Trabecular bone score in healthy ageing

Effects of Dual-Release Hydrocortisone on Bone Metabolism in Primary and Secondary Adrenal Insufficiency: A 6-Year Study

Context

Patients with primary (PAI) and secondary adrenal insufficiency (SAI) experience bone metabolism alterations, possibly due to excessive replacement. Dual-release hydrocortisone (DR-HC) has shown promising effects on several parameters, but bone metabolism has seldom been investigated.

Objective

We evaluated the long-term effects of once-daily DR-HC on bone in PAI and SAI.

Methods

Patients on immediate-release glucocorticoid therapy were evaluated before and up to 6 years (range, 4-6) after switching to equivalent doses of DR-HC, yielding data on bone turnover markers, femoral and lumbar spine bone mineral density (BMD), and trabecular bone score (TBS).

Results

Thirty-two patients (19 PAI, 18 female), median age 52 years (39.4-60.7), were included. At baseline, osteopenia was observed in 38% of patients and osteoporosis in 9%, while TBS was at least partially degraded in 41.4%. Higher body surface area-adjusted glucocorticoid doses predicted worse neck (P < .001) and total hip BMD (P < .001). Longitudinal analysis showed no significant change in BMD. TBS showed a trend toward decrease (P = .090). Bone markers were stable, albeit osteocalcin levels significantly varied. PAI and SAI subgroups behaved similarly, as did patients switching from hydrocortisone or cortisone acetate. Compared with men, women exhibited worse decline in TBS (P = .017) and a similar trend for neck BMD (P = .053).

Conclusion

After 6 years of chronic DR-HC replacement, BMD and bone markers remained stable. TBS decline is more likely due to an age-related derangement of bone microarchitecture rather than a glucocorticoid effect. Our data confirm the safety of DR-HC replacement on bone health in both PAI and SAI patients.

CT and MR for bone mineral density and trabecular bone score assessment in osteoporosis evaluation

Dual energy X-ray absorptiometry (DXA) is widely used modality for measuring bone mineral density (BMD). DXA is used to measure the quantitative areal BMD of bone, but has the disadvantage of not reflecting the bone architecture. To compensate for this disadvantage, trabecular bone score (TBS), a qualitative parameter of trabecular microarchitecture, is used. Meanwhile, there have been recent attempts to diagnose osteoporosis using the Hounsfield unit (HU) from CT and MR-based proton density fat fraction (PDFF) measurements. In our study, we aimed to find out the correlation between HU/PDFF and BMD/TBS, and whether osteoporosis can be diagnosed through HU/PDFF. Our study revealed that the HU value showed a moderate to good positive correlation with BMD and TBS. PDFF showed a fair negative correlation with BMD and TBS. In diagnosing osteopenia and osteoporosis, the HU value showed good performance, whereas the PDFF showed fair performance. In conclusion, both HU values and PDFF can play a role in predicting BMD and TBS. Both HU values and PDFF can be used to predict osteoporosis; further, CT is expected to show better results.

Age, body composition parameters and glycaemic control contribute to trabecular bone score deterioration in acromegaly more than disease activity

Introduction

Impairment of bone structure in patients with acromegaly (AP) varies independently of bone mineral density (BMD). Body composition parameters, which are altered in patients with acromegaly, are important determinants of bone strength.

Purpose

The aim of this study was to examine BMD and lumbar trabecular bone score (TBS) by dual-energy X-ray absorptiometry (DXA) and to assess its relationship with disease activity, age, glucose metabolism, and body composition parameters.

Methods

This cross-sectional prospective study involved 115 patients with acromegaly (70 F, 45 M) and 78 healthy controls (CON) (53 F, 25 M) matched for age, gender, and BMI. Bone mineral density, TBS and body composition parameters were measured using DXA.

Results

AP presented with lower TBS compared to CON (1.2 ± 0.1 v 1.31 ± 0.1, P< 0.001). No significant correlation was observed between IGF-1/GH levels and TBS. Age, glycated haemoglobin, BMI, waist circumference, fat mass, and lean mass negatively correlated with TBS in both sexes. Multiple linear regression analysis of all these parameters revealed age and waist circumference as independent significant predictors of TBS in AP. We did not find difference in BMD (lumbar and femoral sites) between AP and CON nor between active and controlled AP. We observed negative correlation between age and BMD of the femoral neck and total hip (P < 0.001). Testosterone levels in males, BMI, waist circumference, fat mass, and lean mass positively correlated with BMD in AP, with stronger correlation between lean mass and BMD compared to fat mass.

Conclusion

Patients with acromegaly have lower TBS than controls, confirming impaired bone microarchitecture in acromegaly regardless of BMD. Age, body composition parameters and glucose metabolism contribute to TBS deterioration in AP more than disease activity itself.

The effect of body size and composition on lumbar spine trabecular bone score in morphologically diverse subjects

AIM

The trabecular bone score (TBS) is a tool for assessing bone quality and health. Current TBS algorithm corrects for body mass index (BMI), as a proxy of regional tissue thickness. However, this approach fails to consider BMI inaccuracies due to individual differences in body stature, composition and somatotype. This study investigated the relationship between TBS and body size and composition in subjects with a normal BMI, but with large morphological diversity in body fatness and height.

METHODS

Young male subjects (n = 97; age 17.2±1.0 years), including ski jumpers (n = 25), volleyball players (n = 48) and non-athletes (controls n = 39), were recruited. The TBS was determined from L1-L4 dual-energy X-ray absorptiometry (DXA) scans using TBSiNsight software.

RESULTS

TBS correlated negatively with height and tissue thickness in the L1-L4 area in ski jumpers (r = -0.516 and r = -0.529), volleyball players (r = -0.525 and r = -0.436), and the total group (r = -0.559 and r = -0.463), respectively. Multiple regression analyses revealed that height, L1-L4 soft tissue thickness, fat mass and muscle mass were significant determinants of TBS (R2 = 0.587, p<0.001). L1-L4 soft tissue thickness explained 27% and height 14% of the TBS variance.

CONCLUSION

The negative association of TBS and both features suggests that a very low L1-L4 tissue thickness may lead to overestimation of the TBS, while tall stature may have the opposite effect. It seems that the utility of the TBS as a skeletal assessment tool in lean and/or tall young male subjects could be improved if tissues thickness in the lumbar spine area and stature instead of BMI were considered in the algorithm.

Bone Disease in Long-Term Lung Transplant Survivors

Background: During the first two years after lung transplantation (LTx), the incidence of fragility fractures (FX) is estimated to be 15–50% and it is lower in patients with cystic fibrosis (CF) as compared with other end-stage lung diseases (nCF). The aim of our study is to compare the skeletal outcomes, after the first 2 years post-LTx, in long-term survivors with CF and nCF. Materials and Methods: We evaluated the FX rate, the changes in bone mineral density (BMD) and trabecular bone score (TBS) in 68 patients (38 CF and 30 nCF) who underwent LTx in our center and with a follow-up after LTx longer than 5 years (7.3 ± 2.0 years). Results: After the second year post-LTx: (i) the FX rate was lower than during the first two years post-LTx (4.4 vs. 20.6%, p = 0.004), with no difference between CF and nCF patients (5.3 vs. 3.3%, p = 0.589); (ii) BMD at lumbar spine, femoral neck and total hip remained stable (−1.6 ± 1.0 vs. −1.4 ± 1.1, p = 0.431, −1.8 ± 0.9 vs. −1.9 ± 0.9, p = 0.683, −1.5 ± 0.9 vs. −1.4 ± 0.9, p = 0.678, respectively) as well as TBS (1.200 ± 0.124 vs. 1.199 ± 0.205, p = 0.166). Conclusions: After the second year post-LTx, the skeletal complications become less frequent and have similar incidence in patients with CF and nCF.

Accuracy in body composition scanning by adult half-body DXA scanning

INTRODUCTION

dual-energy X-ray absorptiometry (DXA) is the gold standard method, although one limitation is the size of the scan area.

OBJECTIVE

the objective was to verify the accuracy of body composition (BC) scanning through half-body DXA scanning compared to standard total body scanning.

METHODS

a study was conducted on 145 volunteers. Weight and height were assessed. Body mass index (BMI) was calculated. DXA was used for whole-body scan (WBS) and half-body scan (HBS). WBS was used as the reference method and the following indicators were extracted: bone mineral content (BMC), fat mass (FM), lean soft tissue (LST) and percentage fat mass (%FM).

RESULTS

no differences were observed in the body composition indicators (BMC, FM, LST and %FM) when compared between the reference WBS scanner and the HBS scanner. The predictive power between both scans ranged in both sexes between R2 = 0.94 and 0.98. The DRI desirable reproducibility index values defining the degree of agreement between both scans ranged from 0.97 to 0.99, and the values for precision (0.97 to 0.99) and accuracy (0.99) were high.

CONCLUSION

HBS scanning by DXA evidenced agreement, and high values of accuracy and precision to assess body composition indicators (BMC, FM, LST and %FM).

