Performance of osteoporosis risk indices in a Japanese population

Association Between Osteoporosis Self-Assessment Tool for Asians and Airflow Limitation in Japanese Post-Menopausal Women

Purpose

This study aimed to reveal the association between the osteoporosis self-assessment tool for Asians (OSTA) and airflow limitation (AL) in post-menopausal Japanese women.

Participants and Methods

This cross-sectional study included 1580 participants undergoing a comprehensive health examination using spirometry and dual-energy X-ray absorptiometry. The OSTA was calculated by subtracting the age in years from the body weight (BW) in kilograms, and the result was multiplied by 0.2. The OSTA risk level was defined as low (>-1), moderate (-4 to -1), or high (<-4). AL was defined as forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) <0.7. The association between the OSTA and AL was assessed using logistic regression analysis.

Results

The prevalence of AL was significantly higher in the high OSTA group (15.3%) than in the low OSTA group (3.1%) (p<0.001). In multiple linear regression analysis, the OSTA was independently associated with FEV1/FVC. In logistic regression models adjusted for smoking status, alcohol consumption, current use of medication for diabetes, hyperglycemia, rheumatoid arthritis, second-hand smoke, and ovary removal showed a significantly higher risk of AL (odds ratio: 5.48; 95% confidence interval: 2.90-10.37; p<0.001) in participants with OSTA high risk than in those with OSTA low risk.

Conclusion

These results suggest that the OSTA high risk indicates reduced BMD at the femoral neck and presence of AL in Japanese post-menopausal women aged ≥45 years.

Assessing the utility of osteoporosis self-assessment tool for Asians in patients undergoing hip surgery

Objectives

Diagnosis and treatment of osteoporosis are instrumental in obtaining good outcomes of hip surgery. Measuring bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) is the gold standard for diagnosing osteoporosis. However, due to limited access to DXA, there is a need for a screening tool to identify patients at a higher risk of osteoporosis. We analyzed the potential utility of the Osteoporosis Self-assessment Tool for Asians (OSTA) as a screening tool for osteoporosis.

Methods

A total of 1378 female patients who underwent hip surgery at 8 institutions were analyzed. For each patient, the BMD of the proximal femoral region was measured by DXA (DXA-BMD), and the correlation with OSTA score (as a continuous variable) was assessed. Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of OSTA score to predict osteoporosis. Lastly, the OSTA score was truncated to yield an integer (OSTA index) to clarify the percentage of patients with osteoporosis for each index.

Results

DXA-BMD showed a strong correlation with OSTA (r = 0.683; P < 0.001). On ROC curve analysis, the optimal OSTA score cut-off value of -5.4 was associated with 73.8% sensitivity and 80.9% specificity for diagnosis of osteoporosis (area under the curve: 0.842). A decrease in the OSTA index by 1 unit was associated with a 7.3% increase in the probability of osteoporosis.

Conclusions

OSTA is a potentially useful tool for screening osteoporosis in patients undergoing hip surgery. Our findings may help identify high-risk patients who require further investigation using DXA.

Osteoporosis Screening and Fracture Risk Assessment Tool: Its Scope and Role in General Clinical Practice

Osteoporosis is a widely prevalent condition among postmenopausal women characterized by low bone mass and skeletal fragility that increases the risk of fractures specifically in the hip, spine, wrist, humerus, and pelvis. It has become a major public health problem around the world. An osteoporotic fracture affects one in every three women and one in every five men aged 50 and above. Hip and spine fractures are linked to a higher death rate and can cause ambulation problems, depression, chronic pain, independence loss, and persistent discomfort. It not only puts a lot of strain on the individual but also causes a significant cost to society. Osteoporosis is a silent disease that goes unrecognized until a patient develops a pathological fracture. Diagnosis of osteoporosis is based on bone mineral density (BMD) estimation by dual-energy x-ray absorptiometry (DXA) as defined by WHO. However, in many resource-constrained and underdeveloped or low-middle income countries, it is not widely available. There are a number of questionnaire-based techniques available to identify such postmenopausal women and older men who may be at risk of having low BMD and osteoporosis. Our aim of the study is to search and compile such simple yet useful and validated screening and assessment tools for osteoporosis that can help to identify people at risk of having low BMD and the potential candidate who can benefit from BMD estimation in a resource-restricted geographical area or low/middle-income countries and benefit from treatment. Though these tools are not diagnostic can have broader applicability in general clinical practice and usefulness in identifying high-risk individuals and may prove cost-effective. Although it has limitations, FRAX is a widely used osteoporotic fracture risk assessment tool around the globe and when used with femoral neck BMD it has greater accuracy.

