Quantitative Ultrasond in the assessment of Osteoporosis

The Biomechanics of Musculoskeletal Tissues during Activities of Daily Living: Dynamic Assessment Using Quantitative Transmission-Mode Ultrasound Techniques

The measurement of musculoskeletal tissue properties and loading patterns during physical activity is important for understanding the adaptation mechanisms of tissues such as bone, tendon, and muscle tissues, particularly with injury and repair. Although the properties and loading of these connective tissues have been quantified using direct measurement techniques, these methods are highly invasive and often prevent or interfere with normal activity patterns. Indirect biomechanical methods, such as estimates based on electromyography, ultrasound, and inverse dynamics, are used more widely but are known to yield different parameter values than direct measurements. Through a series of literature searches of electronic databases, including Pubmed, Embase, Web of Science, and IEEE Explore, this paper reviews current methods used for the in vivo measurement of human musculoskeletal tissue and describes the operating principals, application, and emerging research findings gained from the use of quantitative transmission-mode ultrasound measurement techniques to non-invasively characterize human bone, tendon, and muscle properties at rest and during activities of daily living. In contrast to standard ultrasound imaging approaches, these techniques assess the interaction between ultrasound compression waves and connective tissues to provide quantifiable parameters associated with the structure, instantaneous elastic modulus, and density of tissues. By taking advantage of the physical relationship between the axial velocity of ultrasound compression waves and the instantaneous modulus of the propagation material, these techniques can also be used to estimate the in vivo loading environment of relatively superficial soft connective tissues during sports and activities of daily living. This paper highlights key findings from clinical studies in which quantitative transmission-mode ultrasound has been used to measure the properties and loading of bone, tendon, and muscle tissue during common physical activities in healthy and pathological populations.

Association of nocturnal sleep duration and sleep midpoint with osteoporosis risk in rural adults: a large-scale cross-sectional study

BACKGROUND

Evidence has suggested the linkage between sleep habits and several metabolic diseases, but the association of sleep factors with bone health remains unclear, especially in regions with low economic levels. Thus, this study aimed to investigate the relationship of nocturnal sleep duration and sleep midpoint with the osteoporosis risk in a rural population.

METHOD

Eligible subjects were derived from the Henan Rural Cohort Study. The Pittsburgh Sleep Quality Index was applied to collect sleep information including sleep initiating time and wake-up time. The bone mineral density of the calcaneus was measured by the ultrasonic bone density apparatus. Multivariable logistic regression models and restricted cubic splines were utilized to evaluate the odds ratio (OR) and 95% confidence intervals (95% CI).

RESULTS

For 8033 participants, 1636 subjects suffered from osteoporosis. Compared with the reference group (7 ~ h group), the ORs and 95% CI of osteoporosis associated with duration of nocturnal sleep were 1.32 (1.10, 1.56), 1.59 (1.25, 2.01), and 1.82 (1.25, 2.65) in the 8 ~ h, 9 ~ h, and ≥ 10 h group, respectively. Additionally, the adjusted ORs and 95% CI were 1.20 (1.01, 1.44) in the early sleep midpoint group and 1.09 (0.92, 1.29) in the intermediate sleep midpoint, compared with the late. Furthermore, there was a joint effect of long duration of nocturnal sleep and the early sleep midpoint on osteoporosis.

CONCLUSION

Long duration of nocturnal sleep and early sleep midpoint were independently and jointly associated with higher risk of osteoporosis in rural areas.

TRIAL REGISTRATION

The Henan Rural Cohort Study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Technical note: Application and potentiality of quantitative ultrasonometry for the evaluation of bone mineral density status

The evaluation of bone mineral density (BMD) is an important task in paleopathology. Techniques commonly applied in bone quantity assessment, such as DXA or radiogrammetry (XR), suffer from several limitations when applied to skeletal remains. In recently published research, we developed a new methodology and new reference curves for the evaluation of BMD on human skeletal remains, applying for the first time Quantitative Ultrasonometry (QUS), a user-friendly, portable, and reliable clinical technique. This study aims to apply this new methodology to an archeological sample and to compare the results with those obtained through XR. We apply QUS and XR to a sample of 104 adults from Medieval Italian cemeteries. Fragility fractures were recorded. Descriptive statistics and comparisons between sexes, age-at-death cohorts, and individuals with and without fragility fractures were performed. Moreover, univariate and multivariate logistic regression models were used to define the parameters most predictive of fracture risk in past populations. The comparison between sexes showed no significant results concerning BMD parameters, whereas a decrease in BMD with increasing age is confirmed. The comparison between fracture and non-fracture individuals and the logit model demonstrated that QUS parameters, especially UBPI, are more reliable predictors of fracture risk in comparison to XR. Our results confirmed that QUS is a valuable technique that can be efficiently applied to archeological remains, also considering its portability. We also propose a modification of the previously published QUS standard curves, to easily assess osteopenia and osteoporosis in archeological material.

Quantitative Ultrasound Examination (QUS) of the Calcaneus in Long-Term Martial Arts Training on the Example of Long-Time Practitioners of Okinawa Kobudo/Karate Shorin-Ryu

Quantitative research of bone tissue related to physical activity (PA) and sport has a preventive dimension. Increasing the parameters of bone tissue strength, especially reaching the maximum value of peak bone strength in childhood, adolescence, and early adulthood due to practicing sports can contribute to maintaining bone health throughout life. Practicing martial arts (tai chi, traditional karate, judo, and boxing) can effectively improve the quality of bone and reduce the risk of falls and fractures. The study aimed to evaluate the calcaneus bones among Okinawa Kobudo/Karate Shorin-Ryu practitioners using the quantitative ultrasound method as an indicator for assessing bone fracture risk. Forty-four adult martial arts practitioners with a mean age of 36.4 participated in this study. Quantitative ultrasound (QUS) with a portable Bone Ultrasonometer was used in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (SI) were measured. Subjects were assigned to two groups of black and color belts, according to the advancement in Kobudo/karate practice. The measurements of the SI, BUA, SOS, T-score, and Z-score were significantly higher in subjects from the advanced, long-term practice (black belts) (p < 0.05). The long-term martial arts training in traditional karate and Kobudo significantly impacts the parameters of the calcaneus quantitative ultrasound measurements. Significantly higher bone density was observed among the black belt holders. Long-term practice subjects achieved results far beyond the norm for their age groups. Further studies using non-invasive methods of bone quantification are needed to determine the specific conditions for preventing osteoporosis through physical activity, sports, and martial arts, particularly the duration of the activity, the magnitude of loads, and other related factors.

Prevalence of lactose intolerance and malabsorption among children of two ethnic groups from the urban areas of Malaysia and its relation to calcium intake and bone health status

Lactase insufficiency could develop into lactose intolerance (LI) and disrupt the intake of calcium, which is a core nutrient for bone development in children. However, data regarding the prevalence of LI and bone health status (BHS) among Malaysian children are scarcely reported.

PURPOSE

This study aimed to determine the prevalence of LI and lactose malabsorption (LM) in Malay and Chinese children and examine its relationship with calcium intake (CI) and BHS.

METHODS

A total of 400 children participated in this study. The prevalence of lactose tolerance (LT) was assessed using hydrogen breath test, LT test, and visual analogue scales. Assessment of CI was performed using a 24-h dietary recall interview (24-h DR) and food frequency questionnaire (FFQ). Calcaneal broadband ultrasound attenuation (BUA) was measured using a quantitative ultrasonometer.

RESULTS

The prevalence of LI among Chinese children (37%) was significantly higher (p = 0.002) than among Malay children (22.5%). However, 61.5% of Malay and 54.5% of Chinese children were found to have LM. CI of the children fulfilled 30.5% and 33.9% of the Malaysian recommended CI (1300 mg/day) for 24-h DR and FFQ, respectively. The BUA score of Malay children was significantly higher (p < 0.001) than that of Chinese children. However, LT and CI were not correlated with BHS (p > 0.05, respectively).