Comparison of Trabecular Bone Score-Adjusted Fracture Risk Assessment (TBS-FRAX) and FRAX Tools for Identification of High Fracture Risk among Taiwanese Adults Aged 50 to 90 Years with or without Prediabetes and Diabetes

Background and Objectives: The burden of osteoporosis is projected to increase. Identification and prompt intervention for osteoporotic fractures are important. Adjusting the Fracture Risk Assessment (FRAX®) tool with trabecular bone score (TBS) could improve risk prediction. However, little is known about whether TBS-adjusted FRAX® would change the proportion of individuals qualified for osteoporosis intervention. Therefore, the aim of the present study was to compare the proportions of Taiwanese adults who qualified for intervention, according to the FRAX® and TBS-adjusted FRAX®, with stratification by sex, age group, and glucose regulation status. Materials and Methods: A medical record review on adults 50−90 years who had undergone a general health examination in a regional hospital in Taiwan was conducted. FRAX® and TBS-adjusted FRAX® were calculated. FRAX® cut-points of ≥ 20% for major osteoporotic fracture and ≥3% for hip fracture were adopted to identify individuals qualified for osteoporosis intervention. Individuals were classified as prediabetes and diabetes if their HbA1c was 5.7−6.4% and >6.4%, respectively. Results: A total of 8098 individuals with a mean age of 61.0 years were included. The proportion of men qualified for intervention for hip fracture was significantly lower according to TBS-adjusted FRAX® (17.2%) compared with FRAX® (20.7%) (p < 0.001), with a similar pattern across all three age groups and in those with prediabetes. In contrast, the proportion of women qualified for intervention for major osteoporotic fracture was significantly higher according to TBS-adjusted FRAX® (4.6%) compared with FRAX® (3.7%) (p < 0.001), particularly among those with prediabetes 60−69 years. Conclusions: TBS-adjusted FRAX® led to small but significant changes in the proportions of individuals qualified for intervention in specific age groups and glucose regulation status.

Differential blood counts do not consistently predict clinical measurements of bone mineral density and microarchitecture at homeostasis

The hematopoietic stem cell niche constitutes a complex bone marrow (BM) microenvironment. Osteoporosis is characterized by both reduced bone mineral density (BMD) and microarchitectural deterioration, constituting the most frequent alteration of the BM microenvironment. It is unclear to which extent modifications of the BM microenvironment, including in the context of osteoporosis, influence blood cell production. We aimed to describe the association between lumbar spine and total hip BMD and microarchitecture (assessed by trabecular bone score [TBS]) and differential blood counts. Data were collected at two time points from 803 (first assessment) and 901 (second assessment) postmenopausal women participating in the CoLaus/OsteoLaus cohort, a population‐based sample in Lausanne, Switzerland. Participants with other active disease or treatment that could influence hematopoiesis or osteoporosis were excluded. Bivariate and multivariate associations between each peripheral blood cell count and BMD or TBS were performed. Additionally, participants in the highest BMD and TBS tertiles were compared with participants in the lowest BMD and TBS tertiles. At first assessment, only neutrophils were significantly different in the lowest BMD and TBS tertile (3.18 ± 0.09 versus 3.47 ± 0.08 G/L, p = 0.028). At the second assessment, leucocytes (5.90 ± 0.11 versus 5.56 ± 0.10 G/L, p = 0.033), lymphocytes (1.87 ± 0.04 versus 1.72 ± 0.04 G/L p = 0.033), and monocytes (0.49 ± 0.01 versus 0.46 ± 0.1 G/L, p = 0.033) were significantly different. Power analysis did not identify quasi‐significant associations missed due to sample size. Although significant associations between blood counts and BMD or TBS were found, none was consistent across bone measurements or assessments. This study suggests that, at homeostasis and in postmenopausal women, there is no clinically significant association between the osteoporotic microenvironment and blood production output as measured by differential blood counts. In the context of conflicting reports on the relationship between osteoporosis and hematopoiesis, our study represents the first prospective two time‐point analysis of a large, homogenous cohort at steady state. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Abnormal Trabecular Bone Score, Lower Bone Mineral Density and Lean Mass in Young Women With Premature Ovarian Insufficiency Are Prevented by Oestrogen Replacement

Background

Low bone density (BMD) and fractures commonly affect women with premature ovarian insufficiency (POI). However, bone microarchitecture and body composition data are lacking.

Objective

To assess and characterise musculoskeletal phenotype and effects of oestrogen replacement therapy (ERT) in women with POI.

Method

Cross-sectional and longitudinal studies of 60 normal karyotype women with POI, aged 20-40 years, from 2005-2018. Dual x-ray absorptiometry (DXA)-derived spinal (LS) and femoral neck (FN) BMD, trabecular bone score (TBS), appendicular lean mass (ALM), total fat mass (TFM), and fracture prevalence were compared with 60 age-, and BMI-matched population-based controls. Longitudinal changes in bone and body composition variables and ERT effects were analysed using linear mixed models over a median duration of 6 years.

Results

Women with POI were subdivided into spontaneous (s)-POI (n=25) and iatrogenic (i)-POI (n=35). Median(range) age of POI diagnosis was 34 (10-40) years with baseline DXA performed at median 1(0-13) year post-diagnosis. ERT was used by 82% women (similar for both POI groups). FN-BMD were lowest in s-POI (p<0.002). Low TBS was more common in s-POI [(44%), p=0.03], versus other groups. LS-BMD and ALM were lower in both s-POI and i-POI groups than controls (p<0.05). Fracture prevalence was not significantly different: 20% (s-POI), 17% (i-POI), and 8% (controls) (p=0.26). Longitudinal analysis of 23 POI women showed regular ERT was associated with ALM increment of 127.05 g/year (p<0.001) and protected against bone loss. However, ERT interruption was associated with annual reductions in FN BMD and TBS of 0.020g/cm2 and 0.0070 (p<0.05), respectively.

Conclusion

Deficits in BMD, trabecular microarchitecture, and lean mass were present in women with POI. However, regular ERT protected against declines in bone variables, with an increase in ALM. Assessment of skeletal and muscle health, and advocating ERT adherence, is essential in POI to optimise musculoskeletal outcomes.

Dairy food intake is not associated with spinal trabecular bone score in men and women: the Framingham Osteoporosis Study

BACKGROUND

Previous studies reported that dairy foods are associated with higher areal bone mineral density (BMD) in older adults. However, data on bone texture are lacking. We determined the association of dairy food intake (milk, yogurt, cheese, milk + yogurt and milk + yogurt + cheese) with spinal trabecular bone score (TBS).

METHODS

In this cross-sectional study, a validated semi-quantitative food frequency questionnaire was used to assess dairy food intake (servings/wk). TBS, an analysis of bone texture, was calculated from dual energy X-ray absorptiometry (DXA) scans. Sex-specific multivariable linear regression was used to estimate the association of dairy food intake (energy adjusted via residual methods) with each bone measure adjusting for covariates.

RESULTS

Mean age of 4,740 participants was 49 (SD: 13) years and mean milk + yogurt + cheese intake was 10.1 (SD: 8.4) servings/week in men and 10.9 (SD: 8.0) servings/week in women. There were no associations between dairy food intake and spinal TBS in adjusted models.

CONCLUSIONS

In this cohort of primarily healthy adults, dairy intake was not associated with bone texture.

Age-Related Changes in Trabecular Bone Score and Bone Mineral Density in Chinese Men: A Cross-Sectional and Longitudinal Study

Purpose

This study was designed to explore age-related changes in trabecular bone score (TBS) and bone mineral density (BMD) in Chinese men through cross-sectional and longitudinal studies.

Patients and Methods

We included adult men who had at least twice TBS and BMD examinations in our hospital between January 2013 and December 2020. All men were divided into an age subgroup per 10 years, comparing differences in baseline lumbar spine (LS) TBS and BMD at various parts between each age group and analyzing age-related changes in TBS and BMD during follow-up.

Results

Baseline data showed that in men aged 36 to 85 years, BMD in the hip region showed a decreasing trend with age (P for trend < 0.01). However, TBS reached a high value around the age of 50, after which it decreased with age (P for trend = 0.03). During a mean follow-up of 3 years, the average annual change rate at TBS was −0.17% in men aged 36 to 85 years, with the fastest decrease rate −1.08% at 66 to 75 years (P < 0.05). The mean annual rate of change in LS BMD in different age subgroups increased with age (P for trend = 0.001). There was no significant decrease in mean annual change in BMD in hip regions.

Conclusion

In men aged 36~85 years, the trend of TBS was inconsistent with BMD. Men experience a high value of LS TBS around age 50, later than the commonly believed age of peak BMD, which may reflect developmental differences between bone microstructure and bone minerals. The TBS may be used as a better indicator of changes in bone strength than BMD in adult men at short-term follow-up. The rapid loss of TBS at age 66 to 75 may have implications for the prevention and medication of osteoporosis in men.

Bone Response to High-Intensity Interval Training versus Moderate-Intensity Continuous Training in Adolescents with Obesity

INTRODUCTION

Since adolescents with obesity are prone to bone fragility during weight loss, the aim was to compare the impact of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) on bone density, geometry, and strength.