A comparison of 6 osteoporosis risk assessment tools among postmenopausal women in Kuala Lumpur, Malaysia

Objectives

To compare and assess the performance of 6 osteoporosis risk assessment tools for screening osteoporosis in Malaysian postmenopausal women.

Methods

Six osteoporosis risk assessments tools (the Simple Calculated Osteoporosis Risk Estimation [SCORE], the Osteoporosis Risk Assessment Instrument, the Age Bulk One or Never Estrogen, the body weight, the Malaysian Osteoporosis Screening Tool, and the Osteoporosis Self-Assessment Tool for Asians) were used to screen postmenopausal women who had not been previously diagnosed with osteoporosis/osteopenia. These women also underwent a dual-energy X-ray absorptiometry (DXA) scan to confirm the absence or presence of osteoporosis.

Results

A total of 164/224 participants were recruited (response rate, 73.2%), of which only 150/164 (91.5%) completed their DXA scan. Sixteen participants (10.7%) were found to have osteoporosis, whilst 65/150 (43.3%) were found to have osteopenia. Using precision-recall curves, the recall of the tools ranged from 0.50 to 1.00, whilst precision ranged from 0.04 to 0.14. The area under the curve (AUC) ranged from 0.027 to 0.161. The SCORE had the best balance between recall (1.00), precision (0.04-0.12), and AUC (0.072-0.161).

Conclusions

We found that the SCORE had the best balance between recall, precision, and AUC among the 6 screening tools that were compared among Malaysian postmenopausal women.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of the Predictive Index for Osteoporosis as a Clinical Tool to Identify the Risk of Osteoporosis in Korean Men by Using the Korea National Health and Nutrition Examination Survey Data

BACKGROUND

We previously proposed the Predictive Index for Osteoporosis as a new index to identify men who require bone mineral density measurement. However, the previous study had limitations such as a single-center design and small sample size. Here, we evaluated the usefulness of the Predictive Index for Osteoporosis using the nationally representative data of the Korea National Health and Nutrition Examination Survey.

METHODS

Participants underwent bone mineral density measurements via dual energy X-ray absorptiometry, and the Predictive Index for Osteoporosis and Osteoporosis Self-Assessment Tool for Asians were assessed. Receiver operating characteristic analysis was used to obtain optimal cut-off points for the Predictive Index for Osteoporosis and Osteoporosis Self-Assessment Tool for Asians, and the predictability of osteoporosis for the 2 indices was compared.

RESULTS

Both indices were useful clinical tools for identifying osteoporosis risk in Korean men. The optimal cut-off value for the Predictive Index for Osteoporosis was 1.07 (sensitivity, 67.6%; specificity, 72.7%; area under the curve, 0.743). When using a cut-off point of 0.5 for the Osteoporosis Self-Assessment Tool for Asians, the sensitivity and specificity were 71.9% and 64.0%, respectively, and the area under the curve was 0.737.

CONCLUSION

The Predictive Index for Osteoporosis was as useful as the Osteoporosis Self-Assessment Tool for Asians as a screening index to identify candidates for dual energy X-ray absorptiometry among men aged 50-69 years.

Validation of osteoporosis risk assessment tools in middle-aged Thai women

OBJECTIVES

To validate osteoporosis risk assessment tools in middle-aged Thai women.

METHODS

A total of 1038 women who had bone mineral density (BMD) measurements using dual-energy X-ray absorptiometry were reviewed. Clinical data were used to validate the diagnostic test performance of various osteoporosis risk assessment tools, including ABONE, FRAX^®, ORAI, OSIRIS, SCORE, SOFSURF, and OSTA. The following parameters were evaluated: sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy; those with 95% confidence interval (CI) of the receiver operator characteristics area under the curve (ROC-AUC) > 0.5 were considered statistically significant.

RESULTS

The subjects had a mean age of 53.01 ± 6.20 years and body mass index (BMI) of 23.98 ± 3.38 kg/m². Among the osteoporosis risk assessment tools being evaluated, the tools that had ROC-AUC >0.8 and 95% CI >0.5, and could predict osteoporosis at the femoral neck with high specificity of >75% and NPV of >90%, were FRAX^® without BMD (ROC-AUC 0.83; 95% CI 0.73-0.93; specificity 99.90; NPV 98.89), SCORE (ROC-AUC 0.86; 95% CI 0.78-0.94; specificity 98.79; NPV 98.99), and OSTA (ROC-AUC 0.86; 95% CI 0.79-0.94; specificity 75.03; NPV 99.73).