CONCLUSIONS

LI was diagnosed among Malay and Chinese children. However, the higher prevalence of LM is rather worrying as it could develop to LI. The prevalence possibly has been worsened by insufficient CI. Thus, effective approaches to increase CI are highly needed as bone development occurs rapidly at this age and is important for the attainment of the optimum peak bone mass during late adolescence.

Focal Bone-Marrow Defects in the Jawbone Determined by Ultrasonography-Validation of New Trans-Alveolar Ultrasound Technique for Measuring Jawbone Density in 210 Participants

Ultrasound imaging of the jawbone is not currently used in dental medicine to determine bone density. Bone-marrow defects in the human jawbone (BMDJ/FDOJ) are widely discussed in dentistry owing to their role in implant failures and as sources of inflammation in various immune diseases. The use of through-transmission alveolar ultrasonography (TAU) to locate BMDJ/FDOJ was evaluated in this study using a new TAU apparatus (TAU-n). The objective was to determine whether TAU-n readings accurately indicate the clinical parameters to detect BMDJ/FDOJ. Three parameters were compared with TAU-n measurements: 2-D orthopantomogram, Hounsfield units using digital volume tomography and post-operatively measured levels of RANTES/CCL5 expression in BMDJ/FDOJ samples. Based on the available clinical data, Hounsfield units, RANTES/CCL5 expression and TAU-n color codes yielded consistent results with respect to bone mineral density. Thus, ultrasonography with TAU-n is a reliable and efficient diagnostic method to screen for BMDJ/FDOJ in dentistry.

To study the awareness of osteoporosis in postmenopausal Indian women in a Northeast part of India: An evaluation of the Osteoporosis Health Belief Scale

Aim and Objective:

Our study's objective is to determine the level of awareness in postmenopausal women in Guwahati, Northeast part of India, using the Osteoporosis Health Belief Scale (OHBS).

Settings and Design:

Osteoporosis is the most common silent health problem in postmenopausal Indian women. An awareness level among this subset of women needs to study. The present study is based on a self-explanatory questionnaire.

Methods:

We conducted a self-explanatory questionnaire study on 2000 postmenopausal women in Guwahati, North East region of India. The bone mineral density (BMD) was measured using calcaneum Quantitative ultrasound (QUS) to assess BMD. Baseline characteristics were noted and analyzed.

Results:

The awareness level was noted only in757 (37.85%). Women with education level 12^th standard and above have some awareness regarding osteoporosis.

Conclusions:

Based on the present study, we can conclude that there is a lack of awareness in postmenopausal women regarding osteoporosis in India's North-East region. This subset of women is unaware of the condition that can leads to fragility fracture if not address in time. The study emphasizes that health care professionals should conduct frequent awareness programs in the community to prevent this silent disease, and morbidities so arise from osteoporosis can be minimized.

Cross-sectional and longitudinal associations between sleep duration, sleep quality, and bone stiffness in European children and adolescents

In this large perspective cohort among European children and adolescents, we observed that daytime napping was positively associated with bone stiffness, while short or long sleep duration combined with poor sleep quality was associated with less bone stiffness. Our findings are important for obtaining optimal bone stiffness in childhood.

INTRODUCTION

To examine the cross-sectional and longitudinal associations between sleep duration, sleep quality, and bone stiffness index (SI) in European children and adolescents.

METHODS

Four thousand eight hundred seventy-one children aged 2-11 years from the IDEFICS study and 861 children aged 6-15 years from the subsequent I.Family study were included. Sleep duration (i.e., nocturnal sleep and daytime napping) and sleep quality (i.e., irregularly bedtime routine, have difficulty falling asleep and trouble getting up in the morning) were reported by self-administrated questionnaires. Nocturnal sleep duration was converted into age-specific z-scores, and total sleep duration was classified into short, adequate, and long based on the National Sleep Recommendation. Calcaneal SI of both feet were measured using quantitative ultrasound. Linear mixed-effects models with country as a random effect were used, with adjustments for sex, age, pubertal status, family socioeconomic status, physical activity, screen time, body mass index, and daylight duration.

RESULTS

Nocturnal sleep duration z-scores were positively associated with SI percentiles among participants with adequate sleep duration at baseline. Moreover, the positive association between daytime napping and SI percentiles was more pronounced in participants with adequate sleep duration at baseline, while at 4-year follow-up was more pronounced in participants with short sleep duration. In addition, extreme sleep duration at baseline predicted lower SI percentiles after 4 years in participants with poor sleep quality.

CONCLUSION

The positive associations between nocturnal sleep, daytime napping and SI depended on total sleep duration. Long-term detrimental effect of extreme sleep duration on SI only existed in individuals with poor sleep quality.

Ultrasound reference values for the calcaneus of children and adolescents at moderate altitudes in Peru

OBJECTIVE

a) Establish reference values for bone parameters by using the speed of sound (SOS, m/s) of broadband ultrasound attenuation (BUA, dB/MHz) and establish a bone quality index (BQI=αSOS+βBUA) for children and adolescents living in a region of moderate altitude, b) compare bone parameters with an international standard (with different ethnic, socio-economic, and lifestyle backgrounds) by using ultrasound of the calcaneus (heel bone) (QUS).

METHODS

A descriptive cross-sectional study was carried out with children and adolescents between the ages of 6.0 and 16.9 years old. The sample was selected randomly. A total of 1322 subjects were studied. Weight, height, and bone parameters, using ultrasound of the calcaneus, were evaluated SOS, BUA, and BQI. Body Mass Index BMI was calculated.

RESULTS

The average age of males was 11.44±0.35 years old, and for females, it was 11.43±0.35 years old. The students in this research showed slightly higher values of SOS, BUA, and BQI for both sexes when compared with the international reference (the 50th percentile). Percentiles were generated (P3, P10, P25, P50, P75, P90, and P97) using the LMS method [median (M), standard deviation (S), and power of the Box-Cox transformation (L)] by age and sex.

CONCLUSION

The students living at a moderate altitude showed slightly higher values in bone parameters in relation to the international reference. This pattern depicted a population with a better state of bone health. The proposed percentiles may be used to categorize adequate to at risk bone parameters based on age and sex.

Short and medium-term effects of a multicomponent physical exercise program with a Mediterranean diet on bone mineral density, gait, balance, and fall risk for patients with Alzheimer disease: Randomized controlled clinical trial study protocol

INTRODUCTION

Reduced bone mineral density and increased risk of falls are related with Alzheimer disease, and these increase likelihood of bone osteoporotic fractures causing serious complications such as disability, fear of falling, loss autonomy, decreased quality of life, and anticipated mortality in elderly patients. Gait and balance disturb are 2 factors to favor falls in elderly, and in patients with cognitive impairment, the risk of falls increases to double. Exercise and Mediterranean diet produce beneficial effects for aging, cognitive decline, and are widely recommended to reduce the effects of osteoporosis, fall risk, and related fragility fractures. The primary objective of this study is to evaluate the short and medium-term effects during 6 months, of a multicomponent physical exercise program with a Mediterranean diet on bone mineral density, fall risk, balance, and gait by a controlled clinical trial in patients with Alzheimer disease.

METHODS

The study is a 6-month, randomized controlled parallel-group, single-blinded clinical trial. Institutionalized patients with Alzheimer disease will be included. The intervention group will perform a multicomponent physical exercise program in reduced groups, with a frequency of 3 sessions per week, associated with a Mediterranean diet. This program includes strength, balance, and aerobic resistance exercises, and in the main part of the session, also ludic exercises to improve agility, coordination, and balance. The control group will receive usual care. The outcomes to assess are the change of physical functions, such as gait and balance, and the change of bone mineral density by calcaneal quantitative ultrasound, during the study follow-up at 1, 3, and 6 months. This clinical trial will generate more and new evidence on the effects of a multicomponent physical exercise program and Mediterranean diet in patients with Alzheimer disease on risk of falls and osteoporotic fractures, the relation of these with bone mineral density, gait and balance, and the correlations between them.