METHODS

Sixty-one adolescents were randomly assigned to 2 cycling trainings (HIIT and MICT) and a control (CTR, without training) group. Anthropometry, dual-energy X-ray absorptiometry with hip structural analysis and the trabecular bone score (TBS) were assessed before and after the 16-week intervention.

RESULTS

Body mass index (BMI) and fat mass (FM) percentage decreased at T1 versus T0 in both training groups (p < 0.001 for HIIT, p = 0.01 for MICT), though to a larger extent in HIIT (p < 0.05). Total body bone mineral density (BMD) and bone mineral content (BMC) increased in both training groups (p < 0.001), but to a greater extent in HIIT for BMC (p < 0.05). Lumbar spine BMD and BMC increased in both training groups (p < 0.001 for HIIT, p < 0.01 for MICT), with a time × group interaction between HIIT and CTR (p < 0.05) only. TBS increased in both training groups (p < 0.01 for HIIT, p < 0.05 for MICT). Hip BMD and BMC increased in both HIIT (p < 0.001 and p < 0.01) and MICT (p < 0.01 and p < 0.05). At the narrow neck (NN), endocortical diameter, width (p < 0.01), cross-sectional moment of inertia, and section modulus (Z) (p < 0.05) increased only in the HIIT group, such as BMD and Z (p < 0.05) at the intertrochanteric region (IT) and average cortical thickness (p < 0.001) and width (p < 0.05) at the femoral shaft. At the NN and IT, the buckling ratio decreased only in the HIIT group (p < 0.05), predicting higher resistance to fracture.

CONCLUSIONS

In addition to inducing greater BMI and FM percentage decreases in comparison to MICT, HIIT improves multisite bone density, geometry, and strength, which heighten the justification for HIIT as part of weight loss interventions in adolescents with obesity.

Does the severity of obesity influence bone density, geometry and strength in adolescents?

BACKGROUND

Relationships between the severity of obesity and bone health remain underexplored.

OBJECTIVES

To compare whole-body and localized bone mineral content (BMC) and density (BMD), trabecular bone score (TBS) and hip geometry and strength between adolescents with obesity versus extreme obesity.

METHODS

This cross-sectional study included 154 adolescents (12-15 years, 62% females) who were classified as having obesity (OG, [95th-99th] percentile) or extreme obesity (EOG, >99th percentile). Fat mass (FM), lean mass (LM), BMC, BMD for total-body-less-head (TBLH), lumbar spine (LS), hip, TBS and geometric and strength indices at the narrow-neck (NN), femoral shaft (FS) and intertrochanteric regions (IT) were assessed by Dual-X-ray Absorptiometry (DXA).

RESULTS

There was no significant sex-interaction. For both sexes, TBLH BMC and BMD were not different between groups. TBS was lower in EOG compared with OG in both sexes in univariate analysis and after adjustment with maturation and body weight (p < 0.05). Hip BMD was significantly higher in the EOG compared to OG only after adjustment with maturation and fat mass percentage (p < 0.05 for men, p < 0.01 for women). For both sexes, TBLH, LS and hip BMC and BMD positively correlated with weight, BMI, LM and FM. TBS negatively correlated with BMI-percentile in both sexes, with a negative correlation with FM for males alone. Hip BMC and BMD, BMD, ACT and CSA at the three hip sites positively correlated with BMI-percentile in males.

CONCLUSIONS

Extreme obesity impacts bone health depending on anatomical sites, altering lumbar trabecular bone in both males and females adolescents.

Age-Specific Normative Values of Lumbar Spine Trabecular Bone Score (TBS) in Taiwanese Men and Women

Trabecular bone score (TBS) is a novel method for assessing trabecular microarchitecture. Normative values of TBS are available for various populations of the world but are not yet available for Taiwanese adults. Therefore, the purpose of this study was to estimate age-specific, normative TBS curves for Taiwanese men and women. Medical records of general health examinations from a regional hospital in Southern Taiwan were reviewed. Individuals aged 30–90 years with data on lumbar spine bone mineral density (BMD) were included. TBS was retrospectively calculated from dual-energy X-ray absorptiometry scans using TBS iNsight software. Of the 12,028 patients included, 4533 (37.7%) were male and the mean age was 55.8 years. The mean TBS was 1.392 (standard deviation (SD) 0.089) for men and 1.344 (SD 0.107) for women. In women, TBS declined at a rate of 0.0004/year among those aged 30.0–45.9 years, 0.0106/year among those 46.0–60.7 years, and 0.0028/year among those 60.8–90.0 years. In men, TBS declined at a constant rate of 0.0023/year over the entire age range. In conclusion, age-adjusted, normative curves of TBS for Taiwanese men and women are presented, which could be used to facilitate the use of TBS in assessing bone status in clinical practice.

Association of short sleep duration and trabecular bone score

Short sleep duration has been found to be associated with bone health deterioration by using bone mineral density (BMD). Only a few attempts have been made to assess the association of sleep duration and bone by utilizing the trabecular bone score (TBS). The aim of this study was to examine the association between sleep duration and TBS from a national database. A total of 4480 eligible participants older than 20 years who attended the United States National Health and Nutrition Examination Survey (NHANES) from 2005 to 2006 with TBS data and self-reported sleep duration. The association between sleep duration and TBS was investigated using a multivariate regression model with covariate adjustment. TBS was lowest in individuals with a short sleep duration (≤ 5 h) and it was increased in those with longer self-reported total sleep times. After a full adjustment for covariates, those sleeping less than 5 h had a significantly lower TBS than the reference group (sleep duration of 7 h). In subgroup analyses, an association between short sleep duration (≤ 5 h) and lower TBS persisted in older ages (≥ 60 years old), women, obese adults (BMI ≥ 30 kg/m²), and non-Hispanic Whites. Short sleep duration is associated with low TBS in women, obese adults (BMI ≥ 30 kg/m²), and non-Hispanic whites. Strict self-monitoring of body weight, well-tailored controls of underlying disease(s), and adequate sleep may help prevent osteoporosis.

DXA parameters, Trabecular Bone Score (TBS) and Bone Mineral Density (BMD), in fracture risk prediction in endocrine-mediated secondary osteoporosis

Osteoporosis, a disease characterized by low bone mass and alterations of bone microarchitecture, leading to an increased risk for fragility fractures and, eventually, to fracture; is associated with an excess of mortality, a decrease in quality of life, and co-morbidities. Bone mineral density (BMD), measured by dual X-ray absorptiometry (DXA), has been the gold standard for the diagnosis of osteoporosis. Trabecular bone score (TBS), a textural analysis of the lumbar spine DXA images, is an index of bone microarchitecture. TBS has been robustly shown to predict fractures independently of BMD. In this review, while reporting also results on BMD, we mainly focus on the TBS role in the assessment of bone health in endocrine disorders known to be reflected in bone.

Volumetric BMD by 3D-DXA and Trabecular Bone Score in Adults With Down Syndrome

Adults with Down syndrome (DS) have lower bone mineral density (BMD) than the general population. The objective of our study was to describe bone mineral status in DS population through volumetric BMD (vBMD) and trabecular bone score (TBS). Retrospective study of 297 subjects recruited from the Adult DS Outpatient Clinic of a tertiary care hospital in Spain, who underwent a bone densitometry for clinical purposes between January 2010 and June 2015. vBMD determination and TBS analysis on conventional DXA (Hologic QDR 4500) densitometer were performed in this cohort. The mean (±SD) age of our population was 34.3 (±10.9) years; 51% were women. Trabecular vBMD at total hip and femoral neck was lower in males than in females (191.7 ± 48.4 mg/cm³ vs 206.9 ± 46.7 mg/cm³, p = 0.007, and 250.5 ± 70.1 mg/cm³ vs 275.7 ± 66.2 mg/cm³, p = 0.002, respectively). Trabecular and cortical vBMD decreased with age, but age decline in trabecular vBMD was more pronounced in males. Likewise, lumbar TBS declined with age being normal in 63%, low in 29% and very low in 8% of subjects with DS, without differences between sexes. TBS showed a positive correlation (r = 0.37; p < 0.001, Kappa index= 0.275) with conventional DXA lumbar Z-score. vBMD at the hip showed lower values in DS subjects than in the general population, especially in males. Moreover, TBS was also lower at lumbar spine. Therefore, both assessments could be used as complementary tools to areal BMD (Z-score) to assess bone status in DS subjects.

Effect of metformin and insulin vs. placebo and insulin on whole body composition in overweight patients with type 2 diabetes: a randomized placebo-controlled trial

Some studies indicate potential beneficial effects of metformin on body composition and bone. This trial compared metformin + insulin vs placebo + insulin. Metformin treatment had a small but positive effect on bone quality in the peripheral skeleton, reduced weight gain, and resulted in a more beneficial body composition compared with placebo in insulin-treated patients with type 2 diabetes.

