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Fu SH, Lai CY, Wang CY, Hung CC, Ye JD, Yen HK, Wu CH, Ku LJE, Yu T, Yang RS, Hsiao FY, Li CY. Screening of Fracture Risk and Osteoporosis Among Older Long-term Care Residents: A Prospective Study. J Nutr Health Aging 2023; 27:1255-1261. [PMID: 38151877 DOI: 10.1007/s12603-023-2045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023]
Abstract
This prospective study assessed the effectiveness of screening older long-term care residents (LTCRs) for fracture risk and osteoporosis in Taiwan. Fracture risk screening was done using the Fracture Risk Assessment Tool (FRAX), and those with high or moderate risk were offered osteoporosis workup and treatment at the hospital. Among 785 LTCRs screened, 338 men (mean age 75.6) and 447 women (mean age 81.2) were included. Only 5.2% of women and no men were using anti-osteoporosis medication. Based on the Bone Health and Osteoporosis Foundation (BHOF) recommendations, 69.2% of men and 92.6% of women were classified as high fracture risk. In 110 participants willing to receive bone mineral density examination, osteoporosis was diagnosed in 86.2% of women and half of men. FRAX could effectively differentiate fracture risk in 648 LTCRs who completed 2-year follow-ups; no fracture occurred in the low-risk group. The study emphasizes the importance of fracture risk screening to enhance osteoporosis diagnosis and treatment among LTCRs.
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Affiliation(s)
- S-H Fu
- Chung-Yi Li, Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, No. 138, Sheng Li Road, Tainan City 704, Taiwan, , Tel: +886-6-2353535, ext. 5862 and 5863
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Churilla BM, Perera S, Greenspan SL, Resnick NM, Kotlarczyk MP. Zoledronic acid and bone health in older adults with cognitive impairment. Osteoporos Int 2022; 33:293-298. [PMID: 34341833 PMCID: PMC8758516 DOI: 10.1007/s00198-021-06063-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/02/2021] [Indexed: 01/03/2023]
Abstract
UNLABELLED Fracture prevention in cognitively impaired individuals is lacking. This work highlights the benefits of zoledronic acid on bone health in cognitively impaired older adults. Demonstrating benefits of therapy may increase treatment uptake and reduce fracture risk in this group. INTRODUCTION Osteoporosis has detrimental consequences for frail older adults. The effects on those with both osteoporosis and cognitive impairment are compounded due to increased risk of falls and changes in mobility, both of which can lead to fracture. However, there are limited data on treatment benefits for osteoporotic individuals with cognitive impairment. METHODS This post hoc, secondary analysis of data from a randomized, double-blind, placebo-controlled clinical trial of single-dose zoledronic acid included 179 women age ≥ 65 years residing in assisted living facilities or nursing homes, 43 of whom had mild to severe cognitive impairment. We assessed bone mineral density (BMD) of the total hip, femoral neck, and lumbar spine by dual-energy x-ray absorptiometry and serum bone turnover markers (C-terminal telopeptide of type I collagen and procollagen type I N propeptide) at 6 and 12 months. RESULTS In participants with cognitive impairment, those who received zoledronic acid had 4.3% greater BMD at the total hip (p=.005) and 5.3% greater BMD at the femoral neck (p<.001) after 12 months compared to those in the placebo group. Bone turnover markers demonstrated significant decreases at 6 months in those with cognitive impairment who received active treatment compared to the placebo group. Improvements in bone health measures with zoledronic acid were similar to those seen in participants without cognitive impairment. CONCLUSION Zoledronic acid improves bone health in frail older women with cognitive impairment similar to those without impairment. Further studies are warranted to assess the benefit for fracture reduction in this undertreated population.
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Affiliation(s)
- B M Churilla
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - S Perera
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - S L Greenspan
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - N M Resnick
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - M P Kotlarczyk
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Abstract
With increasing longevity of the population globally, the prevalence of osteoporosis will rise, associated with significant morbidity, disability and increased mortality. Adequate intake of calcium, vitamin D, increasing physical activity, a strategy of avoiding falls, cessation of smoking and avoiding excessive alcohol intake are pivotal in maintaining healthy bones in all age groups. Oral bisphosphonates remain the most cost-effective first line of treatment. Better methods of identifying patients with high fracture risk is needed as there is adequate effective treatment for osteoporosis.