ETHICS AND DISSEMINATION

This study protocol has been approved by the Ethics Committee of the University of Salamanca. The results will be published in peer-reviewed journals and disseminated in national and international conferences, to the participants and their families, and the general public through the associations of people with AD.

TRIAL REGISTRATION ID

ClínicalTrials.gov ID: NCT04439097.

Computer-aided diagnosis systems for osteoporosis detection: a comprehensive survey

Computer-aided diagnosis (CAD) has revolutionized the field of medical diagnosis. They assist in improving the treatment potentials and intensify the survival frequency by early diagnosing the diseases in an efficient, timely, and cost-effective way. The automatic segmentation has led the radiologist to successfully segment the region of interest to improve the diagnosis of diseases from medical images which is not so efficiently possible by manual segmentation. The aim of this paper is to survey the vision-based CAD systems especially focusing on the segmentation techniques for the pathological bone disease known as osteoporosis. Osteoporosis is the state of the bones where the mineral density of bones decreases and they become porous, making the bones easily susceptible to fractures by small injury or a fall. The article covers the image acquisition techniques for acquiring the medical images for osteoporosis diagnosis. The article also discusses the advanced machine learning paradigms employed in segmentation for osteoporosis disease. Other image processing steps in osteoporosis like feature extraction and classification are also briefly described. Finally, the paper gives the future directions to improve the osteoporosis diagnosis and presents the proposed architecture. Graphical abstract.

Long-term exposure to air pollution might increase prevalence of osteoporosis in Chinese rural population

OBJECTIVES

The associations of long-term exposure to air pollution with osteoporosis are rarely reported, especially in rural China. This study aimed to explore the association among rural Chinese population.

METHODS

A total of 8033 participants (18-79 years) derived from the Henan Rural Cohort Study (n = 39,259) were included in this cross-sectional study. Exposure to air pollutants was estimated using machine learning algorithms with satellite remote sensing, land use information, and meteorological data [including particulate matter with aerodynamic diameters ≤1.0 μm (PM₁), ≤2.5 μm (PM_2.5), and ≤10 μm (PM₁₀), and nitrogen dioxide (NO₂)]. The bone mineral density of each individual was measured by using ultrasonic bone density apparatus and osteoporosis was defined based on the T-score ≤ -2.5. Multiple logistic regression models were used to examine the association of air pollution and osteoporosis prevalence.

RESULTS

We observed that per 1 μg/m³ increase in PM₁, PM_2.5, PM₁₀ and NO₂ were associated with a 14.9%, 14.6%, 7.3%, and 16.5% elevated risk of osteoporosis. Compared with individuals in the first quartile, individuals in the fourth quartile had higher odds ratio (OR) of osteoporosis (P-trend < 0.001), the ORs (95% confidence interval) were 2.08 (1.72, 2.50) for PM₁, 2.28 (1.90, 2.74) for PM_2.5, 1.93 (1.60, 2.32) for PM₁₀, and 2.02 (1.68, 2.41) for NO₂. It was estimated that 20.29%-24.36% of osteoporosis cases could be attributable to air pollution in the rural population from China.

CONCLUSIONS

Long-term exposure to air pollutants were positively associated with high-risk of osteoporosis, indicated that improving air quality may be beneficial to improve rural residents health.

Calcaneal quantitative ultrasound has a role in out ruling low bone mineral density in axial spondyloarthropathy

OBJECTIVE

The aim of this study was to investigate the role of quantitative ultrasound (QUS) of the calcaneus in screening for osteoporosis in adults with axial spondyloarthropathy (axSpA).

METHOD

Postmenopausal women and men over 50 years with axSpA were recruited for this observational cross-sectional study. Dual-energy x-ray absorptiometry (DXA) assessed bone mineral density (BMD) of the spine and hip. QUS of the calcaneus produced broadband ultrasound attenuation (BUA), speed of sound (SOS), stiffness index (SI), and T-scores. Receiver-operating characteristics (ROC) curve analysis determined the ability of QUS to discriminate between low and normal BMD. Thresholds were identified to (1) out rule low BMD, (2) identify osteoporosis, and (3) identify low BMD. The number of DXAs which could be avoided using this approach was calculated.

RESULTS

56 participants were analyzed. BUA, SI, and T-score QUS parameters correlated with BMD by DXA; SOS did not. All QUS parameters had the ability to discriminate between low and normal BMD (area under the curve varied from 0.695 to 0.779). QUS identified individuals without low BMD with 90% confidence, with BUA performing best (sensitivity 93%, negative predictive value 86%). Using QUS as a triage tool, up to 27% of DXA assessments could have been avoided. QUS could not confidently identify individuals with osteoporosis.

CONCLUSIONS

QUS of the calcaneus confidently out ruled low BMD in individuals with axSpA, reducing the need for onward DXA referral by up to 27%. QUS is promising as a non-invasive triage tool in the assessment of osteoporosis in adults with axSpA.Key Points• Osteoporosis is common in axial spondyloarthropathy (SpA), but evaluation of bone health is suboptimal in this population.• Quantitative ultrasound (QUS) of the calcaneus can out rule low bone mineral density in individuals with axial SpA, reducing the need for DXA assessment.• QUS is a promising non-invasive triage tool in the assessment of bone health in axial SpA.

Gender-specific prevalence and influencing factors of osteopenia and osteoporosis in Chinese rural population: the Henan Rural Cohort Study

OBJECTIVE

The aims of this study were to describe distributions of the prevalence of osteopenia and osteoporosis and identify the potential risk factors by gender in a Chinese rural population.

DESIGN

A cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 8475 participants (18-79 years) were obtained from the Henan Rural Cohort Study. Bone mineral density (BMD) of the calcaneus for each individual was measured by ultrasonic bone density apparatus. Logistic regression models were used to evaluate associations of potential risk factors with prevalence of osteopenia and osteoporosis. Furthermore, a meta-analysis of prevalence of osteoporosis which included eight studies was conducted to confirm this study results.

RESULTS

The mean of BMD were 0.42 and 0.32 g/cm² for men with osteopenia and osteoporosis (p<0.001), as well as 0.40 and 0.30 g/cm² (p<0.001) for women with osteopenia and osteoporosis, respectively. The overall age-standardised prevalence of osteopenia and osteoporosis were 42.09% and 11.76% in all participants. The age-standardised prevalence of osteopenia in men (45.98%) was significantly higher than that in women (39.73%), whereas the age-standardised prevalence of osteoporosis in men (7.82%) was lower than that in women (14.38%). Meta-analysis results displayed pooled prevalence of osteoporosis of 18.0% (10.1%-25.8%) in total sample, 7.7% (5.7%-9.7%) in men and 22.4% (17.1%-27.6%) in women. Multivariable logistic regression models showed that ageing, women, low education level or income, drinking or underweight was related to increased risk for osteopenia or osteoporosis.

CONCLUSIONS

About one-sixth of the participants suffered osteoporosis in rural China, and the prevalence in women was higher than men. Although the results were lower than that of meta-analysis, osteoporosis still accounts for huge burden of disease in rural population due to limited medical service and lack of health risk awareness rather than urban area.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR-OOC-15006699; Pre-results).

Association between long-term occupational manganese exposure and bone quality among retired workers

Despite well documents for manganese-induced neurological deficits, limited researches are available for effects of manganese (Mn) exposure on the bone. Here we aimed to explore the associations between long-term occupational Mn exposure and bone quality among retired workers. We conducted a cross-sectional study of 304 exposed subjects (n, male = 161 and female = 143) and 277 control retired workers (n, male = 65 and female = 212) recruited from a ferromanganese refinery. Self-reported occupation types were used as exposure classification confirmed by expert consultation. Bone quality was measured by quantitative ultrasound (QUS). In sex-stratified analyses throughout, stiffness index (SI) and T-score levels of the participants in the highest exposed group [tertile 3 of Mn cumulative exposure index (Mn-CEI)] were significantly lower as compared with the control group among female workers (SI, mean, 61.60 vs. 68.17; T-score, mean, -3.01 vs. -2.34, both P < 0.05). In addition, SI and T-score were found to be negatively associated with Mn-CEI only in the highest exposure group as compared with the female controls (both P = 0.01). However, we did not find the significant difference for SI or T-score among the male subjects in exposure models and the male controls (P > 0.05). Our results suggest that female retired workers in the highest Mn-exposed model (tertile 3 of Mn-CEI) potentially experience a higher risk of developing osteoporosis compared with the female controls. Further investigations on possible mechanisms on bone quality alteration are needed in the future.