INTRODUCTION

Glucose-lowering medications affect body composition. We assessed the long-term effects of metformin compared with placebo on whole body bone and body composition measures in patients with type 2 diabetes mellitus.

METHODS

This was a sub-study of the Copenhagen Insulin and Metformin Therapy trial, which was a double-blinded randomized placebo-controlled trial assessing 18-month treatment with metformin compared with placebo, in combination with different insulin regimens in patients with type 2 diabetes mellitus (T2DM). The sub-study evaluates the effects on bone mineral content (BMC), density (BMD), and body composition from whole body dual-energy X-ray absorptiometry (DXA) scans which were assessed at baseline and after 18 months.

RESULTS

Metformin had a small, but positive, (p < 0.05) effect on subtotal, appendicular, and legs BMC and BMD compared with placebo. After adjustment for sex, age, vitamin D, smoking, BMI, T2DM duration, HbA1c, and insulin dose, the effects on appendicular BMC and BMD persisted (p < 0.05 for both). The changes in appendicular BMC and BMD corresponded approximately to a 0.7% and 0.5% increase in the metformin group and 0.4% and 0.4% decrease in the placebo group, respectively. These effects were mostly driven by an increase in BMC and BMD in the legs and a loss of BMC and BMD in the arms. During 18 months, all participants increased in weight, fat mass (FM), FM%, and lean mass (LM), but decreased in LM%. The metformin group increased less in weight (subtotal weight (weight-head) - 2.4 [- 3.5, - 1.4] kg, p value < 0.001) and FM (- 1.5 [- 2.3, - 0.8] kg, p value < 0.001) and decreased less in LM% (0.6 [0.2, 1.1] %, p value < 0.001) compared with the placebo group.

CONCLUSION

Metformin treatment had a small positive effect on BMC and BMD in the peripheral skeleton and reduced weight gain compared with placebo in insulin-treated patients with T2DM.

The usefulness of trabecular bone score in patients with ankylosing spondylitis

BACKGROUNDS/AIMS

This study was performed to reveal the usefulness of the trabecular bone score (TBS) in assessing bone strength in patients with ankylosing spondylitis (AS) in comparison with dual-energy X-ray absorptiometry (DXA) methods.

METHODS

A total of 215 AS patients (75.8% male) were enrolled from a single university hospital in Korea. Demographic and clinical information were assessed. Patients completed X-rays of the cervical and lumbar spine (L-spine), and spinal ankyloses were quantified using the modified Stoke AS Spine Score (mSASSS). Hip, anteroposterior and lateral L-spine bone mineral density (BMD) and TBS were assessed by DXA methods. Clinical characteristics and bone strength measurement results were compared between male and female AS patients. The accuracy of each bone strength evaluation method in predicting Fracture Risk Assessment Tool (FRAX) scores indicating moderate or higher fracture risk was compared by receiver operating characteristic curves in patients aged ≥ 40 years. Correlations between each bone strength measurement method and mSASSS were examined.

RESULTS

Male patients showed higher mSASSS and less prevalent peripheral joint involvement compared to female patients (p < 0.05). TBS, hip BMD, and L-spine lateral BMD showed comparably high areas under the curve (AUCs) for predicting FRAX-major osteoporotic fractures (MOF) ≥ 10% (AUC ranged 0.72 to 0.76). TBS negatively correlated with mSASSS in both male and female patients (p < 0.01).

CONCLUSION

TBS could predict the risk of MOF and is not influenced by spinal osteoproliferation in AS patients, even in those with advanced spinal changes.

Impact of bone-active drugs and underlying disease on bone health after lung transplantation: A longitudinal study

INTRODUCTION

the effect of bone-active drugs on the risk of fragility fractures (Fx), bone mineral density (BMD) and trabecular bone score (TBS) changes in patients receiving lung transplantation (LTx) is largely unknown. This study assessed the bone-active drugs effect in patients undergoing LTx both with (CF) and without (nCF) cystic-fibrosis.

METHODS

We evaluated incident Fx, both clinical and morphometric vertebral Fx by spinal X-ray, BMD and trabecular bone score (TBS) in 117 patients (CF=50, nCF n = 67) before and 24-months after LTx. A bone-active therapy was proposed to all LTx candidates.

RESULTS

83.8% of patients started a bone-active drug. Lumbar-spine (LS) T-score improved significantly only in treated patients (-1.4 ± 1.0 vs -2.0±1.0, p = 0.0001), whereas femur BMD and TBS remained stable in treated and not treated subjects. The rate of incident Fx was 15.3%, with no difference between treated and not treated patients. After LTx, LS T-score improved significantly only in nCF group (-1.3 ± 1.0 vs -1.8 ± 1.1, p = 0.0001), while femur remained stable in both nCF and CF groups. Patients with CF showed a significant Z-TBS increase (-3.6 ± 1.7 vs -3.0 ± 1.7, p = 0.019) and a lower Fx incidence as compared with nCF patients (4.1% vs 24.2%, p  =0.003). Incident Fx were associated with nCF diagnosis (OR 7.300, CI95% 1.385-38.461, p = 0.019) regardless of prevalent Fx, previous glucocorticoid therapy and bone-active therapy introduced at least 6 months before LTx.

CONCLUSIONS

A prompt medical intervention helps in preventing BMD loss after LTx. As compared with nCF patients, CF patients show a TBS increase and a lower Fx risk after LTx.

Validation of Dual Energy X-Ray Absorptiometry and Nuclear Magnetic Resonance in the Analysis of Body Composition in Mice

Background

As an instrument for measuring body composition in experimental animals, dual energy X-ray absorptiometry (DXA) is ideal for accuracy, cost, and measurement efficiency. However, there is too little insight into the effectiveness of the various aspects of applying DXA to experimental animals. We investigated whether to compare and verify the precision and accuracy of DXA and nuclear magnetic resonance (NMR) animal body composition analyzers.

Methods

We used 30 Institution of Cancer Research mice in the study. First, in order to evaluate the reproducibility of DXA and NMR, we did repeated measurements by repositioning each mouse in anesthesia and euthanasia states. Subsequently, the accuracy of each device was evaluated by comparing the weight measured before the experiment, the weight of the tissue extracted from the mice after the experiment, and the measured DXA and NMR. In addition, when measuring the body composition of animals, we compared the time and the measurable body composition parameters and summarized the advantages and disadvantages of the 2 devices.

Results

Compared to NMR, DXA had the advantage of a fast measurement of bone composition and rapid image analysis. In addition, DXA showed a higher correlation (>95%) with fat mass, lean mass baseline than did NMR (>85%).

Conclusions

In conclusion, DXA was confirmed to have higher precision and measurement accuracy than did NMR. Therefore, DXA is an effective method for evaluating the body composition of experimental animals.

Reduction of visceral fat could be related to the improvement of TBS in diabetes mellitus

INTRODUCTION

Diabetes has been proposed as a risk factor for increased skeletal fragility. Visceral fat is known to yield adverse effects on bone metabolism in people with diabetes. We investigated the relationship between the change in visceral fat mass over time and TBS or BMD.

MATERIALS AND METHODS

This retrospective study enrolled 690 (male: 367; female: 323) subjects with type 2 diabetes mellitus. Visceral fat mass, lumbar and femoral neck BMD, and lumbar spine TBS were measured via dual-energy X-ray absorptiometry (DXA), including the follow-up data within a 3-year period.

RESULTS

TBS significantly increased as visceral fat mass decreased in both sexes (p < 0.001), whereas lumbar BMD and femoral neck BMD showed meaningful changes only in men. The multiple regression model with adjustment for age, weight, creatinine level, lipid profile, HbA1C, and status of osteoporosis medication use revealed that TBS and femoral neck BMD were correlated with visceral fat mass. However, regarding longitudinal changes, only the change in visceral fat mass had a significant relationship with TBS (males: β = - 0.298, p < 0.001; females: β = - 0.216, p < 0.001).

CONCLUSIONS

The results of this study may suggest the beneficial effect of controlling visceral fat mass on bone health in type 2 diabetes patients. Besides, DXA-derived TBS could be a useful diagnostic tool for evaluating the bone changes according to metabolic changes in type 2 diabetes, which are not entirely achieved with BMD.

The reference value of trabecular bone score (TBS) in the Iranian population

Background

Trabecular bone score (TBS), as a tool for measurement of bone microarchitecture, represents fracture risk independently of bone density. The aim of this study was to estimate the reference values of TBS in both genders among the Iranian population to evaluate osteoporotic fractures in the future.

Methods

The study was performed on healthy Iranian subjects who live in urban areas of Bushehr city, the capital of Bushehr province in southwestern Iran. The participants in this study were selected through a multistage, age and sex stratified, cluster random sampling. The TBS of L1-L4 was assessed by spine DXA images using TBS iNsight software (Discovery WI, Hologic Inc, USA). Age-related models of TBS were constructed using piecewise linear regression analysis.

