in radial SOS, the risk of overall fragility fracture and hip fracture was increased by 21% and 55%, respectively. Particularly, the risk was increased by 32% and 66% for women. The association was even stronger for postmenopausal women. Radius QUS showed great potential as an effective tool for fracture risk evaluation, especially for women.

Trabecular bone mineral density correlations using QCT: Central and peripheral human skeleton

Musculoskeletal injuries to the lower leg and foot-ankle joint are associated with external mechanical loads resulting from motor vehicle crashes, under body blasts, falls from height, or sports. As an intrinsic material property, the bone mineral density (BMD) is related to bone strength. The clinically recognized biological sites for BMD evaluation are the hip and spine. The focus of this study was to define the correlation between BMD from standard clinical sites (hip and lumbar spine) compared to BMD from non-standard sites (foot-ankle-distal tibia bones). Twenty-one post-mortem human subjects (PMHS) with mean age, height, and mass of 63 ± 11 years, 179 ± 7 cm, and 86 ± 13 kg, respectively were used for analysis. Clinical BMD software (Mindways Software, Inc.) was used for trabecular BMD quantification using quantitative computed tomography (QCT). In quantification of BMD of the foot-ankle-distal tibia (hind foot), the trabecular BMD of the talus (316 ± 86mg/cc) was highest followed by the distal tibia (238 ± 72 mg/cc) and then calcaneus (147 ± 51 mg/cc). To correlate BMD values from foot bone regions with the central skeleton BMD values within the same PMHS, there were 18 lumbar spine and 12 hip BMDs available. The BMD of the distal tibia correlated best with the hip intertrochanter BMD (R² of 0.72). Calcaneus BMD best correlated with the hip femoral neck BMD (R² = 0.64). In summary, the hind foot bone BMD values correlated better with the hip as compared to the lumbar spine BMD from the same PMHS. These findings indicate that, in the absence of a direct measure of foot-bone BMD, hip BMD might be a better predictor of injury risk to hind foot rather than lumbar spine BMD, or alternatively, calcaneal trabecular BMD can be used to predict the risk of injury to hip. Further, these relationships between central and peripheral regions can also be implemented in finite element models for improved failure predictions.

The Performance of a Calcaneal Quantitative Ultrasound Device, CM-200, in Stratifying Osteoporosis Risk among Malaysian Population Aged 40 Years and Above

BACKGROUND

Calcaneal quantitative ultrasound (QUS) is widely used in osteoporosis screening, but the cut-off values for risk stratification remain unclear. This study validates the performance of a calcaneal QUS device (CM-200) using dual-energy X-ray absorptiometry (DXA) as the reference and establishes a new set of cut-off values for CM-200 in identifying subjects with osteoporosis.

METHODS

The bone health status of Malaysians aged ≥40 years was assessed using CM-200 and DXA. Sensitivity, specificity, area under the curve (AUC) and the optimal cut-off values for risk stratification of CM-200 were determined using receiver operating characteristic (ROC) curves and Youden's index (J). Results: From the data of 786 subjects, CM-200 (QUS T-score <-1) showed a sensitivity of 82.1% (95% CI: 77.9-85.7%), specificity of 51.5% (95% CI: 46.5-56.6%) and AUC of 0.668 (95% CI: 0.630-0.706) in identifying subjects with suboptimal bone health (DXA T-score <-1) (p < 0.001). At QUS T-score ≤-2.5, CM-200 was ineffective in identifying subjects with osteoporosis (DXA T-score ≤-2.5) (sensitivity 14.4% (95% CI: 8.1-23.0%); specificity 96.1% (95% CI: 94.4-97.4%); AUC 0.553 (95% CI: 0.488-0.617); p > 0.05). Modified cut-off values for the QUS T-score improved the performance of CM-200 in identifying subjects with osteopenia (sensitivity 67.7% (95% CI: 62.8-72.3%); specificity 72.8% (95% CI: 68.1-77.2%); J = 0.405; AUC 0.702 (95% CI: 0.666-0.739); p < 0.001) and osteoporosis (sensitivity 79.4% (95% CI: 70.0-86.9%); specificity 61.8% (95% CI: 58.1-65.5%); J = 0.412; AUC 0.706 (95% CI: 0.654-0.758); p < 0.001). Conclusion: The modified cut-off values significantly improved the performance of CM-200 in identifying individuals with osteoporosis. Since these values are device-specific, optimization is necessary for accurate detection of individuals at risk for osteoporosis using QUS.