CONCLUSION

The prevalence of osteoporosis in the middle-aged Thai women attending Siriraj Menopause Clinic is 7.3% at the lumbar spine and/or femoral neck. FRAX^® without BMD, SCORE, and OSTA have appropriate validity as tools for ruling out osteoporosis in these women.

Development and Validation of an Osteoporosis Self-Assessment Tool for Taiwan (OSTAi) Postmenopausal Women-A Sub-Study of the Taiwan OsteoPorosis Survey (TOPS)

Background

To develop an OSTAi tool and compare this with the National Osteoporosis Foundation recommendations in 2013 (NOF 2013) for bone mineral density (BMD) testing among Taiwan postmenopausal women.

Methods

Taiwan Osteoporosis Association (TOA) conducted a nationwide BMD survey by a bus installed with a dual energy X-ray absorptiometry (DXA) between 2008 and 2011. All of the participants completed questionnaire, which included demographics and risk factors of osteoporotic fracture in FRAX tool. We used the database to analyze potential risk factors for osteoporosis and followed the model by Koh et al. to develop a risk index via multiple variable regression analysis and item reduction. We used the index values to set up a simple algorithm (namely OSTAi) to identify those who need BMD measurement. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) was used to compare the sensitivity/specificity analysis of this model with that of recommendations by NOF 2013.

Results

A total of 12,175 Taiwan postmenopausal women enrolled in this survey. The index value was derived by age and body weight of the participants according to weighted odds of each risk factor and the selected cutoff value was set at “-1”. There are 6393 (52.5%) participants whose index value is below “-1” and whose risk of osteoporosis was 57.5% (3674/6393). The AUC for OSTAi and NOF 2013 were 0.739 (95% confidence interval (CI), 0.728–0.749, P<0.001) and 0.618 (95% CI, 0.606–0.630, P<0.001), respectively. The sensitivity and specificity of OSTAi, at the selected cutoff value of -1, and NOF 2013 to identify osteoporosis were 73.1%, 62.0% and 78.3%, 45.7%, respectively.

Conclusions

As OSTA for Asian populations, OSTAi is an useful tool to identify Taiwan postmenopausal women with osteoporosis, In comparison with NOF 2013, OSTAi may be an easier and better tool for referral to BMD measurement by DXA in this area.

Clinical performance of seven prescreening tools for osteoporosis in Iranian postmenopausal women

This study was designed to evaluate seven prescreening osteoporosis models in postmenopausal Iranian women. This study was performed on 8644 postmenopausal women who have been referred for bone mineral densitometry (BMD) in BMD center of Shariati hospital in Tehran between 2001 and 2011. Diagnostic properties of seven prescreening instruments were evaluated. With regard to area under curve (AUC), these models have low accuracy (AUC ≤ 0.65). Considering only femoral neck or total femur area, these models had low accuracy but were more sensitive. Except for three models with sensitivities of ≤65 % in both osteoporosis and fracture threshold, other models were around 70 % sensitive. However, these models were not considered clinically useful regarding their positive predictive values (PPV) especially in BMDs ≤02.5. With regard to different measures of diagnostic property, none of these models were good screening tools for osteoporosis or fracture threshold. Although some of them are sensitive, considering other measures such as PPV indicates that they are not completely useful for clinical use. Attempts should be made for developing newer prescreening methods and calibration of the existing models with regard to the studied population.

Systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for osteoporosis or low bone density

We performed a systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for DXA-determined osteoporosis or low bone density. Commonly evaluated risk instruments showed high sensitivity approaching or exceeding 90% at particular thresholds within various populations but low specificity at thresholds required for high sensitivity. Simpler instruments, such as OST, generally performed as well as or better than more complex instruments.

INTRODUCTION

The purpose of the study is to systematically review the performance of clinical risk assessment instruments for screening for dual-energy X-ray absorptiometry (DXA)-determined osteoporosis or low bone density.

METHODS

Systematic review and meta-analysis were performed. Multiple literature sources were searched, and data extracted and analyzed from included references.

RESULTS

One hundred eight references met inclusion criteria. Studies assessed many instruments in 34 countries, most commonly the Osteoporosis Self-Assessment Tool (OST), the Simple Calculated Osteoporosis Risk Estimation (SCORE) instrument, the Osteoporosis Self-Assessment Tool for Asians (OSTA), the Osteoporosis Risk Assessment Instrument (ORAI), and body weight criteria. Meta-analyses of studies evaluating OST using a cutoff threshold of <1 to identify US postmenopausal women with osteoporosis at the femoral neck provided summary sensitivity and specificity estimates of 89% (95%CI 82-96%) and 41% (95%CI 23-59%), respectively. Meta-analyses of studies evaluating OST using a cutoff threshold of 3 to identify US men with osteoporosis at the femoral neck, total hip, or lumbar spine provided summary sensitivity and specificity estimates of 88% (95%CI 79-97%) and 55% (95%CI 42-68%), respectively. Frequently evaluated instruments each had thresholds and populations for which sensitivity for osteoporosis or low bone mass detection approached or exceeded 90% but always with a trade-off of relatively low specificity.