Results

In total, 691 participants aged ≥ 18 years (381 men and 310 women) were selected for the study. The mean and standard deviation (SD) of TBS value for men was 1.420 ± 0.094 and the age at the peak TBS was 30.0 years. Among women, the corresponding value for the mean of TBS was 1.428 ± 0.070 and the age at the peak TBS was 24.5 years. Two SDs below the mean of TBS were 1.326 in men and 1.357 in women. Therefore, the following normal range for TBS values has been proposed: Among men, TBS ≥ 1.326 is considered to be normal; TBS between 1.231 and 1.326 is considered to be partially degraded microarchitecture; and TBS ≤ 1.231defined degraded microarchitecture. Among women, TBS categories are defined as normal ≥ 1.357, partially degraded between 1.287 and 1.357 and degraded ≤ 1.287.

Conclusions

This was the first study to propose evaluation of the normal range for TBS values in both genders in the Middle- East and Iran. According to our results: TBS ≤ 1.231 in men and TBS ≤ 1.287 in women is considered to be degraded microarchitecture among the Iranian population.

Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis

Areal bone mineral density (aBMD) is currently the gold standard for the diagnosis of osteoporosis, however, it has its own pitfalls. Trabecular bone score (TBS), a novel tool in the evaluation of osteoporosis is an indirect indicator of bone microarchitecture. It is a textural index that evaluates pixel gray-level variations in the lumbar spine DXA (dual energy X-ray absorptiometry) image. Both cross-sectional and longitudinal studies have demonstrated that TBS may independently predict fragility fractures. TBS can also be used to adjust FRAX probabilities of fracture, though data available till date doesn't support any additional benefit. TBS also shows an improving trend with anti-osteoporotic treatment; however, the least significant change (LSC) is high that it takes more than 2 years for the change to manifest. TBS is also used in the evaluation of bone strength in cases of secondary osteoporosis. Though TBS predicts fracture risk independently in both genders, with the currently available data, it cannot be recommended as a standalone tool for decision regarding treatment of osteoporosis. TBS can be used as a tool to complement BMD in assessment of bone health. Additional studies are needed to assess its utility in clinical practice.

Decreased Trabecular Bone Score in Patients With Active Endogenous Cushing's Syndrome

INTRODUCTION

The impairment in bone microarchitecture and reduced bone quality are relevant mechanisms underlying the increased fracture risk in Cushing's syndrome (CS). The trabecular bone score (TBS) is a relatively novel textural index of bone microarchitecture.

PURPOSE

The objective of the study was to compare TBS, bone mineral density (BMD), and fracture risk in patients with endogenous CS to controls. We have investigated the association of TBS with anthropometric parameters and 25(OH) vitamin D concentrations.

MATERIALS AND METHODS

The study group comprised 19 consecutive patients with CS (14 women and 5 men; mean age 45.84 ± 13.15 years) and sex-, age-matched 36 controls (25 women and men; mean age 52.47 ± 8.98 years). Anthropometric parameters, biochemical and hormonal data were compared between groups. Lumbar spine (L1-L4) and femoral neck BMD (LS BMD, FN BMD) measurements were performed. TBS values were obtained from lumbar spine DXA images.

RESULTS

TBS was significantly lower in patients with CS compared to controls (p = 0.0002). The 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture were significantly higher in the CS group than in controls (p = 0.03, p < 0.0001, respectively). All subjects from the CS group with fractures had low TBS value (degraded microarchitecture). TBS correlated negatively with the duration of disease in patients with CS (r = -0.590 p = 0.008).

CONCLUSIONS

The patients with active CS have altered bone microstructure as indicated by the decreased TBS and are at higher risk of hip and a major osteoporotic fractures. TBS seems to be a very important analytical tool facilitating fracture risk assessment in endogenous hypercortisolism.

The Correlation between Trabecular Bone Score and Lumbar Spine Bone Mineral Density in Patients with Normal and High Body Mass Index

Background:

Trabecular bone score (TBS) measures the underlying quality of bone texture using dual-energy X-ray absorptiometry (DXA) images. The present study aimed to investigate the correlation between lumbar spine bone mineral density (BMD) and TBS, and subsequently determine whether the association varies with the body mass index (BMI).

Methods:

Data from 548 patients were collected and categorized into three groups according to the relationship between BMD and age. BMD of the lumbar spine (LS) using DXA and TBS from DXA images were measured. Pearson’s correlation coefficient (SPSS software, version 24.0) was used to investigate the association between LS-BMD and TBS, as well as the effect of BMI and age on these parameters. P<0.05 was considered statistically significant.

Results:

The total mean TBS was 1.31±0.12. LS-BMD and TBS values significantly decreased with age in both sexes. A statistically significant correlation was found between TBS and LS-BMD (r=0.601). An increase in BMI was associated with a higher LS-BMD score and a lower TBS level. The correlation coefficient between LS-BMD and TBS reduced as the BMI increased. By comparing TBS with BMD, the majority of the patients with osteopenia and osteoporosis had fully degraded and partially degraded TBS, respectively.

Conclusion:

TBS was positively correlated with LS-BMD and decreased with age. Moreover, the extent of the correlation varied with respect to BMI.

Factors associated with low trabecular bone scores in patients with end-stage kidney disease

The trabecular bone score (TBS) is a textural index that indirectly assesses bone trabecular microarchitecture using lumbar spine images obtained by dual-energy X-ray absorptiometry (DXA). This study compared the TBS of patients with end-stage kidney disease (ESKD) with that of matched controls to identify risk factors associated with a low TBS. TBS and bone mineral density (BMD) were assessed in ESKD patients (n = 76) and age- and sex-matched control subjects (n = 76) using DXA. The TBS of both groups was then compared, and risk factors associated with a low TBS (defined as ≤ 1.31) were evaluated. The mean TBS in the ESKD group was significantly lower than that in the control group (1.34 ± 0.15 vs. 1.43 ± 0.08, respectively; p < 0.001). More subjects in the ESKD group had a low TBS [34.2% (ESRD) vs. 5.3% (controls); p < 0.001]. The TBS was negatively correlated with age, alkaline phosphatase and C-reactive protein levels, and dialysis vintage, and positively correlated with BMD at the lumbar spine, femoral neck, and hip. Multivariate analysis identified lower estimated glomerular filtration rate and increased C-reactive protein levels as being significantly associated with a low TBS. In conclusion, ESKD patients had abnormal bone microarchitecture (as assessed by the TBS). The TBS was positively correlated with BMD. Renal function and inflammatory marker levels were independently associated with a low TBS. Thus, TBS may be a useful clinical tool for assessing cancellous bone connectivity in ESKD patients.

Subregional areal bone mineral density (aBMD) is a better predictor of heterogeneity in trabecular microstructure of vertebrae in young and aged women than subregional trabecular bone score (TBS)

BACKGROUND

Currently, bone densitometry fails to identify nearly half of those elderly patients at immediate fracture risk. To improve clinical assessment of vertebral fracture risk, we aimed to determine how the DXA-based 2D parameter Trabecular Bone Score (TBS) relates to subregional variability in 3D trabecular microstructure in young and elderly women compared to aBMD.

METHODS

T12 vertebrae from 29 women (11 young: 32 ± 6 years, 18 aged: 71 ± 5 years) were DXA-scanned ex vivo in anterior-posterior (AP) and lateral projection providing vertebral aBMD and TBS. Additionally, aBMD and TBS were measured for three horizontal (superior, mid-horizontal, inferior) and three vertical subregions (anterior, mid-vertical, posterior) and related to 3D microstructure indices, i.e. bone volume per tissue volume (BV/TV), trabecular number and thickness (Tb.N, Tb.Th), based on HRpQCT.

RESULTS

Subregional high-resolution tomography showed significant differences in trabecular parameters for both age groups: In horizontal subregions, BV/TV was lowest superiorly, Tb.Th was highest mid-horizontally, and Tb.N was lowest mid-horizontally and highest inferiorly. Correspondingly, aBMD varied between horizontal subregions, with differences depending on projection direction. TBS varied only in lateral projections of the aged group, with lower values for the mid-horizontal subregion. In vertical subregions, BV/TV, Tb.N, and aBMD were highest posteriorly for both groups. TBS did not differ between vertical subregions. Regression analysis showed aBMD as a predictor explained more of the variance in subregional 3D microstructure compared to TBS. Stepwise multi-regression analysis revealed only three combinations of subregion, projection, and group where aBMD and TBS were both significant predictors.

CONCLUSIONS

Subregional aBMD reflects variations in trabecular bone microstructure better than subregional TBS for trisected regions. Specifically, lateral aBMD identifies microstructural heterogeneities independent of age and may improve prediction of vertebral strength and susceptibility to specific fracture types.