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Kotlarczyk MP, Perera S, Resnick NM, Nace DA, Greenspan SL. Early changes in bone turnover predict longer-term changes in bone mineral density but not trabecular bone score in frail older women. Arch Osteoporos 2020; 15:79. [PMID: 32458096 PMCID: PMC8006805 DOI: 10.1007/s11657-020-00749-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Clinicians and patients want to know if therapy is working early in their course of treatment. We found that early changes in bone turnover markers at 6 months were associated with long-term changes in bone mineral density but not trabecular bone score at 12 and 24 months. PURPOSE We sought to examine the association between shorter-term changes in markers of bone turnover and longer-term changes in bone mineral density (BMD) and microstructure in a cohort of frail elderly women with multiple comorbid conditions including osteoporosis. METHODS We performed a secondary analysis of a 2-year zoledronic acid trial for osteoporosis in 155 women residents of long-term care communities (mean age 86.9 years). We examined the association of the 6-month change in serum C-terminal crosslinking telopeptide of type I collagen (CTX) and serum intact procollagen type I N propeptide (PINP) with the 12- and 24-month changes in BMD at the spine and hip and the trabecular bone score (TBS), an indirect measure of bone microstructure. RESULTS For every 0.2-ng/ml 6-month CTX decrease, the corresponding increase in spine BMD at 12 and 24 months was 0.2% (p = 0.7210) and 1.1% (p = 0.0396), respectively; total hip BMD 1.1% (p = 0.0279) and 0.9% (p = 0.0716); and femoral neck BMD 1.7% (p = 0.0079) and 0.9% (p = 0.1698). Similarly, for every 20-ng/ml 6-month PINP decrease, the corresponding increase in spine BMD at 12 and 24 months was 0.9% (p = 0.0286) and 1.4% (p = 0.0012), respectively; total hip BMD 1.4% (p = 0.0005) and 1.4% (p = 0.0006); and femoral neck BMD 2.3% (p < 0.0001) and 2.0% (p < 0.0001). Bone marker changes were not consistently associated with TBS changes. CONCLUSION Shorter-term 6-month changes in bone turnover markers are associated with the long-term changes in BMD over 1-2 years in the spine and hip but not with TBS.
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Affiliation(s)
- Mary P Kotlarczyk
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Subashan Perera
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Neil M Resnick
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David A Nace
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan L Greenspan
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Greenspan SL, Vujevich K, Britton C, Herradura A, Gruen G, Tarkin I, Siska P, Hamlin B, Perera S. Teriparatide for treatment of patients with bisphosphonate-associated atypical fracture of the femur. Osteoporos Int 2018; 29:501-506. [PMID: 29085957 PMCID: PMC6468986 DOI: 10.1007/s00198-017-4286-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED The Fracture Improvement with Teriparatide (Fix-IT) study randomized 13 women with an atypical femur fracture to immediate vs delayed teriparatide therapy; all were followed for 12 months. Results suggested a trend for superior healing and lesser bone mineral density declines in the immediate vs delayed group with no differences in adverse events. PURPOSE Little clinical data are available on the use of teriparatide for the treatment of bisphosphonate-associated atypical femur fractures (AFF). The goal of the Fix-IT study was to determine if immediate therapy with teriparatide was superior for fracture healing after an AFF compared to a 6-month delay in teriparatide therapy. METHODS This randomized pilot clinical trial included 13 women with an AFF who were randomized to immediate teriparatide vs a delay of 6 months. All were followed for 12 months on teriparatide. The primary outcomes included individual and composite measures of radiologic bone healing (scored 1 point [no healing] to 4 points [complete healing]) at 6 and 12 months. Secondary outcomes included bone mineral density of the unfractured contralateral hip, spine, 1/3 distal radius, and adverse events. RESULTS We found there was a trend for superior healing with the composite score (12.6 vs 11.2 at 6 months and 15.4 vs 13.2 at 12 months), and lesser bone mineral density declines at the 1/3 distal radius (12-month change - 1.9 vs - 6.1%) in the immediate vs the delayed group. There were no differences in adverse events. There was one implant failure in the delayed group. CONCLUSIONS There is a preliminary signal for greater improvements with immediate teriparatide therapy vs delayed therapy. However, because an AFF is a rare event, and only a small number of patients were included, the results must be interpreted with caution.