Trabecular bone score and quantitative ultrasound measurements in the assessment of bone health in breast cancer survivors assuming aromatase inhibitors

PURPOSE

Aromatase inhibitors (AIs) represent the first-line adjuvant therapy for hormone receptor-positive breast cancer (BC) women. AIs have been associated with an increased rate of fractures. The aim of our study was to investigate trabecular bone score (TBS) and bone quantitative ultrasound (QUS) measurements as bone quality surrogates in AIs users.

METHODS

Sixty postmenopausal BC women starting AIs and forty-two controls (mean age 61.64 ± 8.33 years) were considered. Bone mineral density (BMD) at lumbar spine and femoral neck and TBS were measured by DXA; QUS-derived Amplitude-Dependent Speed of Sound (AD-SoS), Bone Transmission Time (BTT), and Ultrasound Bone Profile Index (UBPI) were assessed at phalangeal site; morphometric vertebral fractures (Vfx) by X-ray, serum bone-specific alkaline phosphatase (BSAP), and C-telopeptide of type 1 collagen (CTX) were also evaluated.

RESULTS

After 18 months, changes of TBS vs baseline were significantly different between AIs group and controls [Δ TBS - 2.2% vs - 0.4%, respectively, p = 0.001]. AD-SoS, BTT and UBPI values decreased only in AIs' group (- 3.7%, - 6.45%, -8.5%, vs baseline, respectively, p_all < 0.001). 3 Vfx occurred in AIs users and were associated with the greater TBS and AD-SoS modifications. In the AIs' group, ΔTBS was associated with ΔAD-SoS (r = 0.58, p < 0.001) and ΔUBPI (r = 0.415, p = 0.001), but not with ΔBMD. Moreover, ΔTBS was independently predicted by ΔAD-SoS, after correcting for BMD, CTX and BSAP level changes (β = 0.37, SE = 2.44, p < 0.001).

CONCLUSIONS

TBS and phalangeal QUS provide useful information related to bone quality in AI-treated BC survivors and could be considered for fracture risk evaluation.

Serum Prolactin and Bone Mineral Density in Schizophrenia: A Systematic Review

The relationship between serum prolactin and bone mineral density (BMD) in schizophrenia is unclear. We conducted a literature review of databases from inception until December 2018 for cross-sectional, case-control, prospective and retrospective studies analyzing correlations between serum prolactin and BMD measured using dual energy X-ray absorptiometry or quantitative ultrasound at any skeletal site in people with schizophrenia. Data was summarized with a best evidence synthesis. This review identified 15 studies (1 longitudinal study, 10 cross-sectional and 4 case-control studies; 1,360 individuals with a psychotic disorder; mean age 45.1 ± 9.4 [standard deviation] years, female 742 [54.6%], mean illness duration 17.7 ± 11.3 years) assessing the relationship between serum prolactin and BMD in schizophrenia. There was a statistically significant inverse correlation between serum prolactin and BMD identified in eight of the studies (53% of all studies), suggesting mixed evidence for an association between serum prolactin and BMD. Of those studies which identified a significant inverse correlation between serum prolactin and BMD (n = 5), 152 (52.1%) of patients were treated with prolactin raising antipsychotics, compared to 197 (48.1%) of patients in those studies which did not identify a significant correlation between prolactin and BMD. Available studies cannot resolve the link between excess prolactin and reduced BMD in schizophrenia. Future studies should be longitudinal in design and combine measures of serum prolactin along with other risk factors for reduced BMD such as smoking and vitamin D and sex hormone levels in assessing the relationship between prolactin and BMD in schizophrenia.

Lipid profiles as potential mediators linking body mass index to osteoporosis among Chinese adults: the Henan Rural Cohort Study

This study is to examine the relationship between body mass index (BMI) and osteoporosis in rural areas of China, and then explore whether this association was mediated by lipid profiles. Results showed that with the increasing of BMI, the risk of osteoporosis was reduced, and lipid profiles mediate this association.

INTRODUCTION

To examine the relationship between BMI and osteoporosis, and explore whether this association was mediated by lipid profiles.

METHODS

A total of 8272 participants (18-79 years) were enrolled from the Henan Rural Cohort Study. The bone mineral density of the calcaneus was measured using an ultrasonic bone density apparatus. Logistic regression and restricted cubic splines were used to evaluate the odds ratio (OR) and 95% confidence intervals (95% CI). Mediation analysis using bootstrap was performed to examine the contribution of lipid profiles to BMI-related osteoporosis.

RESULTS

The crude and age-standardized prevalence of osteoporosis were 15.93% and 11.77%, respectively. The mean BMIs were 24.12 kg/m² for participants with osteoporosis and 25.06 kg/m² for non-osteoporosis participants (P < 0.001). After adjusting for potential confounders, subjects with obesity had a lower OR of osteoporosis (0.493 [95% CI: 0.405-0.600], P_trend < 0.001) compared with normal-weight individuals. Mediation analysis showed that lipid profile partly mediated the relationship between BMI and osteoporosis with indirect effect OR (95% CI) of 0.985 (0.978-0.992), and the proportion explained of BMI was 15.48% for lipid profile.

CONCLUSION

With the increasing of BMI, the risk of osteoporosis was reduced in the Chinese adult population, and lipid profiles may be a potential mediator linking reduced risk of osteoporosis. Elucidating the underlying mechanisms will facilitate developing feasible preventive and therapeutic measures for osteoporosis. Chinese clinical trial register: ChiCTR-OOC-15006699.

Calcaneal Broadband Ultrasound Attenuation and Speed of Sound Measurements in a Population of Nigerian Children: Reference Data and the Influence of Sociodemographic Variables

OBJECTIVES

The aim of our study was to establish a reference database of calcaneal broadband ultrasound attenuation (BUA) and the speed of sound (SOS) in a healthy Nigerian population of children aged 6 to 14 years and also to investigate the influence of sociodemographic and anthropometric variables on them.

METHODS

The BUA and SOS of 1016 healthy children were measured by quantitative ultrasound densitometry. Height and weight were measured with a stadiometer and weighing balance, respectively, whereas the sociodemographic parameters of the participants were collected on a semistructured questionnaire. A multiple regression model using stepwise selection and Pearson correlation coefficients were used to examine the relationship between the ultrasound parameters and sociodemographic and anthropometric parameters. Comparisons between various age groups were made by analysis of variance.

RESULTS

The mean BUA and SOS ± SD of the participants were 60.57 ± 16.21 dB/MHz and 1563.48 ± 21.74 m/s, respectively, for boys and 58.18 ± 15.16 dB/MHz and 1560.03 ± 22.32 m/s for girls. The BUA in both sexes was positively influenced by age and weight (P < .05), whereas only the father's educational status was its predictor (P < .05) in the boys. For the girls, the family size and mother's educational status were predictors of the BUA (P < .05). The SOS was marginally influenced by age and family size in the boys (P < .05), whereas the father's educational status was the predictor in the girls.

CONCLUSIONS

The established BUA and SOS values in this study are baseline values, and further study, which would also involve data from a large number of Nigerian children, would be needed to support their effectiveness as reference values.