Older Age and Higher Body Mass Index Are Associated With a More Degraded Trabecular Bone Score Compared to Bone Mineral Density

Trabecular bone score (TBS) may detect subjects with a more degraded microarchitecture but whose bone mineral density (BMD) reflects normal or osteopenia. The purpose of this study was to evaluate whether age and body sizes were associated with the discordance between BMD and TBS. We analyzed BMD and TBS in 1505 Korean women over 40 yr of age who had no history of osteoporotic fractures or conditions that affect bone metabolism. We considered 3 groups to have TBS values that reflected a more degraded TBS than their BMD values: (1) normal BMD but partially degraded TBS, (2) normal BMD but degraded TBS, and (3) osteopenia but degraded TBS. We compared subjects in these 3 groups with other subjects in terms of age and body sizes, and used multivariable logistic regression to analyze the odds ratios (ORs) for the occurrence of a more degraded TBS than their BMD level using age and body mass index (BMI). One hundred sixty subjects (10.6%) were found to have a more degraded TBS than their BMD level; these subjects were older, heavier, and had higher BMIs than the other subjects. Age (OR: 1.038, 95% confidence interval: 1.020-1.057, p< 0.001) and BMI (OR: 1.223, 95% confidence interval: 1.166-1.283, p< 0.001) were statistically significant in the multivariable analysis for the occurrence of this feature. Women with a more degraded TBS than their BMD level are older and have higher BMIs than the other subjects. It may be helpful to consider the possibility of trabecular bone degradation when clinically evaluating fracture risk in patients who are older or who have high BMIs with normal BMD or osteopenia.

Lower Trabecular Bone Score is Associated With the Use of Proton Pump Inhibitors

INTRODUCTION

Trabecular bone score (TBS) provides indirect indices of trabecular microarchitecture and bone quality. Several studies have evaluated the influence of proton pump inhibitors (PPIs) on bone mass and geometric parameters, but no studies have evaluated the influence of PPIs on TBS.

METHODS

We reviewed the medical records of 1505 women aged 40-89 yr who had bone mineral density (BMD) examinations as a part of the medical diagnosis and disease prevention program and who did not have osteoporotic fractures or conditions that could affect bone metabolism. Among these, we identified 223 women with exposure to PPIs and selected the same number of age- and body mass index (BMI)-matched control patients. We compared TBS and BMD between the PPI exposure group and the control group and performed multivariate regression analyses to determine whether TBS and BMDs are associated with age, BMI, and PPIs exposure. We also examined whether TBS and BMDs are associated with PPIs exposure timing (current, recent, and past).

RESULTS

TBS and BMDs were significantly lower in the PPI exposure group than in the control group. In a multivariable linear regression analysis, TBS was significantly associated with age (p < 0.001) and PPI exposure (p = 0.02). In addition, all BMDs were found to be significantly associated with age, BMI, and PPI exposure. Lower TBS was associated with current PPIs use (p = 0.005), but not with recent or past PPIs usage. However, the influence of PPI exposure timing on the BMDs was not consistent between BMD measurement sites.

CONCLUSIONS

This study found that TBS is lower in subjects with PPIs exposure than in controls. The association of lower TBS with current PPIs use suggests that trabecular bone quality could be affected early by PPIs, and but the effect might be reversible.

Effect of denosumab on trabecular bone score in de novo kidney transplant recipients

Background

Kidney transplant recipients (KTR) are at risk to lose bone mass. The trabecular bone score (TBS) represents a recently developed parameter of lumbar spine trabecular bone texture that correlates with the occurrence of fractures.

Methods

We analysed the 1-year changes in TBS in 44 de novo KTR that were randomized 1:1 to denosumab or no treatment. TBS was derived from dual energy X-ray absorptiometry and was correlated with 1-year areal bone mineral density (aBMD) changes at the lumbar spine and total hip. Correlations were also performed with parameters of peripheral bone microarchitecture and bone strength at the distal tibia and distal radius, as assessed by high-resolution peripheral quantitative computed tomography (HRpQCT) and micro-finite element analysis.

Results

The baseline TBS in KTR amounted to 1.312 ± 0.101, which is lower than the TBS of an age-matched normal control population (range 1.364–1.471). The TBS correlated positively with aBMD at the lumbar spine (Spearman’s ρ = 0.56; P < 0.001) and total hip (ρ = 0.33; P < 0.05). The baseline TBS also correlated with HRpQCT-derived total (ρ = 0.49; P < 0.05) and trabecular volumetric BMD (ρ = 0.57; P < 0.01) and trabecular separation (ρ = −0.46; P < 0.05) at the tibia. Denosumab treatment led to an increase in TBS, paralleling the BMD changes at the lumbar spine.

Conclusions

The TBS is a useful additional score of bone health, which may help to better define fracture risk. Treatment with denosumab led to improved trabecular bone texture in de novo KTR in addition to its beneficial effect on BMD.

Reference Ranges for Trabecular Bone Score in Australian Men and Women: A Cross-Sectional Study

Trabecular bone score (TBS) is a novel method for indirectly assessing trabecular microarchitecture at the lumbar spine, providing information complementary to areal BMD. However, limited reference ranges exist for the normative distribution of TBS, particularly in men. The aim of this study was to develop such a reference range in Australian men and women. This study included 894 men and 682 women (aged 24 to 98 years) enrolled in the Geelong Osteoporosis Study. TBS was determined retrospectively by analysis of lumbar spine DXA scans (Lunar Prodigy) using TBS iNsight software (version 2.2). Multivariable regression techniques were used to determine best-fit models for TBS incorporating age, height, and weight. Age-related differences in TBS were best modelled with a linear relationship in men and a cubic relationship in women. Combined best-fit models for TBS included age and weight in men, and age and height in women. This study provides normative reference ranges for TBS in Australian men and women, and further indicates that TBS may identify individuals at risk for fracture despite normal BMD. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

VITamin D and OmegA-3 TriaL (VITAL) bone health ancillary study: clinical factors associated with trabecular bone score in women and men

We investigated the association of clinical variables with TBS at baseline in the bone health sub-cohort of the VITamin D and OmegA-3 TriaL (VITAL). Lower TBS was associated with female sex, aging, BMI ≥ 25 kg/m², SSRI use, high alcohol intake, and presence of diabetes; there was a trend towards significance between lower TBS and history of fragility fractures.

INTRODUCTION

We investigated whether TBS differs by sex, race, body mass index (BMI), and other clinical variables.

METHODS

The VITamin D and OmegA-3 TriaL (VITAL) is determining effects of vitamin D₃ and/or omega-3 fatty acid (FA) supplements in reducing risks of cancer and cardiovascular disease. In the VITAL: Effects on Bone Structure/Architecture ancillary study, effects of these interventions on bone will be investigated. Here, we examine the associations of clinical risk factors with TBS assessments at baseline in the bone health sub-cohort, comprised of 672 participants (369 men and 303 women), mean (± SD) age 63.5 ± 6.0 years; BMI ≤ 37 kg/m², no bisphosphonates within 2 years or other bone active medications within 1 year.

RESULTS

TBS was greater in men than women (1.311 vs. 1.278, P < 0.001) and lower with elevated BMIs (P < 0.001), higher age (P = 0.004), diabetes (P = 0.008), SSRI use (P = 0.044), and high alcohol intake (P = 0.009). There was a trend for history of fragility fractures (P = 0.072), and lower TBS. TBS did not vary when analyzed by race, smoking, history of falls, and multivitamin or caffeine use.

CONCLUSIONS

Lower TBS was associated with female sex, aging, BMI ≥ 25 kg/m², SSRI use, alcohol use, and presence of diabetes; there was a trend between lower TBS and history of fragility fractures. TBS may be useful clinically to assess structural changes that may be associated with fractures among patients who are overweight or obese, those on SSRIs, or with diabetes. Ongoing follow-up studies will clarify the effects of supplemental vitamin D₃ and/or FA's on TBS and other bone health measures.

TRIAL REGISTRATION

NCT01747447.

A Cross-Sectional and Longitudinal Analysis of Trabecular Bone Score in Adults With Turner Syndrome

CONTEXT

Turner syndrome (TS) is associated with short stature, gonadal failure, and fractures. Spinal trabecular bone score (TBS) is a novel bone imaging modality that has not been evaluated in TS.

OBJECTIVE

To evaluate TBS in TS and its association with bone mineral density (BMD), prevalent fracture, and risk factors.

DESIGN AND SETTING

Longitudinal study of TS from a single tertiary hospital between 2006 and 2017.

PATIENTS OR OTHER PARTICIPANTS

Fifty-eight subjects with TS aged 20 to 49 years who underwent dual-energy X-ray absorptiometry (DXA).

MAIN OUTCOME MEASURES

TBS, DXA parameters, and prevalent fractures were investigated.

RESULTS

Normal, partially degraded, and degraded TBSs were observed in 39 (67%), 15 (26%), and four (7%) subjects, respectively. High rates of prescribed estrogen replacement therapy (ERT) with stable TBS and BMD were observed during follow-up. TBS was positively correlated with spine and femoral neck (FN) BMD and Z-scores (all P < 0.05) and negatively correlated with age (-0.004 per year; P = 0.014) and delay in ERT initiation in women with primary amenorrhea (-0.010 per year; P < 0.001). Fractures were present in 17 (31%) subjects. Low TBS had a significantly higher area under the receiver operator curve for predicting prevalent fracture than low bone mass at either the spine or FN (P < 0.05). Subjects with no history of fracture were more likely to have a normal TBS (P = 0.023).