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Affiliation(s)
- S L Greenspan
- Department of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 1110 Kaufmann Medical Building, Pittsburgh, PA, 15213, USA.
| | - K Vujevich
- Department of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 1110 Kaufmann Medical Building, Pittsburgh, PA, 15213, USA
| | - C Britton
- Department of Radiology, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - A Herradura
- Department of Radiology, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - G Gruen
- Department of Orthopedic Surgery, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - I Tarkin
- Department of Orthopedic Surgery, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - P Siska
- Department of Orthopedic Surgery, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - B Hamlin
- Department of Orthopedic Surgery, University of Pittsburgh Physicians, Pittsburgh, PA, USA
| | - S Perera
- Department of Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 1110 Kaufmann Medical Building, Pittsburgh, PA, 15213, USA
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Greenspan SL, Vujevich KT, Brufsky A, Lembersky BC, van Londen GJ, Jankowitz RC, Puhalla SL, Rastogi P, Perera S. Prevention of bone loss with risedronate in breast cancer survivors: a randomized, controlled clinical trial. Osteoporos Int 2015; 26:1857-64. [PMID: 25792492 PMCID: PMC4766869 DOI: 10.1007/s00198-015-3100-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In postmenopausal women with low bone mass and hormone-receptor-positive breast cancer on an aromatase inhibitor, risedronate maintained skeletal health assessed by bone density and turnover markers. Women with the greatest decreases in bone turnover markers at 12 months had the greatest increases in bone density at 24 months. INTRODUCTION Aromatase inhibitors (AIs), adjuvant endocrine therapy for postmenopausal women with hormone-receptor-positive breast cancer, are associated with bone loss and fractures. Our objectives were to determine if (1) oral bisphosphonate therapy can prevent bone loss in women on an AI and (2) early changes in bone turnover markers (BTM) can predict later changes in bone mineral density (BMD). METHODS We conducted a 2-year double-blind, placebo-controlled, randomized trial in 109 postmenopausal women with low bone mass on an AI (anastrozole, letrozole, or exemestane) for hormone-receptor-positive breast cancer. Participants were randomized to once weekly risedronate 35 mg or placebo, and all received calcium plus vitamin D. The main outcome measures included BMD, BTM [carboxy-terminal collagen crosslinks (CTX) and N-terminal propeptide of type 1 procollagen (P1NP)], and safety. RESULTS Eighty-seven percent completed 24 months. BMD increased more in the active treatment group compared to placebo with an adjusted difference at 24 months of 3.9 ± 0.7 percentage points at the spine and 3.2 ± 0.5 percentage points at the hip (both p < 0.05). The adjusted difference between the active treatment and placebo groups were 0.09 ± 0.04 nmol/LBCE for CTX and 23.3 ± 4.8 μg/mL for P1NP (both p < 0.05). Women with greater 12-month decreases in CTX and P1NP in the active treatment group had a greater 24-month increase in spinal BMD (p < 0.05). The oral therapy was safe and well tolerated. CONCLUSION In postmenopausal women with low bone mass and breast cancer on an AI, the oral bisphosphonate risedronate maintained skeletal health.
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Affiliation(s)
- S L Greenspan
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA.
| | - K T Vujevich
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - A Brufsky
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - B C Lembersky
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - G J van Londen
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - R C Jankowitz
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - S L Puhalla
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - P Rastogi
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
| | - S Perera
- Department of Medicine, University of Pittsburgh, 3471 Fifth Ave., Suite 1110, Kaufmann Bldg, Pittsburgh, PA, 15213, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
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Greenspan SL, Perera S, Ferchak MA, Nace DA, Resnick NM. Efficacy and safety of single-dose zoledronic acid for osteoporosis in frail elderly women: a randomized clinical trial. JAMA Intern Med 2015; 175:913-21. [PMID: 25867538 PMCID: PMC4843134 DOI: 10.1001/jamainternmed.2015.0747] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Eighty-five percent of institutionalized elderly people have osteoporosis and bone fracture rates 8 to 9 times higher than rates observed among community-dwelling elderly people. Nevertheless, most of these persons are left untreated and are excluded from pivotal osteoporosis trials. OBJECTIVE To determine the efficacy and safety of zoledronic acid to treat osteoporosis in frail elderly women in long-term care facilities. DESIGN, SETTING, AND PARTICIPANTS We conducted a 2-year, randomized, placebo-controlled, double-blinded study from December 2007 through March 2012. Included were 181 women 65 or older with osteoporosis, including those with cognitive impairment, immobility, and multimorbidity, who were living in nursing homes and assisted-living facilities. INTERVENTIONS One 5-mg dose of zoledronic acid or placebo intravenously and daily calcium and vitamin D supplementation. MAIN OUTCOMES AND MEASURES Hip and spine bone mineral density (BMD) at 12 and 24 months and adverse events. RESULTS There were no baseline differences in mean (SE) age (85.4 [0.6] years), BMD, or functional or cognitive status, but the treatment group included more participants with frailty, falls history, diabetes, and anticonvulsant medication use. Values for BMD were available for 87% of participants at 12 months and 73% at 24 months. Mean (SE) BMD changes were greater in the treatment group: 3.2 (0.7) and 3.9 (0.7) percentage-point differences in the total hip at 12 and 24 months, respectively (P < .01 for both comparisons), and 1.8 (0.7) and 3.6 (0.7) percentage-point differences at the spine (P < .01); adjusted analyses were similar. The treatment and placebo groups' fracture rates were 20% and 16%, respectively (OR, 1.30; 95% CI, 0.61-2.78); mortality rates were 16% and 13% (OR, 1.24; 95% CI, 0.54-2.86). Groups did not differ in the proportion of single fallers (28% vs 24%; OR, 1.24; 95% CI, 0.64-2.42; P = .52), but more participants in the treatment group had multiple falls (49% vs 35%; OR, 1.83; 95% CI, 1.01-3.33; P = .047); however, this difference was no longer significant when adjusted for baseline frailty. CONCLUSIONS AND RELEVANCE In this group of frail elderly women with osteoporosis, 1 dose of zoledronic acid improved BMD over 2 years. The clinical importance of nonsignificant increases in fracture and mortality rates in the treatment group needs further study. Since it is not known whether such therapy reduces the risk of fracture in this cohort, any change in nursing home practice must await results of larger trials powered to assess fracture rates. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00558012.