CONCLUSIONS

Commonly evaluated clinical risk assessment instruments each showed high sensitivity approaching or exceeding 90% for identifying individuals with DXA-determined osteoporosis or low BMD at certain thresholds in different populations but low specificity at thresholds required for high sensitivity. Simpler instruments, such as OST, generally performed as well as or better than more complex instruments.

Evaluation of Clinical Decision Rules for Bone Mineral Density Testing among White Women

Background. Osteoporosis is a devastating, insidious disease that causes skeletal fragility. Half of women will suffer osteoporotic fractures during their lifetimes. Many fractures occur needlessly, because of inattentiveness to assessment, diagnosis, prevention, and treatment of osteoporosis. Study Purpose. Study Purpose. To evaluate the discriminatory performance of clinical decision rules to determine the need to undergo bone mineral density testing. Methods. A nationally representative sample from the Third National Health and Nutrition Examination Survey consisted of 14,060 subjects who completed surveys, physical examinations, laboratory tests, and bone mineral density exams. Multivariable linear regression tested the correlation of covariates that composed the clinical decision rules with bone mineral density. Results. Increased age and decreased weight were variables in the final regression models for each gender and race/ethnicity. Among the indices, the Osteoporosis Self-Assessment Tool, which is composed of age and weight, performed best for White women. Study Implications. These results have implications for the prevention, assessment, diagnosis, and treatment of osteoporosis. The Osteoporosis Self-Assessment Tool performed best and is inexpensive and the least time consuming to implement.

Association between periodontitis and systemic bone mineral density in Japanese community-dwelling postmenopausal women

OBJECTIVE

The purpose of this cross-sectional study was to evaluate the association between loss of attachment (LA) which is clinical index of periodontitis and bone mineral density (BMD) of the lumbar vertebrae and femur measured with dual energy X-ray absorptiometry (DXA) in Japanese community-dwelling postmenopausal women.

SUBJECTS AND METHODS

Subjects were 374 [corrected] women aged 55-74. The oral cavity was divided into 6 areas according to the WHO's method for the determination of the clinical attachment level score (CALscore); the LA was measured at 6 sites using a WHO probe in 17, 16, 11, 26, 27, 37, 36, 31, 46, and 47, and the values were recorded in mm. Then, we assessed BMD of the lumbar vertebrae (L2-L4) and femur (femoral neck, proximal part) by DXA. Based on these data, analysis of covariance was used to estimate relation between periodontitis and systemic BMD status excluding effect of age. Multiple linear regression analysis was used to estimate relation between periodontitis and BMD adjusted for 17 variables.

RESULTS

Significant differences were observed in the mean value between the mean CALscore=0 and CALscore≥1 groups in the Z value in lumbar vertebrate (106.9±18.7 vs. 102.3±1.0, p<0.05, t-test). Multiple regression analysis was conducted using the mean LA as dependent variable. Lumbar vertebral BMD (regression coefficient: B=-1.039±0.379, p=0.007), femoral neck BMD (B=-1.332±0.627, p=0.034), and proximal femoral BMD (B=-1.329±0.536, p=0.014) all exhibited a significant negative correlation with the mean LA.

CONCLUSION

A significant negative correlation was observed between periodontal disease and truncal bone BMD in this study.

Selecting men for bone densitometry: performance of osteoporosis risk assessment tools in Portuguese men

SUMMARY

Clinicians need tools to identify patients most likely to benefit from bone mineral density (BMD) testing, for which cost-effectiveness does not allow generalized screening. This study supports the utility of osteoporosis risk assessment tools in selecting men for BMD testing. Different cutoff values may be appropriate for different countries and/or ethnic origins.

INTRODUCTION

Our aim was to evaluate the utility of three osteoporosis (OP) risk assessment tools in a large group of Portuguese men aged 50 or more and to determine the best cutoff value to be used for selecting men for bone densitometry.

METHODS

We assessed the performance of three simple tools in 202 randomly selected men: body weight criterion (BWC), osteoporosis self-assessment tool for Asians (OSTA), and a modified version of the OSTA equation (OST). Previously published cutoff values (validated in postmenopausal women) and three additional cutoff values were tested. Sensitivity (SE), specificity (SP), predictive values, and area under the receiver operating characteristic (AUROC) curve for correctly selecting men with OP (defined by BMD testing) were determined.