CONCLUSIONS

BMD and TBS can be preserved with early initiation and continued use of ERT. TBS may provide additional fracture risk prediction to standard DXA parameters in TS and needs to be validated in larger prospective studies.

Standard reference values of the upper body posture in healthy young female adults in Germany: an observational study

OBJECTIVE

Classifications of posture deviations are only possible compared with standard values. However, standard values have been published for healthy male adults but not for female adults.

DESIGN

Observational study.

SETTING

Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University Frankfurt/Main.

PARTICIPANTS

106healthy female volunteers (21-30 years old; 25.1±2.7 years) were included. Their body weight ranged from 46 to 106 kg (60.3±7.9 kg), the heights from 1.53 to 1.82 m (1.69±0.06 m) and the body mass index from 16.9 kg/m² to 37.6 kg/m² (21.1±2.6 kg/m²).

OUTCOME MEASURES

A three-dimensional back scan was performed to measure the upper back posture in habitual standing. The tolerance ranges and CI were calculated. Group differences were tested by the Wilcoxon Mann-Whitney U test.

RESULTS

In normal posture, the spinal column was marginally twisted to the left, and the vertebrae were marginally rotated to the right. The kyphosis angle is larger than the lumbar angle. Consequently, a more kyphotic posture is observed in the sagittal plane. The habitual posture is slightly scoliotic with a rotational component (scapular depression right, right scapula marginally more dorsally, high state of pelvic right, iliac right further rotated anteriorly).

CONCLUSIONS

Healthy young women have an almost ideally balanced posture with minimal ventral body inclination and a marginal scoliotic deviation. Compared with young males, women show only marginal differences in the upper body posture. These values allow a comparison to other studies, both for control and patient data, and may serve as guideline in both clinical practice and scientific studies.

Trabecular bone score as an assessment tool to identify the risk of osteoporosis in axial spondyloarthritis: a case-control study

Objectives

To compare the trabecular bone score (TBS) between patients with axial spondyloarthritis (axSpA) and matched normal controls and identify risk factors associated with a low TBS.

Methods

TBS and BMD were assessed in the two groups (axSpA and control) using DXA. Osteoporosis risk factors and inflammatory markers were also assessed. Disease activity and radiographic progression in the sacroiliac joint and spine were evaluated in the axSpA group. Multivariate linear regression analysis was performed to identify risk factors associated with TBS.

Results

In the axSpA group, 248 subjects were enrolled; an equal number of age- and sex-matched subjects comprised the control group. The mean TBS was 1.43 (0.08) and 1.38 (0.12) in the control and axSpA groups, respectively (P < 0.001); BMD at the lumbar spine did not differ between the two groups. The TBS was negatively correlated with ESR and CRP levels in the axSpA group only (P < 0.001 and P = 0.007, respectively). Syndesmophytes in the axSpA group was associated with lower TBS (P < 0.001) but higher lumbar BMD (P = 0.021) vs controls. In the multivariate analyses, ESR, CRP and spinal radiographic progression were significantly associated with TBS.

Conclusion

TBS assessments revealed poor bone quality in patients with axSpA compared with the matched controls. In axSpA, systemic inflammatory markers were negatively correlated with TBS and spinal radiographic progression and inflammatory markers were independently correlated with low TBS. TBS may, therefore, be a useful clinical tool to identify the risk of osteoporosis in patients with axSpA.

Quantitative imaging techniques for the assessment of osteoporosis and sarcopenia

Bone and muscle are two deeply interconnected organs and a strong relationship between them exists in their development and maintenance. The peak of both bone and muscle mass is achieved in early adulthood, followed by a progressive decline after the age of 40. The increase in life expectancy in developed countries resulted in an increase of degenerative diseases affecting the musculoskeletal system. Osteoporosis and sarcopenia represent a major cause of morbidity and mortality in the elderly population and are associated with a significant increase in healthcare costs. Several imaging techniques are currently available for the non-invasive investigation of bone and muscle mass and quality. Conventional radiology, dual energy X-ray absorptiometry (DXA), computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound often play a complementary role in the study of osteoporosis and sarcopenia, depicting different aspects of the same pathology. This paper presents the different imaging modalities currently used for the investigation of bone and muscle mass and quality in osteoporosis and sarcopenia with special emphasis on the clinical applications and limitations of each technique and with the intent to provide interesting insights into recent advances in the field of conventional imaging, novel high-resolution techniques and fracture risk.

Imaging of metabolic bone disease

Osteoporosis is the most important metabolic bone disease, with a wide distribution among the elderly. It is characterized by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Identify bone weakening with an appropriate and accurate use of diagnostic imaging is of critical importance in the diagnosis and follow-up of osteoporotic patients. The aim of this review is to evaluate the detection rates of the different imaging modalities in the evaluation of bone strength, in the assessment of fracture risk and in the management of fragility fractures. (www.actabiomedica.it)

Usefulness of the Trabecular Bone Score for assessing the risk of osteoporotic fracture

INTRODUCTION AND OBJECTIVES

The trabecular bone score (TBS) is an imaging technique that assesses the condition of the trabecular microarchitecture. Preliminary results suggest that TBS, along with the bone mineral density assessment, could improve the calculation of the osteoporotic fracture risk. The aim of this study was to analyse TBS values and their relationship with the clinical characteristics, bone mineral density and history of fractures of a cohort of posmenopausal women.

MATERIAL AND METHODS

We analysed 2,257 posmenopausal women from the FRODOS cohort, which was created to determine the risk factors for osteoporotic fracture through a clinical survey and bone densitometry with vertebral morphometry. TBS was applied to the densitometry images. TBS values ≤1230 were considered indicative of degraded microarchitecture. We performed a simple and multiple linear regression to determine the factors associated with this index.

RESULTS

The mean TBS value in L1-L4 was 1.203±0.121. Some 55.3% of the women showed values indicating degraded microarchitecture. In the multiple linear regression analysis, the factors associated with low TBS values were age, weight, height, spinal T-score, glucocorticoid treatment, presence of type 2 diabetes and a history of fractures due to frailty.

CONCLUSIONS

TBS showed microarchitecture degradation values in the participants of the FRODOS cohort and was associated with anthropometric factors, low bone mineral density values, the presence of fractures, a history of type 2 diabetes mellitus and the use of glucocorticoids.

Trabecular bone score (TBS) is associated with sub-clinical vertebral fractures in HIV-infected patients

Fragility fractures risk is increased among HIV infected patients. Bone microstructure alterations, in addition to bone mineral density (BMD) reduction, might be responsible for the increased risk. The aim of this study was to determine the prevalence of vertebral fractures (VFs) and their association with trabecular bone score (TBS), an indirect index of bone microstructure, in a cohort of HIV-infected subjects. One-hundred and forty-one HIV-infected patients (87% males, median age 43 years, 94% on stable antiretroviral therapy with undetectable viral load) underwent viro-immunological and bone metabolism biochemical screenings. Lumbar TBS and BMD at femoral neck, total hip, and lumbar spine, were measured with dual-energy X-ray absorptiometry (DXA). VFs were identified using the semiquantitative method and quantitative morphometric analysis from thoracic and lumbar spine X-ray images. VFs were observed in 19 patients (13.5%). BMD was below the expected range for age in 18 (12.8%) subjects. No significant differences were found stratifying VFs prevalence by BMD, whereas patients with lower TBS showed a higher prevalence of VFs (p = 0.03). In multivariate analysis, TBS was the only factor significantly associated to VFs (OR = 0.56; 95% CI = 0.33-0.96; p = 0.034), with increased fracture risk for lower TBS values. VFs are prevalent and associated with low TBS among HIV-positive patients, whereas no significant association was found with BMD.

Is Trabecular Bone Score Valuable in Bone Microstructure Assessment after Gastric Bypass in Women with Morbid Obesity?

Introduction: The effects of bariatric surgery on skeletal health raise many concerns. Trabecular bone score (TBS) is obtained through the analysis of lumbar spine dual X-ray absorptiometry (DXA) images and allows an indirect assessment of skeletal microarchitecture (MA). The aim of our study was to evaluate the changes in bone mineral density (BMD) and alterations in bone microarchitecture assessed by TBS in morbidly obese women undergoing Roux-en-Y gastric bypass (RYGB), over a three-year follow-up. Material/Methods: A prospective study of 38 morbidly obese white women, aged 46.3 ± 8.2 years, undergoing RYGB was conducted. Biochemical analyses and DXA scans with TBS evaluation were performed before and at one year and three years after surgery. Results: Patients showed normal calcium and phosphorus plasma concentrations throughout the study. However, 25-hydroxyvitamin D (25(OH)D₃) decreased, and 71% of patients had a vitamin D deficiency at three years. BMD at femoral neck and lumbar spine (LSBMD) significantly decreased 13.53 ± 5.42% and 6.03 ± 6.79%, respectively, during the three-year follow-up; however Z-score values remained above those for women of the same age. TBS was within normal ranges at one and three years (1.431 ± 106 and 1.413 ± 85, respectively), and at the end of the study, 73.7% of patients had normal bone MA. TBS at three years correlated inversely with age (r = −0.41, p = 0.010), body fat (r = −0.465, p = 0.004) and greater body fat deposited in trunk (r = −0.48, p = 0.004), and positively with LSBMD (r = 0.433, p = 0.007), fat mass loss (r = 0.438, p = 0.007) and lean mass loss (r = 0.432, p = 0.008). In the regression analysis, TBS remained associated with body fat (β = −0.625, p = 0.031; R² = 0.47). The fracture risk, calculated by FRAX^® (University of Sheffield, Sheffield, UK), with and without adjustment by TBS, was low. Conclusion: Women undergoing RYGB in the mid-term have a preserved bone MA, assessed by TBS.