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Affiliation(s)
- Susan L Greenspan
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania3Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Anne Ferchak
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A Nace
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Neil M Resnick
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Thomsen K, Jepsen DB, Matzen L, Hermann AP, Masud T, Ryg J. Is calcaneal quantitative ultrasound useful as a prescreen stratification tool for osteoporosis? Osteoporos Int 2015; 26:1459-75. [PMID: 25634771 DOI: 10.1007/s00198-014-3012-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 12/17/2014] [Indexed: 11/30/2022]
Abstract
Calcaneal quantitative ultrasound (QUS) is attractive as a prescreening tool for osteoporosis, alternative to dual-energy X-ray absorptiometry. We investigated the literature of the usability of calcaneal QUS. We found large heterogeneity between studies and uncertainty about cutoff, device, and measured variable. Despite osteoporosis-related fractures being a major health issue, osteoporosis remains underdiagnosed. Dual-energy X-ray absorptiometry (DXA) of the hip or spine is currently the preferred method for diagnosis of osteoporosis, but the method is limited by low accessibility. QUS is a method for assessing bone alternative to DXA. The aim of this systematic review was to explore the usability of QUS as a prescreen stratification tool for assessment of osteoporosis. Studies that evaluated calcaneal QUS with DXA of the hip or spine as the gold standard was included. We extracted data from included studies to calculate number of DXAs saved and misclassification rates at cutoffs equal to high sensitivity and/or specificity. The number of DXAs saved and percentage of persons misclassified were measures of usability. We included 31 studies. Studies were heterogeneous regarding study characteristics. Analyses showed a wide spectrum of percentage of DXAs saved (2.7-68.8%) and misclassification rates (0-12.4%) depending on prescreen strategy and study characteristics, device, measured variable, and cutoff. Calcaneal QUS is potentially useful as a prescreen tool for assessment of osteoporosis. However, there is no consensus of device, variable, and cutoff. Overall, there is no sufficient evidence to recommend a specific cutoff for calcaneal QUS that provides a certainty level high enough to rule in or out osteoporosis. Calcaneal QUS in a prescreen or stratification algorithm must be based on device-specific cutoffs that are validated in the populations for which they are intended to be used.
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Affiliation(s)
- K Thomsen
- Institute of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29 Entrance 112, 7th floor, 5000, Odense C, Denmark,
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Greenspan SL, Perera S, Nace D, Zukowski KS, Ferchak MA, Lee CJ, Nayak S, Resnick NM. FRAX or fiction: determining optimal screening strategies for treatment of osteoporosis in residents in long-term care facilities. J Am Geriatr Soc 2012; 60:684-90. [PMID: 22316237 DOI: 10.1111/j.1532-5415.2011.03884.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine screening strategies for osteoporosis and fractures for treatment of long-term care residents. DESIGN Cross-sectional analysis to examine screening strategies for treatment. SETTING Assisted living and skilled care facilities. PARTICIPANTS Two hundred two frail women aged 65 and older (mean 85), excluding those receiving bisphosphonates. MEASUREMENTS Clinical fractures of the hip or spine (Clin Fx); Clin Fx or bone mineral density (BMD); Clin Fx, BMD, or vertebral fractures (VF) assessed according to dual-energy X-ray absorptiometry-based vertebral fracture assessments; fracture risk algorithm using femoral neck BMD (FRAX-FN); fracture risk algorithm using body mass index (FRAX-BMI); or Clin Fx or heel ultrasound (heel US). RESULTS Treatment eligibility ranged from 17% (Clin Fx) to 98% (FRAX-BMI). VFs were found in 47%, 74% of which were silent. Criteria with Clin Fx, BMD, or VF identified 73% of study participants for treatment. FRAX-FN suggested treatment in 81% but would have missed approximately 10% of individuals with silent VFs. Clin Fx or heel US suggested that 39% of participants were eligible for treatment. CONCLUSION Long-term care residents eligible for osteoporosis treatment ranged from fewer than 20% to roughly all residents depending on screening criteria. VFs are common and identify a subset of residents missed by conventional BMD scans or FRAX-FN. A reasonable clinical approach could consider treatment for those with Clin Fx of the hip or spine, radiological evidence of a VF, or osteoporosis according to BMD classification. Prospective studies are needed to determine optimal screening strategies for treatment in this cohort.