RESULTS

Mean age of the cohort was 63.8 years. According to the World Health Organization diagnostic categories, 16.8% had osteoporosis. The best performing cutoffs for correctly selecting men with OP for BMD testing were OST < 3 (SE = 75.5%, SP = 50.0%, AUROC = 0.632), OSTA < 3 (SE = 73.5%, SP = 58.3%, AUROC = 0.659), and BWC < 75 kg (SE = 73.5%, SP = 61.3%, AUROC = 0.674).

CONCLUSIONS

OP risk assessment tools seem to be useful in men aged 50 or more. Best cutoff values are different from those recommended for postmenopausal women. Different cutoff values may be appropriate for different countries and/or ethnic origins.

The Osteoporosis Self-Assessment Tool versus alternative tests for selecting postmenopausal women for bone mineral density assessment: a comparative systematic review of accuracy

SUMMARY

We performed a systematic review of studies comparing the Osteoporosis Self-Assessment Tool (OST) and other tests used to select women for bone mineral density (BMD) assessment. In comparative meta-analyses, we found that the accuracy of OST was similar to other tests that are based on information from the medical history. By contrast, assessment by quantitative ultrasonography at the heel was more accurate than OST in discriminating between women with high and low BMD. The methodological quality of the included studies was generally low.

INTRODUCTION

Numerous tests are suggested for triaging postmenopausal women for bone mineral density (BMD) assessment by dual-energy X-ray absorptiometry. Previous studies suggest that OST, based on age and weight only, may be as accurate as more complex triage tests. We systematically compare the accuracy of OST and alternative triage tests in postmenopausal women.

METHODS

We searched PubMed, Embase, Web of Science, citation lists, and conference proceedings. Our main measure of accuracy was the diagnostic odds ratio (DOR). We compared summary estimates of DOR (sDOR) for OST and alternative tests in pairwise meta-analyses by using the Moses-Littenberg approach.

RESULTS

Summary estimates of DOR for OST and the clinical decision rules Simple Calculated Osteoporosis Risk Estimation (SCORE) and Osteoporosis Risk Assessment Instrument (ORAI) did not differ significantly in white women (relative sDOR: 0.57-1.17, all p >or= 0.11). By contrast, sDOR was higher for Stiffness Index assessed by calcaneal quantitative ultrasonography than for OST (relative sDOR: 1.9, p = 0.005). Studies were few in Asian and black women. Methodological quality, assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist, was generally low.

CONCLUSIONS

In white women, the accuracy of OST and alternative clinical decision rules was similar, whereas Stiffness Index was more accurate than OST. Low study quality renders transferability to clinical settings uncertain.

Use of Fuzzy Neural Network in Diagnosing Postmenopausal Women with Osteoporosis Based on Dental Panoramic Radiographs

A thin or eroded cortex of the mandible detected on dental panoramic radiographs is independently associated with low skeletal bone mineral density (BMD) or osteoporosis in postmenopausal women. The purposes of this study were to develop new computer-aided diagnosis system that combines these two panoramic measures by using fuzzy neural networks (FNN) for identifying postmenopausal women with osteoporosis. Dental panoramic radiographs of 100 postmenopausal women who visited our clinic and had BMD assessments at the lumbar spine and the femoral neck were used in this study. Mandibular cortical width and shape were measured by computer-aided systems and used as the inputs. This system partitioned the input space into a set of subspaces using a novel fuzzy thresholding and constructed the fuzzy inference system incorporated with multi layer perceptron neural network. Our results show that the combination of cortical width and shape by using FNN can be used for the identification of postmenopausal women with osteoporosis in dental clinic. Dentists may identify postmenopausal women accurately by using the new FNN based system and refer them to medical professional for BMD testing.

Performance of the Osteoporosis Self-Assessment Tool in ruling out low bone mineral density in postmenopausal women: a systematic review

The Osteoporosis Self-Assessment Tool (OST) is a simple test that may be of clinical value to rule-out low bone mineral density. We performed a systematic review to assess its performance in postmenopausal women. We included 36 studies. OST performed moderately in ruling-out femoral neck T-score <or= -2.5, but poorly in ruling-out lumbar spine T-score <or= -2.5. Methodological study quality was generally low.

INTRODUCTION

The Osteoporosis Self-Assessment Tool (OST) is a simple clinical decision rule based on age and weight that may be of clinical value to rule-out low bone mineral density (BMD). Our aim was to systematically assess the performance of OST in postmenopausal women.