Utility of trabecular bone score in the evaluation of osteoporosis

PURPOSE OF REVIEW

Trabecular bone score (TBS) is a lumbar spine dual-energy absorptiometry texture index which provides information on skeletal quality partially independent of bone mineral density (BMD). A body of work has emerged demonstrating the relationship between TBS and fracture risk, with lower TBS values associated with increased risk for osteoporotic fracture in postmenopausal women and older men. TBS is derived from standard DXA images; however, the information provided by TBS is complementary to that provided by BMD. In this article, we review the current state of TBS and its evolving role in the assessment and management of osteoporosis, with particular emphasis on the literature of the previous year.

RECENT FINDINGS

TBS-adjusted The Fracture Risk Assessment tool (FRAX) probabilities enhance fracture risk prediction compared with conventional FRAX predictions. TBS has been found to better categorize fracture risk and assists in FRAX-based treatment decisions, particularly for patients close to an intervention threshold. However, change in lumbar spine TBS while undergoing antiresorptive treatment is not a useful indicator of antifracture effect.

SUMMARY

Lumbar spine TBS is a recently developed image-based software technique for skeletal assessment, complementary to conventional BMD, which has been shown to be clinically useful as a fracture risk prediction tool.

Imaging of diabetic bone

Diabetes is an important concern in terms of medical and socioeconomic costs; a high risk for low-trauma fractures has been reported in patients with both type 1 and type 2 diabetes. The mechanism involved in the increased fracture risk from diabetes is highly complex and still not entirely understood; obesity could play an important role: recent evidence suggests that the influence of fat on bone is mainly dependent on the pattern of regional fat deposition and that an increased amount of visceral adipose tissue negatively affects skeletal health.Correct and timely individuation of people with high fracture risk is critical for both prevention and treatment: Dual-energy X-ray Absorptiometry (currently the "gold standard" for diagnosis of osteoporosis) underestimates fracture risk in diabetic patients and therefore is not sufficient by itself to investigate bone status. This paper is focused on imaging, covering different modalities involved in the evaluation of skeletal deterioration in diabetes, discussing the limitations of conventional methods and exploring the potential of new tools and recent high-resolution techniques, with the intent to provide interesting insight into pathophysiology and fracture risk.

Correlation study between osteoporosis and hematopoiesis in the context of adjuvant chemotherapy for breast cancer

This retrospective study attempts to establish if a correlation exists between osteoporosis and hematopoiesis before and after adjuvant chemotherapy in the context of non-metastatic breast cancer. Osteoporosis is interpreted both as a direct marker of osteoblastic decline and as an indirect marker of increased bone marrow adiposity within the hematopoietic microenvironment. Patients from the “Centre du Sein” at CHUV (Centre Hospitalier Universitaire Vaudois) undergoing adjuvant chemotherapy were included in this study. Evolution of blood counts was studied in correlation with the osteoporosis status. Toxicity of chemotherapy was coded according to published probability of febrile neutropenia. One hundred forty-three women were included: mean age 52.1 ± 12.5 years, mean BMI (body mass index) 24.4 ± 4.1. BMD (bone mineral density) scored osteoporotic in 32% and osteopenic in 45%. Prior to chemotherapy, BMD was positively correlated with neutrophil (p < 0.001) and thrombocyte (p = 0.01) count; TBS (trabecular bone score) was not correlated with blood count. After the first cycle of chemotherapy, an increase of one point in TBS correlated with a decrease of 57% on the time to reach leucocyte nadir (p = 0.004). There was a positive correlation between BMD and risk of infection (p < 0.001). Our data demonstrates an association between osteoporosis and lower blood counts in a younger cohort than previously published, extending it for the first time to neutrophil counts in females. Our results suggest that the healthier the bone, the earlier the lowest leucocyte count value, prompting further research on this area.

Trabecular bone score (TBS): Method and applications

Trabecular bone score (TBS) is a texture index derived from standard lumbar spine dual energy X-ray absorptiometry (DXA) images and provides information about the underlying bone independent of the bone mineral density (BMD). Several salient observations have emerged. Numerous studies have examined the relationship between TBS and fracture risk and have shown that lower TBS values are associated with increased risk for major osteoporotic fracture in postmenopausal women and older men, with this result being independent of BMD values and other clinical risk factors. Therefore, despite being derived from standard DXA images, the information contained in TBS is independent and complementary to the information provided by BMD and the FRAX® tool. A procedure to generate TBS-adjusted FRAX probabilities has become available with the resultant predicted fracture risks shown to be more accurate than the standard FRAX tool. With these developments, TBS has emerged as a clinical tool for improved fracture risk prediction and guiding decisions regarding treatment initiation, particularly for patients with FRAX probabilities around an intervention threshold. In this article, we review the development, validation, clinical application, and limitations of TBS.

Comparison of trabecular bone score and hip structural analysis with FRAX® in postmenopausal women with type 2 diabetes mellitus

PURPOSE

To evaluate (a) the performance in predicting the presence of bone fractures of trabecular bone score (TBS) and hip structural analysis (HSA) in type 2 diabetic postmenopausal women compared to a control group and (b) the fracture prediction ability of TBS versus Fracture Risk Calculator (FRAX^®) as well as whether TBS can improve the fracture prediction ability of FRAX^® in diabetic women.

METHODS

Eighty diabetic postmenopausal women were matched with 88 controls without major diseases for age and body mass index. The individual 10-year fracture risk was assessed by FRAX^® tool for Europe-Italy; bone mineral density (BMD) at lumbar spine, femoral neck and total hip was evaluated through dual-energy X-ray absorptiometry; TBS measurements were taken using the same region of interest as the BMD measurements; HSA was performed at proximal femur with the HSA software.

RESULTS

Regarding variables of interest, the only significant difference between diabetic and control groups was observed for the value of TBS (median value: 1.215; IQR 1.138-1.285 in controls vs. 1.173; IQR 1.082-1.217 in diabetic; p = 0.002). The prevalence of fractures in diabetic women was almost tripled than in controls (13.8 vs. 3.4 %; p = 0.02). The receiver operator characteristic curve analysis showed that TBS alone (AUC = 0.71) had no significantly lower discriminative power for fracture prediction in diabetic women than FRAX major adjusted for TBS (AUC = 0.74; p = 0.65).

CONCLUSION

In diabetic postmenopausal women TBS is an excellent tool in identifying fragility fractures.

Peak Bone Mass and Bone Microarchitecture in Adults Born With Low Birth Weight Preterm or at Term: A Cohort Study

CONTEXT AND OBJECTIVES

Peak bone mass (PBM) is regarded as the most important determinant of osteoporosis. Growing evidence suggests a role of intrauterine programming in skeletal development. We examined PBM and trabecular bone score (TBS) in adults born preterm with very low birth weight (VLBW) or small for gestational age (SGA) at term compared with term-born controls.

DESIGN, SETTING, PARTICIPANTS, AND OUTCOMES

This follow-up cohort study included 186 men and women (25 to 28 years); 52 preterm VLBW (≤1500 g), 59 term-born SGA (<10th percentile), and 75 controls (>10th percentile). Main outcome was bone mineral density (BMD) by dual x-ray absorptiometry. Secondary outcomes were bone mineral content (BMC), TBS, and serum bone markers.

RESULTS

VLBW adults had lower BMC and BMD vs controls, also when adjusted for height, weight, and potential confounders, with the following BMD Z-score differences: femoral neck, 0.6 standard deviation (SD) (P = 0.003); total hip, 0.4 SD (P = 0.01); whole body, 0.5 SD (P = 0.007); and lumbar spine, 0.3 SD (P = 0.213). The SGA group displayed lower spine BMC and whole-body BMD Z-scores, but not after adjustment. Adjusted odds ratios for osteopenia/osteoporosis were 2.4 and 2.0 in VLBW and SGA adults, respectively. TBS did not differ between groups, but it was lower in men than in women. Serum Dickkopf-1 was higher in VLBW subjects vs controls; however, it was not significant after adjustment for multiple comparisons.

CONCLUSIONS

Both low-birth-weight groups displayed lower PBM and higher frequency of osteopenia/osteoporosis, implying increased future fracture risk. The most pronounced bone deficit was seen in VLBW adults.