EXPOSURE TO FAMINE IN EARLY LIFE AND THE RISK OF OSTEOPOROSIS IN ADULTHOOD: A PROSPECTIVE STUDY

Objective: To assess the association between famine exposure in early life and osteoporosis in adulthood. Methods: A total of 2,292 participants born between 1955 and 1965 in Fujian Province were selected; after 3 years, 1,378 participants attended a follow-up research visit. Calcaneus bone mineral density and bone quality were measured by quantitative ultrasound. The T-score was used to assess bone mineral density, and the parameters quantitative ultrasound index (QUI), speed of sound (SOS), and broadband ultrasonic attenuation (BUA) were used to assess bone quality. A T-score threshold of -1.8 was defined as osteoporosis, and a possible vertebral fracture was considered as a prospective height loss of 0.8 inches or more. Results: Compared with the nonexposed cohort, risks of osteoporosis for fetal-, early childhood, and mid-childhood famine-exposed cohorts in postmenopausal women were adjusted odds ratio (OR), 3.741 (95% confidence interval [CI], 1.233, 11.44) versus OR 2.894 (95% CI, 0.997, 8.571) versus OR 4.699 (95% CI, 1.622, 13.612) by logistic regression but not significant in men. Moreover, the fetal-exposed cohort had a weak negative relation with QUI (β, -5.07 [-10.226, 0.127]) and BUA (β, -4.321 [-0.88, 0.238]). The early- and mid-childhood-exposed cohorts had significantly lower QUI (β, -7.085 [-11.799, -2.372] versus β, -10.845 [-15.68, -6.01]) and BUA (β, -6.381 [-10.515, -2.246] versus β, -8.573 [-12.815, -4.331]) than the nonexposed cohort by linear regression. None of the famine-exposed cohorts had a significant relationship with SOS. Conclusion: Famine exposure during early life is associated with higher risk of osteoporosis in adulthood, which is most obvious in postmenopausal women. Furthermore, famine exposure in early life has adverse effects on bone quality. Abbreviations: BMD = bone mineral density; BUA = broadband ultrasonic attenuation; CI = confidence interval; OR = odds ratio; QUI = quantitative ultrasound index; QUS = quantitative ultrasound; SOS = speed of sound.

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.

Clinical utilities of quantitative ultrasound in osteoporosis associated with inflammatory rheumatic diseases

Secondary osteoporosis is an important co-morbidity related to inflammatory rheumatic diseases that is attributed to several factors including inflammatory cytokines, inactivity and glucocorticoid treatment. Quantitative ultrasound (QUS) has been utilized in osteoporosis research due to its detectability of bone density as well as bone quality. The current narrative review is to address the potential utilities of QUS in secondary osteoporosis of inflammatory rheumatic diseases, focusing on the clinical aspects of QUS in these diseases, based on the conformity of QUS with dual emission X-ray absorptiometry (DXA), the relationship with disease characteristics, and its capability of fracture prediction. Although limited data demonstrate that QUS had moderate to strong correlation with DXA, and might be useful as a potential imaging tool to screen for osteoporosis, further research is still required for QUS to be utilized effectively for the best outcome in these patients with rheumatic diseases.

Clinical Conformity Between Heel Ultrasound and Densitometry in Postmenopausal Women: A Systematic Review

OBJECTIVES

To assess the conformity between heel ultrasound and densitometry, and the clinical application of densitometry T-score "gold standard" in quantitative ultrasound as a method of osteoporosis diagnosis in postmenopausal women.

METHODS

The study is a systematic review of studies published in the last 17 years in PubMed, NLM Gateway, Medline, Embase, and Cochrane Library. Calcaneal quantitative ultrasound sensitivity and specificity were analyzed with regard to densitometry measurements in postmenopausal women. In addition, we summarized the values of ultrasound T-scores, for which their accuracy in osteoporosis diagnosis is the highest.

RESULTS

The inclusion criteria met 15 research studies conducted on postmenopausal women. In 11 of them, the authors concluded that clinical conformity between heel ultrasound and densitometry is good. The recommended quantitative ultrasound T-score for osteoporosis diagnosis ranged between -1 and -3.65.

CONCLUSIONS

Heel ultrasound should be considered to be as accurate as densitometry in diagnosing osteoporosis. Nevertheless, it needs to have separate T-score ranges determined, because those used in densitometry are not adequate.

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

INTRODUCTION

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Advances in imaging approaches to fracture risk evaluation

Fragility fractures are a growing problem worldwide, and current methods for diagnosing osteoporosis do not always identify individuals who require treatment to prevent a fracture and may misidentify those not a risk. Traditionally, fracture risk is assessed using dual-energy X-ray absorptiometry, which provides measurements of areal bone mineral density at sites prone to fracture. Recent advances in imaging show promise in adding new information that could improve the prediction of fracture risk in the clinic. As reviewed herein, advances in quantitative computed tomography (QCT) predict hip and vertebral body strength; high-resolution HR-peripheral QCT (HR-pQCT) and micromagnetic resonance imaging assess the microarchitecture of trabecular bone; quantitative ultrasound measures the modulus or tissue stiffness of cortical bone; and quantitative ultrashort echo-time MRI methods quantify the concentrations of bound water and pore water in cortical bone, which reflect a variety of mechanical properties of bone. Each of these technologies provides unique characteristics of bone and may improve fracture risk diagnoses and reduce prevalence of fractures by helping to guide treatment decisions.

Diabetes and Obesity as Independent Risk Factors for Osteoporosis: Updated Results from the ROIS/EMEROS Registry in a Population of Five Thousand Post-Menopausal Women Living in a Region Characterized by Heavy Environmental Pressure

Objectives: We aimed to analyze bone mineralization and the effect of different risk factors for osteoporosis in postmenopausal women. Methods: We found 4909 postmenopausal subjects within ≥10,000 records from the ROIS/EMEROS (Ionian and Salento Osteoporosis Registry/Euro Mediterranean Registry of Osteoporosis) registry, a population study carried out in an area characterized by heavy environmental pressure between Brindisi and Taranto from 2009 to 2016. All subjects were assessed via phalangeal quantitative ultrasound (QUS) to evaluate their bone mineralization (assessed via amplitude dependent speed of sound (AD-SoS)) and the association between demineralization and the presence of other conditions or risk factors. Results: Mean age was 64 ± 9.5 years and mean body mass index (BMI) was 28.7 ± 3.5 kg/m². Pearson correlation analyses revealed a negative association between bone mineralization (AD-SoS) and BMI (p < 0.001). By using multivariate logistic regression analysis, we observed significant values of odds ratios (ORs) of osteoporosis (adjusted for age, physical activity, and the use of drugs known to increase the risk of fractures) in subjects with diabetes and obesity: 1.39 (confidence interval (CI): 1.05-1.83) and 1.46 (CI: 1.20-1.78), respectively. A statistically significant linear trend of higher ORs of osteoporosis was found for increasing values of BMI. Conclusions: Our study confirmed the high impact of obesity and type 1 and type 2 diabetes on osteoporosis.

Bone measurements of infants with hyperbilirubinemia by quantitative ultrasound: the influence of phototherapy

OBJECTIVE

The purpose of the current study was to investigate the possible effects of phototherapy on bone status of term infants evaluated by measurement of tibial bone speed of sound (SOS).

MATERIALS AND METHODS

The phototherapy group (n = 30) consisted of children who had undergone phototherapy for at least 24 h and the control group (n = 30) comprised children who had not received phototherapy. Blood samples were obtained from all infants for serum calcium, phosphorus, magnesium, alkaline phosphatase, parathyroid hormone and vitamin D concentrations. The left tibial quantitative ultrasound (QUS) measurements were performed using a commercial device.

RESULTS

There was no statistically significant difference between phototherapy-exposed and nonexposed infants in terms of Ca, P, ALP, PTH and vitamin D levels. Comparison of bone SOS between the phototherapy-exposed and control group revealed no statistically difference. Also, no significant difference in Z-score for SOS was observed between those with or without exposure.

CONCLUSION

The data of our study indicate that phototherapy treatment has no impact on bone status in the hyperbilirubinemic infants. Although there is no statistically significant evidence of an excess risk of bone damage following phototherapy, studies with larger sample sizes and longer duration of follow-up are needed to gain a better understanding of its effects.