METHODS

We searched PubMed, Embase, Web of Science, citation lists and conference proceedings for studies evaluating OST using dual X-ray absorptiometry (DXA) as reference test to measure BMD. We evaluated methodological quality using the QUADAS checklist. Our main outcome was the likelihood ratio of a negative OST result (LR-).

RESULTS

OST performed moderately in ruling-out femoral neck T-score <or= -2.5 in whites, summary LR- (sLR-) 0.19 (95% CI, 0.17-0.21) and between-study heterogeneity was low (I(2) = 7%). The corresponding performance in Asians was similar, sLR- 0.19 (0.14-0.28), but there was considerable heterogeneity (I(2) = 64%). OST performed poorly in ruling-out lumbar spine T-score <or= -2.5 in whites and Asians, sLR- 0.43 (0.31-0.59) and 0.32 (0.28-0.38), respectively. The performance in ruling-out T-score <or= -2.0 in whites was poor regardless of region (sLR- >or=0.28). Methodological study quality was generally low.

CONCLUSIONS

The clinical usefulness of OST is uncertain. OST could be useful for ruling-out femoral neck T-score <or= -2.5, but confirmatory high-quality studies are needed.

Use of decision rules for osteoporosis prevention and treatment: Implications for nurse practitioners

PURPOSE

To describe the current literature regarding the benefits of bone mineral density (BMD) screening and to discuss clinical decision rules for BMD screening.

DATA SOURCES

Extensive review of the scientific literature regarding osteoporosis, BMD screening, and current clinical decision rules.

CONCLUSIONS

Osteoporosis is a disease characterized by deterioration of bone and increased susceptibility to fractures, crippling, and disfigurement. BMD testing is the best predictor for osteoporosis and associated fractures; however, routine global BMD testing is cost-prohibitive. A need exists for a selective and practical clinical decision rule for referral for testing.

IMPLICATIONS FOR PRACTICE

Several effective clinical decision rules are presented, and their uses and applications are described. The osteoporosis self-assessment tool is recommended by the authors because of its predictive power and ease of use.

Performance of the osteoporosis risk assessment tool in Moroccan men

Measuring bone mineral density (BMD) is a widely accepted strategy for identifying subjects with an increased risk of fracture. However, because of limited availability of BMD technology in some communities and cost considerations, it has been proposed that BMD measurements be targeted to subjects with risk factors for osteoporosis. Osteoporosis self-assessment tool (OST) using age and weight have been developed to identify women who are more likely to have low BMD and thus undergo BMD testing. To study the performance of OST in identifying osteoporotic white men in Morocco. We analysed in an epidemiological cross-sectional study the records for 229 white Moroccan men seen at an out-patient rheumatology centre. OST was compared to bone density T scores and the ability of OST to identify men with osteoporosis (T < -2.5) was evaluated. Using an OST score < 2 to recommend dual X-ray absorptiometry (DXA) referral, sensitivity ranged from 63% at the lumbar spine to 87% at the total hip to detect BMD T scores of -2.5 and specificity from 58 to 59%. The negative predictive value was high at all skeletal sites (87-98%), demonstrating the usefulness of the OST to identify patients who have normal BMD and should not receive DXA testing. The performance of OST among men in Morocco was similar to that reported earlier for the other samples in Asian countries and the USA. The OST is an effective and efficient tool to help target high-risk men for DXA measurement.

Visual assessment of the mandibular cortex on panoramic radiographs to identify postmenopausal women with low bone mineral densities

OBJECTIVE

The purpose of this study was to determine whether simple visual estimation of the mandibular inferior cortex width on panoramic radiographs is useful for identifying postmenopausal women with low skeletal bone mineral density (BMD).

STUDY DESIGN

Panoramic radiographs were made on 100 women aged 50-84 years who also had BMD assessment of the lumbar spine and femoral neck by dual-energy x-ray absorptiometry. The panoramic images were examined twice by 4 observers to evaluate the thickness of the mandibular inferior cortex.

RESULTS

Intraobserver agreement varied from moderate to almost perfect. Interobserver agreements varied from fair to almost perfect. Overall mean sensitivity, specificity and positive predictive value in identifying women with low BMD were 54.7%, 82.0%, and 72.5% in the lumbar spine and 51.8%, 82.2%, and 75.7% in the femoral neck, respectively.

CONCLUSIONS

Our results suggest that simple visual estimation of the mandibular inferior cortex on panoramic radiographs may be useful for identifying postmenopausal women with low BMD.

