Challenges and opportunities for quality densitometry in Latin America

High and very high risk of osteoporotic fracture in Colombia, 2003-2022: identifying diagnostic and treatment gaps

This study examined the clinical characteristics and refracture rates of Colombian patients with high- and very high-risk osteoporosis. This reveals osteoporosis diagnoses and treatment gaps. Only 5.3% of the patients were diagnosed with osteoporosis at discharge and 70.5% had refractures. This finding underscores the need for national policies to enhance osteoporosis prevention and treatment.

PURPOSE

This study aimed to assess the clinical features and refracture rates among patients with high- and very-high-risk osteoporosis in Colombia, highlighting diagnostic and treatment gaps.

METHODS

A retrospective observational study was conducted using the medical records of patients aged ≥ 50 years who experienced fragility fractures between 2003 and 2022. Clinical and demographic characteristics at the time of the initial fracture were analyzed, as well as the subsequent imminent risk (refracture rate) and the diagnosis and treatment gap.

RESULTS

303.982 fragility fractures occurred, and only 5.3% of patients were diagnosed with osteoporosis upon discharge. The most prevalent index fractures were forearm, vertebral, rib, and hip. Only 17.8% of the cohort had a matched osteoporosis diagnosis, indicating a low healthcare capture. Among the diagnosed patients, 10.08% were classified as high- and very high-risk of fracture, predominantly women with a mean age of 73 years. Comorbidities included diabetes, Sjögren's syndrome, and heart failure. The prevalence of osteoporosis has increased significantly from 2004 to 2022, possibly due to improved detection methods, an aging population, or a combination of both. Despite this increase, treatment delay was evident. Refractures affected 70.5% of the patients, with forearm, hip, humerus, and vertebral fractures being the most common, with a mean time of refracture of 7 months.

CONCLUSION

Significant delays were observed in the diagnosis and treatment of fragility fractures. Colombia's government and health system must address osteoporosis by implementing national policies that prioritize osteoporosis and fragility fracture prevention and reduce delays in diagnosis and treatment.

Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX

Appropriate use of FRAX reduces the number of people requiring DXA scans, while contemporaneously determining those most at risk. We compared the results of FRAX with and without inclusion of BMD. It suggests clinicians to carefully consider the importance of BMD inclusion in fracture risk estimation or interpretation in individual patients.

PURPOSE

FRAX is a widely accepted tool to estimate the 10-year risk of hip and major osteoporotic fracture in adults. Prior calibration studies suggest this works similarly with or without the inclusion of bone mineral density (BMD). The purpose of the study is to compare within-subject differences between FRAX estimations derived using DXA and Web software with and without the inclusion of BMD.

METHOD

A convenience cohort was used for this cross-sectional study, consisting of 1254 men and women aged between 40 and 90 years who had a DXA scan and complete validated data available for analysis. FRAX 10-year estimations for hip and major osteoporotic fracture were calculated using DXA software (DXA-FRAX) and the Web tool (Web-FRAX), with and without BMD. Agreements between estimates within each individual subject were examined using Bland-Altman plots. We performed exploratory analyses of the characteristics of those with very discordant results.

RESULTS

Overall median DXA-FRAX and Web-FRAX 10-year hip and major osteoporotic fracture risk estimations which include BMD are very similar: 2.9% vs. 2.8% and 11.0% vs. 11% respectively. However, both are significantly lower than those obtained without BMD: 4.9% and 14% respectively, P < 0.001. Within-subject differences between hip fracture estimates with and without BMD were < 3% in 57% of cases, between 3 and 6% in 19% of cases, and > 6% in 24% of cases, while for major osteoporotic fractures such differences are < 10% in 82% of cases, between 10 and 20% in 15% of cases, and > 20% in 3% of cases.

CONCLUSIONS

Although there is excellent agreement between the Web-FRAX and DXA-FRAX tools when BMD is incorporated, sometimes there are very large differences for individuals between results obtained with and without BMD. Clinicians should carefully consider the importance of BMD inclusion in FRAX estimations when assessing individual patients.