Lessons from the Bone Chapter of the Malaysian Aging Men Study

Male osteoporosis in Malaysia is a largely neglected problem. Therefore, a bone health study in men using quantitative ultrasonometry was launched as part of the Malaysian Aging Men Study in 2009–2012. This review aimed to summarize the findings of the aforementioned bone health study. The study examined the bone health of Chinese and Malaysian men aged 20 years and above living in Kuala Lumpur using a quantitative ultrasound device. Participants answered a questionnaire on their demographic details and physical activity status. Body anthropometry of the participants was measured and their blood collected for biochemical analysis. Results showed that a significant proportion of the Malaysian Chinese and Malay men had suboptimal bone health indicated by calcaneal speed of sound and vitamin D status. Age-related decline of the calcaneal speed of sound in these men was gradual and biphasic without ethnic difference. Body anthropometry such as height, weight, body mass index, and body fat percentage contributed to the variation of the calcaneal speed of sound in Malaysian men. Age-related changes in testosterone, insulin-like growth factor 1, and thyroid stimulating hormone also influenced the calcaneal speed of sound in these men. This study serves as a reminder that male osteoporosis in Malaysia should be an issue of concern. It is also a basis for a more comprehensive study on bone health in men in the future.

New perspectives in echographic diagnosis of osteoporosis on hip and spine

Currently, the accepted "gold standard" method for bone mineral density (BMD) measurement and osteoporosis diagnosis is dual-energy X-ray absorptiometry (DXA). However, actual DXA effectiveness is limited by several factors, including intrinsic accuracy uncertainties and possible errors in patient positioning and/or post-acquisition data analysis. DXA employment is also restricted by the typical issues related to ionizing radiation employment (high costs, need of dedicated structures and certified operators, unsuitability for population screenings). The only commercially-available alternative to DXA is represented by "quantitative ultrasound" (QUS) approaches, which are radiation-free, cheaper and portable, but they cannot be applied on the reference anatomical sites (lumbar spine and proximal femur). Therefore, their documented clinical usefulness is restricted to calcaneal applications on elderly patients (aged over 65 y), in combination with clinical risk factors and only for the identification of healthy subjects at low fracture risk. Literature-reported studies performed some QUS measurements on proximal femur, but their clinical translation is mostly hindered by intrinsic factors (e.g., device bulkiness). An innovative ultrasound methodology has been recently introduced, which performs a combined analysis of B-mode images and corresponding "raw" radiofrequency signals acquired during an echographic scan of the target reference anatomical site, providing two novel parameters: Osteoporosis Score and Fragility Score, indicative of BMD level and bone strength, respectively. This article will provide a brief review of the available systems for osteoporosis diagnosis in clinical routine contexts, followed by a synthesis of the most promising research results on the latest ultrasound developments for early osteoporosis diagnosis and fracture prevention.

Radial quantitative ultrasound and dual energy x-ray absorptiometry: intermethod agreement for bone status assessment in children

Aim. To validate a radial quantitative ultrasound (QUS) system with dual energy X-ray absorptiometry (DXA), a criterion technique in bone status assessment among children. Methods. Bone health was evaluated using a radial QUS system (Sunlight Omnisense 8000P) to measure the speed of sound (SOS) at one-third distal radius of the nondominant hand and DXA (Hologic QDR) was used to assess whole body bone mineral density (BMD). Results. Some 29.9% of the children were grossly misclassified according to quartiles of BMD and radial SOS. Poor agreement was observed between Z-scores of radial SOS and whole-body BMD (mean difference = 0.6 ± 0.9; 95% limits of agreement = −1.4 to 2.6). With a cut-off value of −1.0, radial SOS yielded satisfactory sensitivity (80%) and specificity (93%) for the detection of children with low BMD. Conclusion. The observed poor agreement in the present study suggests that radial QUS and DXA are not comparable and hence are not interchangeable in evaluating bone status of the children.

Bone speed of sound throughout lifetime assessed with quantitative ultrasound in a Mexican population

The purpose of this study was to assess the bone speed of sound (SoS) through lifetime of a large Mexican population sample by determining the SoS from the radius and tibia using quantitative ultrasound (QUS). This is a cross-sectional evaluation of participants in the Mexican Health Workers Cohort Study. QUS measurements were performed using Sunlight Omnisense 8000P; Z- and T-scores were calculated for both sexes at the distal third of the radius and midshaft tibia, both on the nondominant side. A locally weighted regression smoothing scatterplot model was used to identify different phases of bone accretion and loss. A total of 9128 participants aged 1-75 yr were measured with QUS. Bone SoS accretion began 5 yr earlier in girls than boys (p<0.05). Maximal SoS or peak bone SoS was noted at 28 yr in the radius and at 22 yr in the tibia. Postmenopausal women (45-50 yr) showed significant SOS decrease at both sites (p<0.05) compared with men. Using the locally weighted regression smoothing scatterplot model, we found 5 different phases that constitute the biological development of bone over the life course, from ages 1-6, 7-12, 12-25, 25-50, and 50-75 yr (p<0.05). Our study shows the age- and sex-dependent changes and different phases of bone development expressed by SoS measurements of the radius and tibia. The values reported in this study can be used as a reference for urban Mexican population.

Measurement properties of radial and tibial speed of sound for screening bone fragility in 10- to 12-year-old boys and girls

The objective of this study was to analyze measurement properties of the radial and tibial speed of sound (SoS) evaluated by quantitative ultrasound (QUS) for screening bone fragility. Bone fragility was defined as low whole body less head bone mineral density (WBLH BMD) measured by DXA (first tertile, 95% CI -1.1 to -0.9) and as past fractures evaluated by questionnaire. The sample included 319 nonobese boys and girls, ages 10-12 yr. All bone variables were standardized. The results revealed concordance coefficient correlations between WBLH BMD and radial and tibial SoS of 0.129 and 0.038, respectively. The regression lines between DXA and QUS variables were different from the identity lines. Cross-classification analysis by Kappa statistic showed that only 34% and 36% of the 113 participants categorized in the first tertile of WBLH BMD were also categorized in the first tertile of tibial and radial SoS, correspondingly. Logistic regression with gender and maturity adjustments demonstrates that radial SoS was the single significant variable in predicting OR for identifying participants with past fractures. In conclusion, the radial QUS revealed itself to be a valuable tool for screening bone fragility in youth of 10-12 yr, despite the absence of agreement with DXA WBLH BMD.

Diabetes and Obesity as Independent Risk Factors for Osteoporosis in Postmenopausal Women: A Population Study

We aimed to analyze bone mineralization and the effect of different risk factors for osteoporosis in postmenopausal women. We studied 2,756 postmenopausal subjects out of ≥10,000 records from the ROIS registry in the frame of the PROF Project, a population study carried out in Salento (Taranto, Brindisi, Lecce) from 2009 to 2012. All subjects were assessed by phalangeal Quantitative Ultrasound (QUS) to evaluate their bone mineralization (assessed by Amplitude Dependent Speed of Sound, AD-SoS) and the association between demineralization and the presence of other conditions or risk factors. Mean age was 64±9.5 years and mean BMI was 28.7±3.5 Kg/m2. Pearson correlation analyses revealed a negative association between bone mineralization (AD-SoS) and BMI (P<0.001). By using multivariate logistic regression analysis, we observed significant values of Odds Ratios of osteoporosis (adjusted for age, physical activity and the use of drugs known to increase the risk of fractures) in subjects with diabetes and obesity: 1.39 (CI: 1,05–1,83) and 1.46 (CI: 1.20–1.78), respectively. A statistically significant linear trend of higher Odds Ratios of osteoporosis was found for increasing values of BMI. The percent change in the odds of vertebral fractures per single SD decrease of AD-SoS was 47% (P<0.001). Diabetes and obesity in postmenopausal women are likely to represent independent risk factors for osteoporosis. Phalangeal QUS showed a good power of predictivity in identifying subjects with vertebral fractures.

Insulin-like growth factor-1 is a mediator of age-related decline of bone health status in men

OBJECTIVE

The role of insulin-like growth factor-1 (IGF-1) in bone health in men is debatable. This study aimed to determine whether IGF-1 is a mediator in age-related decline of bone health status measured by calcaneal speed of sound (SOS) in Malaysian men.