Computer-aided system for measuring the mandibular cortical width on dental panoramic radiographs in identifying postmenopausal women with low bone mineral density

INTRODUCTION

Mandibular inferior cortical width manually measured on dental panoramic radiographs may be useful for identifying postmenopausal women with low skeletal bone mineral density (BMD). Automatic measurement of cortical width may enable us to identify a large number of postmenopausal women with suspected low skeletal BMD. The purposes of this study were to develop a computer-aided system for measuring mandibular cortical width on dental panoramic radiographs and clarify the diagnostic efficacy of this system.

METHODS

Panoramic radiographs of 100 postmenopausal women who had had BMD assessments of the lumbar spine and the femoral neck were used in this study. Experienced oral radiologist determined the position of the mental foramen on 100 digitized dental panoramic radiographs. After determination of the mental foramen, mandibular cortical width below the mental foramen was measured automatically with a computer-aided system by identifying the area of interest, enhancing the original image, determining inner and outer margins of the cortex, and selecting an appropriate point. Cortical width measured by this system was compared with BMD of the lumbar spine and the femoral neck.

RESULTS

There were statistically significant correlation between cortical width measured by the computer-aided system and spinal BMD (r=0.50) and femoral neck BMD (r=0.54). These correlations were similar with those between cortical width by manual measurement and skeletal BMD. Sensitivity and specificity for identifying postmenopausal women with low spinal BMD by the computer-aided system were about 88.0% and about 58.7%, respectively. Those for identifying postmenopausal women with low femoral neck BMD by this system were about 87.5% and about 56.3%, respectively.

CONCLUSION

Our results suggest that our computer-aided system may be useful for identifying postmenopausal women with low skeletal BMD.

Validation of OSTA among Filipinos

Osteoporosis is the most common metabolic bone disease in humans. It is a special concern not only among postmenopausal women, but men as well. In developing countries where there are meager resources, it will definitely be helpful to search for ways to identify patients with low bone mineral density who have a high risk of future fractures. These people need to be identified for treatment consideration in order to reduce the incidence of the disease and its complications. A simple risk index called the Osteoporosis Screening Tool for Asians (OSTA), based only on two variables, age and body weight, performed well in identifying the risk of osteoporosis among postmenopausal women. This index has been validated in Japan, Korea and other Caucasian populations as a useful tool in identifying individuals who will require BMD measurement. This is the first study that validated the said index in 1,597 Filipino women and men referred to a tertiary center for BMD measurement. It had sensitivity of 97 and 90% and specificity of 59 and 66% with areas under the curve of 0.8506 and 0.8475, respectively, for women and men. We conclude that OSTA performed just as well or even better than other indices used in other populations to identify individuals who are at varying degrees of risk for osteoporosis. The tool also proves to be a useful and practical guide to help clinicians to be more prudent and judicious in employing bone mineral density measurement.

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

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

Clinical risk indices, prediction of osteoporosis, and prevention of fractures: diagnostic consequences and costs

The primary aim of this study was to validate the Osteoporosis Self-Assessment Tools for Asians (OSTA) instrument in Thai women, and to evaluate its utility in terms of economic costs and fracture prediction. Femoral neck and lumbar spine BMD was measured by dual energy X-ray absorptiometry in 322 Thai women, aged 60+/-10 years (mean+/-SD; range: 45-84 years). The women were classified as having osteoporosis if their BMD T-scores were < or =-2.5. The OSTA score was calculated for each woman using her age and weight according to the formula: 0.2(weight-age). Women with OSTA scores < or =-1 and >-1 were classified as "high risk" and "low risk," respectively. The prevalence of osteoporosis was 33% by femoral neck or lumbar spine BMD. Using the OSTA score, 165 (51.2%) women were classified as high risk. The sensitivity, specificity and positive predictive value of OSTA was 82% 64% and 53%, respectively. If the OSTA score is used to identify women with high risk of fracture, and assuming that the incidence of fracture among osteoporotic and non-osteoporotic women are 2% and 1% per year, respectively, the OSTA score can identify 59% of fracture cases correctly, and 41% are expected to be missed. Furthermore, if the high-risk subjects identified by OSTA are to be treated, and if the treatment reduces fracture incidence by 50%, and assuming that the treatment cost is $1 per day, then the cost to prevent one fracture is estimated to be $48,530. Results of this study suggest that, in the Thai population, the OSTA score had high sensitivity but low specificity and low positive predictive value in the identification of osteoporotic women. Its use in the general population can result in a high false-positive rate and incur significant cost to the community.

A risk assessment tool (OsteoRisk) for identifying Latin American women with osteoporosis

OBJECTIVE

To develop a simple and easy-to-use tool for identifying osteoporotic women (femoral neck bone mineral density [BMD] T-scores<or=-2.5) in Latin America.

DESIGN

Retrospective study involving review of medical records.