Bi-Directional Axial Transmission measurements applied in a clinical environment

Accurate measurement of cortical bone parameters may improve fracture risk assessment and help clinicians on the best treatment strategy. Patients at risk of fracture are currently detected using the current X-Ray gold standard DXA (Dual XRay Absorptiometry). Different alternatives, such as 3D X-Rays, Magnetic Resonance Imaging or Quantitative Ultrasound (QUS) devices, have been proposed, the latter having advantages of being portable and sensitive to mechanical and geometrical properties. The objective of this cross-sectional study was to evaluate the performance of a Bi-Directional Axial Transmission (BDAT) device used by trained operators in a clinical environment with older subjects. The device, positioned at one-third distal radius, provides two velocities: VFAS (first arriving signal) and VA0 (first anti-symmetrical guided mode). Moreover, two parameters are obtained from an inverse approach: Ct.Th (cortical thickness) and Ct.Po (cortical porosity), along with their ratio Ct.Po/Ct.Th. The areal bone mineral density (aBMD) was obtained using DXA at the femur and spine. One hundred and six patients (81 women, 25 men) from Marien Hospital and St. Anna Hospital (Herne, Germany) were included in this study. Age ranged from 41 to 95 years, while body mass index (BMI) ranged from 16 to 47 kg.m-2. Three groups were considered: 79 non-fractured patients (NF, 75±13years), 27 with non-traumatic fractures (F, 80±9years) including 14 patients with non-vertebral fractures (NVF, 84±7years). Weak to moderate significant Spearman correlations (R ranging from 0.23 to 0.53, p < 0.05) were found between ultrasound parameters and age, BMI. Using multivariate Partial Least Square discrimination analyses with Leave-One-Out Cross-Validation (PLS-LOOCV), we found the combination of VFAS and the ratio Ct.Po/Ct.Th to be predictive for all non traumatic fractures (F) with the odds ratio (OR) equals to 2.5 [1.6-3.4] and the area under the ROC curve (AUC) equal to 0.63 [0.62-0.65]. For the group NVF, combination of four parameters VA0. Ct.Th, Ct.Po and Ct.Po/Ct.Po, along with age provides a discrimination model with OR and AUC equals to 7.5 [6.0-9.1] and 0.75 [0.73-0.76]. When restricted to a smaller population (87 patients) common to both BDAT and DXA, BDAT ORs and AUCs are comparable or slightly higher to values obtained with DXA. The fracture risk assessment by BDAT method in older patients, in a clinical setting, suggests the benefit of the affordable and transportable device for the routine use.

Improvement of Patient Classification Using Feature Selection Applied to Bidirectional Axial Transmission

Osteoporosis is still a worldwide problem, particularly due to associated fragility fractures. Patients at risk of fracture are currently detected using the X-Ray gold standard dual-energy X-ray absorptiometry (DXA), based on a calibrated 2-D image. Different alternatives, such as 3-D X-rays, magnetic resonance imaging (MRI) or ultrasound, have been proposed, the latter having advantages of being portable and sensitive to mechanical and geometrical properties. Bidirectional axial transmission (BDAT) has been used to classify between patients with or without nontraumatic fractures using "classical" ultrasonic parameters, such as velocities, as well as cortical thickness and porosity, obtained from an inverse problems. Recently, complementary parameters acquired with structural and textural analysis of guided wave spectrum images (GWSIs) have been introduced. These parameters are not limited by solution ambiguities, as for inverse problem. The aim of the study is to improve the patient classification using a feature selection strategy for all available ultrasound features completed by clinical parameters. To this end, three classical feature ranking methods were considered: analysis of variance (ANOVA), recursive feature elimination (RFE), and extreme gradient boosting importance feature (XGBI). In order to evaluate the performance of the feature selection techniques, three classical classification methods were used: logistic regression (LR), support vector machine (SVM), and extreme gradient boosting (XGB). The database was obtained from a previous clinical study [Minonzio et al., 2019]. Results indicate that the best accuracy of 71 [66-76]% was achieved by using RFE and SVM with 22 (out of 43) ultrasonic and clinical features. This value outperformed the accuracy of 68 [64-73]% reached with 2 (out of 6) DXA and clinical features. These values open promising perspectives toward improved and generalizable classification of patients at risk of fracture.