METHODS

The study recruited 279 Chinese and Malay men. Their demographic data, weight, height, calcaneal SOS were taken and fasting blood was collected for total testosterone, sex-hormone binding globulin and IGF-1 assays. The associations between the studied variables were assessed using multiple linear regression (MLR) analysis. Mediator analysis was performed using Sobel test.

RESULTS

There was a significant and parallel decrease of IGF-1 and SOS with age (p < 0.05). Serum IGF-1 was significantly and positively associated with SOS (p < 0.05) but after further adjustment for age, the significance was lost (p > 0.05). The strength of the association between age and SOS decreased after adjusting for IGF-1 level but it remained significant (p < 0.05). Sobel test revealed that IGF-1 was a significant partial mediator in the relationship between age and SOS (z = -4.3).

CONCLUSION

Serum IGF-1 is a partial mediator in the age-related decline of bone health in men as determined by calcaneal ultrasound. A prospective study should be performed to validate this relationship.

Discrepancy between the quantitative ultrasound value of Malaysian men and the manufacturer's reference and the impact on classification of bone health status

The local normative value in quantitative ultrasound (QUS) equipment needs to be established for wider application and accurate classification of patients into respective fracture risk groups. The present study aimed to establish the calcaneal speed of sound (SOS) value for Chinese and Malay men in Malaysia and determine the difference between calcaneal SOS of the local population and the reference values provided by the manufacturer for each age group. This study will also determine the effect of using the manufacturer's young adult (20-29yr) reference or the local young adult reference to classify the subjects into the respective risk groups. Eight hundred forty Malay and Chinese men residing in central peninsular Malaysia were recruited and their calcaneal QUS value was determined using the CM-200 machine (Furuno Electric, Nishinomiya City, Japan). The results showed that the differences in SOS values between Chinese and Malay men were not significant across all the age groups studied (p>0.05). The age-dependent reduction of SOS value assumed a biphasic form, which was evident at 30-39yr and older than 60yr. The calcaneal SOS of the subject under study was significantly higher as compared with the manufacturer's reference (based on Japanese population) in all groups aged 40yr and older (p<0.05). A significant proportion of the subjects in the osteoporosis group was misclassified using the manufacturer's young adult reference as compared with using the local young adult reference (p<0.05). In conclusion, the overall normative value of SOS obtained was suitable for Chinese and Malay men in Malaysia, and a local reference value should be applied to avoid misclassification of subjects into the respective risk groups.

Cortical and trabecular bone structure analysis at the distal radius-prediction of biomechanical strength by DXA and MRI

The purpose of this study was to investigate whether the combination of dual-energy X-ray absorptiometry (DXA)-based bone mass and magnetic resonance imaging (MRI)-based cortical and trabecular structural measures improves the prediction of radial bone strength. Thirty-eight left forearms were harvested from formalin-fixed human cadavers. Bone mineral content (BMC) and bone mineral density (BMD) of the distal radius were measured using DXA. Cortical and trabecular structural measures of the distal radius were computed in high-resolution 1.5T MR images. Cortical measures included average cortical thickness and cross-sectional area. Trabecular measures included morphometric and texture parameters. The forearms were biomechanically tested in a fall simulation to measure absolute radial bone strength (failure load). Relative radial bone strength was determined by dividing radial failure loads by age, body mass index, radius length, and average radius cross-sectional area, respectively. DXA derived BMC and BMD showed statistically significant (p < 0.05) correlations with absolute and relative radial bone strength (r ≤ 0.78). Correlation coefficients for cortical and trabecular structural measures with absolute and relative radial bone strength amounted up to r = 0.59 and r = 0.74, respectively, (p < 0.05). In combination with DXA-based bone mass, trabecular but not, cortical structural measures, added in multiple regression models significant (p < 0.05) information in predicting absolute and relative radial bone strength (up to R adj = 0.88). Thus, a combination of DXA-based bone mass and MRI-based trabecular structural measures most accurately predicted absolute and relative radial bone strength, whereas structural measures of the cortex did not provide significant additional information in combination with DXA.

Thyroid-stimulating hormone is significantly associated with bone health status in men

BACKGROUND AND AIM

Recent studies revealed a novel association between thyroid-stimulating hormone (TSH) and bone health status in healthy male populations. The present study aimed to validate this association and provide new information on the relationship between TSH levels and calcaneal speed of sound (SOS) in men.

METHODS

This cross-sectional study recruited 681 men with complete data of calcaneal SOS, body anthropometry, serum TSH, free triiodothyronine (FT3) and free thyroxine (FT4) levels.

RESULTS

All subjects had FT3 and FT4 levels within the in-house reference range and 13 subjects had lower than normal TSH levels. The results revealed that the SOS value of subjects was significantly associated with TSH after multiple adjustments (p<0.05). When subjects were divided into quintiles according to their TSH levels, the difference of SOS between men with low-normal TSH and high-normal TSH contributed significantly to the association between TSH and bone health status (p<0.05). The significance of the association persisted with the inclusion and exclusion of subclinical hyperthyroid subjects.

CONCLUSIONS

There was a significant association between TSH levels and bone health status in men as assessed by quantitative ultrasound. This age-independent association between TSH and SOS might explain some of the individual variation of bone health status in men.

Calcaneal quantitative ultrasound as a determinant of bone health status: what properties of bone does it reflect?

Quantitative ultrasound (QUS) has emerged as a convenient and popular screening tool for osteoporosis. This review aimed to provide basic information on the principle of QUS measurement and discuss the properties of bone reflected by QUS indices. QUS employed high frequency sound waves generated by the device to determine bone health status in humans. In vitro studies showed that QUS indices were significantly associated with bone mineral density (BMD), bone microarchitecture and mechanical parameters. In humans, QUS indices were found to be associated with BMD as well. In addition, QUS could discriminate subjects with and without fracture history and predict risk for future fracture. In conclusion, QUS is able to reflect bone quality and should be used in the screening of osteoporosis, especially in developing countries where dual-X-ray absorptiometry devices are less accessible to the general population.

Sex steroids and bone health status in men

Male osteoporosis is a health problem which deserves more attention as nearly 30% of osteoporotic fractures happen in men aged 50 years and above. Although men do not experience an accelerated bone loss phase and testosterone deficiency is not a universal characteristic for aged men, osteoporosis due to age-related testosterone deficiency does have a negative impact on bone health status of men. Observations from epidemiological studies indicate that elderly men with higher testosterone can preserve their BMD better and thus are less prone to fracture. Observations on men with estrogen resistance or aromatase deficiency indicate that estrogen is equally important in the maintenance of bone health status. This had been validated in several epidemiological studies which found that the relationships between estrogen and bone health indices are significant and sometimes stronger than testosterone. Studies on the relationship between quantitative ultrasound and bone remodeling markers suggest that testosterone and estrogen may have differential effects on bone, but further evidence was needed. In conclusion, both testosterone and estrogen are important in the maintenance of bone health in men.

Quality assurance of imaging techniques used in the clinical management of osteoporosis

Recent advances in the densitometric and imaging techniques involved in the management of osteoporosis are associated with increasing accuracy and precision as well as with higher exposure to ionising radiation. Therefore, special attention to quality assurance (QA) procedures is needed in this field. The development of effective and efficient QA programmes is mandatory to guarantee optimal image quality while reducing radiation exposure levels to the ALARA principle (as low as reasonably achievable). In this review article, the basic QA procedures are discussed for the techniques applied to everyday clinical practice.

Osteoporosis and fracture risk in people with schizophrenia

PURPOSE OF REVIEW

Excessive bone mineral density (BMD) loss has been associated with schizophrenia, but its mechanisms and clinical implications are less clear. The aim of this review was to summarize the risk of osteoporosis and bone fractures in schizophrenia patients. Moreover, we aimed to examine the impact of antipsychotic-induced hyperprolactinemia on bone metabolism.