SETTING

Osteoporosis clinics in 6 Latin American countries.

PATIENTS

Postmenopausal women ages >or=50 in Latin America who had femoral neck BMD measurements.

MEASUREMENTS AND MAIN RESULTS

A risk index was developed from 1,547 patients based on least square regression using age, weight, history of fractures, and other variables as predictors for BMD T-score. The final model was simplified by reducing the number of predictors; sensitivity and specificity were evaluated before and after reducing the number of predictors to assess performance of the index. The final model included age, weight, country, estrogen use, and history of fractures as significant predictors for T-score. The resulting scoring index achieved 91% sensitivity and 47% specificity. Simplifying the index by using only age and weight yielded similar performance (sensitivity, 92%; specificity, 45%). Three risk categories were identified based on OsteoRisk, the index using only age and body weight: high-risk patients (index <=-2; 65.6% were osteoporotic), moderate-risk patients (-2< index <=1; 26.7% were osteoporotic), and low-risk patients (index>1; 8% were osteoporotic). Similar results were seen in a validation sample of 279 women in Brazil.

CONCLUSION

Age and weight alone performed well for predicting the risk of osteoporosis among postmenopausal women. The OsteoRisk is an easy-to-use tool that effectively targets the vast majority of osteoporotic patients in Latin America for evaluation with BMD.

Korean experience with the OSTA risk index for osteoporosis: a validation study

The Osteoporosis Self-assessment Tool for Asians (OSTA) was developed to help physicians focus their efforts on patients at increased risk, and encourage appropriate use of bone mineral density (BMD) measurements. Previously, OSTA performed well in a sample of women from eight countries in Asia, and in a validation group of Japanese women. In this study, we evaluate the performance of OSTA using a sample of 1101 postmenopausal women from a clinic in Korea who had femoral neck BMD measurements by dual-energy X-ray absorptiometry (DXA). The OSTA had a high sensitivity (87%), and good specificity (67%) for identifying osteoporosis (BMD T-scores <or= -2.5); the corresponding values were 80% and 72% for identifying T-scores <or= -2.0. The prevalence of osteoporosis ranged from 2% among women classified as low risk (OSTA > -1) to 64% among those classified as high risk (OSTA < -4); these results were almost identical to those reported earlier for a sample of women from eight Asian countries. We conclude that the OSTA risk tool performed well in this sample of postmenopausal Korean women, similar to previous results in other Asian women. The OSTA tool is free and very easy to use; risk can be tabulated by age and weight, so that calculations are not necessary. Using OSTA could encourage patients and clinicians to actively assess osteoporosis, and measure BMD when appropriate, before fractures occur.

Performance of risk indices for identifying low bone density in postmenopausal women

OBJECTIVE

To examine the ability of 4 published osteoporosis risk indices to identify women with low bone density.

SUBJECTS AND METHODS

Subjects included postmenopausal women 45 years and older consecutively recruited from US clinics, women from general practice centers in The Netherlands (age range, 50-80 years), women in the Rotterdam Study (The Netherlands) 55 years and older, and women aged 55 to 81 years old screened for a clinical trial of alendronate. Bone mineral density (BMD) was measured at the femoral neck or lumbar spine; T scores represent the number of SDs below the mean for young healthy women. One risk index was calculated from age and weight; the other risk indices included up to 4 additional variables obtained by questionnaire. We calculated the sensitivity and specificity for identifying women with BMD T scores of -2.5 or less or -2.0 or less in the US clinic sample and created 3 risk categories, using each of the 4 indices.

RESULTS

Data were available for 1102 women from the US clinic sample, 3374 women in the Rotterdam Study, 23,833 women screened for a clinical trial of alendronate, and 4204 women from general practice centers in The Netherlands. Specificity for identifying BMD T scores of -2.5 or less ranged from 37% to 58% (depending on risk index) when sensitivity was approximately 90%. The prevalence of osteoporosis (defined as T scores < or = -2.5) differed widely across the 3 risk categories, ranging from 2% to 4% for the low-risk category to 47% to 61% for the high-risk category in the US clinic sample. For spine BMD in the US clinic sample, the prevalence of T scores of -2.5 or less ranged from 7% (low risk) to 38% (high risk). The large differences in prevalence across risk categories were consistent across the other 3 samples of postmenopausal women in the United States and The Netherlands for all 4 risk indices.

CONCLUSIONS

We recommend measuring BMD in women who are classified as having an increased risk of osteoporosis by using any of these risk indices because all 4 indices appear to predict low bone mass equally well. The Osteoporosis Self-assessment Tool index is easiest to calculate and therefore may be most useful in clinical practice.