RECENT FINDINGS

Fifteen of 16 studies (93.8%) reported lower BMD or higher prevalence of osteoporosis in at least one region, or in at least one subgroup of schizophrenia patients compared with controls, but results were inconsistent across measured areas. Higher fracture risk was associated with schizophrenia in 2/2 studies (independently: n = 1), and 3/4 studies with antipsychotics. Reasons for this difference include insufficient exercise, poor nutrition, smoking, alcohol use, and low vitamin D levels. Altogether, 9/15 (60.0%) studies examining the relationship between antipsychotic-induced hyperprolactinemia and BMD loss found some effects of hyperprolactinemia. However, results were mixed, samples and effects were small, and only two studies were prospective.

SUMMARY

Schizophrenia is associated with reduced BMD and fracture risk. Prevention, early detection, and intervention are required. The relative contributions of antipsychotic-related hyperprolactinemia and unhealthy lifestyle behaviors remain unclear, needing to be assessed in well designed, prospective studies, including bone turnover markers as intermediary endpoints.

Bone mineral density measurements of the proximal femur from routine contrast-enhanced MDCT data sets correlate with dual-energy X-ray absorptiometry

OBJECTIVES

To evaluate the utility of femoral bone mineral density (BMD) measurements in routine contrast-enhanced multi-detector computed tomography (ceMDCT) using dual-energy X-ray absorptiometry (DXA) as the reference standard.

METHODS

Forty-one patients (33 women, 8 men) underwent DXA measurement of the proximal femur. Subsequently, transverse sections of routine ceMDCT of these patients were used to measure BMD of the femoral head and femoral neck. The MDCT-to-DXA conversion equations for BMD and T-score were calculated using linear regression analysis. The conversion equations were applied to the MDCT data sets of 382 patients (120 women, 262 men) of whom 74 had osteoporotic fractures.

RESULTS

A correlation coefficient of r = 0.84 (P < 0.05) was calculated for BMD(MDCT) values of the femoral head and DXA T-scores of the total proximal femur using the conversion equation T-score = 0.021 × BMD(MDCT) - 5.90. The correlation coefficient for the femoral neck was r = 0.79 (P < 0.05) with the conversion equation T-score = 0.016 × BMD(MDCT) - 4.28. Accordingly, converted T-scores for the femoral neck in patients with versus those without osteoporotic fractures were significantly different (female, -1.83 versus -1.47; male, -1.86 versus -1.47; P < 0.05).

CONCLUSION

BMD measurements of the proximal femur were computed in routine contrast-enhanced MDCT and converted to DXA T-scores, which adequately differentiated patients with and without osteoporotic fractures.

Serum testosterone, sex hormone-binding globulin and total calcium levels predict the calcaneal speed of sound in men

OBJECTIVES

Variations in sex hormones and the calcium balance can influence bone health in men. The present study aimed to examine the relationship between the calcaneal speed of sound and biochemical determinants of bone mass, such as sex hormones, parathyroid hormones and serum calcium.

METHODS

Data from 549 subjects from the Malaysian Aging Male Study, which included Malay and Chinese men aged 20 years and older residing in the Klang Valley, were used for analysis. The subjects' calcaneal speed of sound was measured, and their blood was collected for biochemical analysis. Two sets of multiple regression models were generated for the total/bioavailable testosterone and estradiol to avoid multicollinearity.

RESULTS

The multiple regression results revealed that bioavailable testosterone and serum total calcium were significant predictors of the calcaneal speed of sound in the adjusted model. After adjustment for ethnicity and body mass index, only bioavailable testosterone remained significant; the total serum calcium was marginally insignificant. In a separate model, the total testosterone and sex hormone-binding globulin were significant predictors, whereas the total serum calcium was marginally insignificant. After adjustment for ethnicity and body mass index (BMI), the significance persisted for total testosterone and SHBG. After further adjustment for age, none of the serum biochemical determinants was a significant predictor of the calcaneal speed of sound.

CONCLUSION

There is a significant age-dependent relationship between the calcaneal speed of sound and total testosterone, bioavailable testosterone and sex hormone-binding globulin in Chinese and Malay men in Malaysia. The relationship between total serum calcium and calcaneal speed of sound is ethnicity-dependent.

The effects of age, physical activity level, and body anthropometry on calcaneal speed of sound value in men

The influences of age, physical activity, and body anthropometry on calcaneal speed of sound are different among young adults, middle-aged, and elderly men.

INTRODUCTION

Quantitative ultrasound assessment of bone health status is much needed for developing countries in the screening of osteoporosis, but further studies on the factors that influence the quantitative ultrasound indices are required.

OBJECTIVES

The present study examined the influence of age, lifestyle factors, and body anthropometry on calcaneal speed of sound (SOS) in a group of Malaysian men of diverse age range.

SUBJECTS AND METHODS

A cross-sectional study was conducted, and data from 687 eligible males were used for analysis. They answered a detailed questionnaire on their physical activity status, and their anthropometric measurements were taken. Their calcaneal SOS values were evaluated using the CM-200 sonometer (Furuno, Nishinomiya City, Japan).

RESULTS

Subjects with higher body mass index (BMI) had higher calcaneal SOS values albeit significant difference was only found in the elderly subjects (p < 0.05). Sedentary subjects had lower calcaneal SOS values than physically active subjects, but significant difference was only found in the middle-aged subjects (p < 0.05). Calcaneal SOS was significantly (p < 0.05) correlated with age in young men; height, BMI, and physical activity score in middle-aged men; height and physical activity score in elderly men; and age and physical activity score for overall subjects. In a multivariate regression model, significant (p < 0.05) predictors for calcaneal SOS included age for young men; physical activity, BMI, body fat percentage, and height for middle-aged men; height for elderly men; and age, height, physical activity, weight, and body fat percentage for overall subjects.

CONCLUSION

Age, body anthropometry, and physical activity level have significant effects on the calcaneal SOS value in men.

Phalangeal quantitative ultrasound in 1,719 children and adolescents with bone disorders

SUMMARY

We measured bone properties by phalangeal quantitative ultrasound in 1,719 pediatric patients with bone disorders, classifying them according to fracture status. Quantitative ultrasound discriminated fractured and nonfractured pediatric patients and enabled us to stratify fractured patients into classes according to the severity of the causative trauma (spontaneous, minimal trauma, appropriate trauma fractures).

INTRODUCTION

The correlation between quantitative bone measurements and fractures is poorly established in pediatric patients with bone disorders. We correlated phalangeal quantitative ultrasound (QUS) and fracture history in children and adolescents with bone disorders and evaluated the ability of QUS to recognize fractured patients.

METHODS

Amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT) were measured in 1,719 pediatric patients with bone disorders and related to fracture history. The patients were classified as (1) spontaneously (77), (2) minimal trauma (101), or (3) appropriate trauma fractured (206), and (4) nonfractured (1,335). The likelihood of fracture according to QUS was calculated as odds ratio per SD decrease (OR/SD), and the effectiveness in discriminating fractured patients was evaluated by receiver operating characteristic (ROC) analysis. The influence of age, sex, puberty, height, and BMI was explored by respective adjustments and multiple logistic regression.

RESULTS

Fractured patients showed significantly reduced AD-SoS and BTT standard deviation score (-0.32 ± 1.54 and -0.78 ± 1.49) compared to nonfractured subjects (0.43 ± 1.63 and -0.11 ± 1.34). QUS measurements paralleled the causative trauma severity, ranging from the lowest values in spontaneously fractured patients to normal values in appropriate trauma fractured subjects. The OR/SD were increasingly higher in appropriate trauma fractured, minimal trauma fractured, and spontaneously fractured patients. At ROC analysis, both parameters proved to have significant discrimination power in recognizing spontaneously and minimal trauma-fractured patients.

CONCLUSIONS

QUS identifies fractured pediatric patients with bone disorders, reflecting the severity of the causative trauma with a high discrimination power for fragility fractures.

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

CONTEXT

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

OBJECTIVE

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

DESIGN AND SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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