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Affiliation(s)
- Susan L Greenspan
- Medicine, Division of Endocrinology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Greenspan S, Nace D, Perera S, Ferchak M, Fiorito G, Medich D, Zukowski K, Adams D, Lee C, Saul M, Resnick N. Lessons learned from an osteoporosis clinical trial in frail long-term care residents. Clin Trials 2011; 9:247-56. [PMID: 22157987 DOI: 10.1177/1740774511430516] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although osteoporosis affects women of all ages, the impact is most pronounced in frail residents in long-term care. Nevertheless, few interventional trials have been performed in this population, and few data on therapeutic alternatives are available in this cohort. PURPOSE We describe the challenges and lessons learned in developing and carrying out a trial in frail long-term-care residents. METHODS The Zoledronic acid in frail Elders to STrengthen bone (ZEST) study was designed to examine the safety and efficacy of a single-dose therapy for osteoporosis in frail residents in long-term care in the Pittsburgh area. Women with osteoporosis who were 65 years of age and older and currently not on therapy were randomized in a blinded fashion to intravenous zoledronic acid or placebo. Follow-up of each participant was planned for 2 years. All participants received appropriate calcium and vitamin D supplementation. RESULTS Seven hundred and thirty-three contacts were made with long-term care residents of nine participating facilities. Of 252 women screened, 181 were eligible, enrolled, and randomized. Multiple barriers to research in long-term-care facilities were encountered but overcome with direct communication, information sessions, in-service trainings, and social events. Lessons learned included designing the study in a manner that avoided placing an additional burden on an already overcommitted facility staff, a two-stage consent process to separate screening from randomization, and a flexible examination schedule to accommodate residents while obtaining the necessary outcome measurements. Furthermore, a mobile unit accessible to participants containing state-of-the-art dual x-ray absorptiometry (DXA), assessment for vertebral fractures, and phlebotomy equipment allows all assessments to be performed on-site at each facility. Serious adverse events are collected from affiliated hospitals in real time with a novel electronic surveillance system. LIMITATIONS The major limitation is selection of outcomes that can be assessed at participating facilities and do not require transport of participants to hospitals or clinics. CONCLUSIONS Clinical research for osteoporosis can be successfully and safely performed with frail residents in long-term care facilities. Lessons learned from this study may inform future investigations among frail elderly residents of these facilities.
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Affiliation(s)
- Sl Greenspan
- Division of Endocrinology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Resnick J, Gupta N, Wagner J, Costa G, Cruz RJ, Martin L, Koritsky DA, Perera S, Matarese L, Eid K, Schuster B, Roberts M, Greenspan S, Abu-Elmagd K. Skeletal integrity and visceral transplantation. Am J Transplant 2010; 10:2331-40. [PMID: 20825384 PMCID: PMC4869861 DOI: 10.1111/j.1600-6143.2010.03245.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite continuous improvement in long-term survival, there is no knowledge about risk of bone health impairment and management strategies before and after intestinal transplantation. Therefore, 147 adults were retrospectively studied via chart review; 70 long-term survivors, 53 candidates and 24 recipients with longitudinal follow-up. Evaluation process included measurement of bone mineral density (BMD) and allied biochemical markers. Both long-term survivors and candidates showed low bone mass with lower (p < 0.05) z-scores at hip, femoral neck and spine. Vitamin D deficiency and secondary hyperparathyroidism were observed in both groups. Prevalence of osteoporosis was 44% among long-term survivors and 36% in candidates with age, BMD, duration of parenteral nutrition, type of immunosuppression and rejection being significant risk factors. Fragility fractures occurred at a higher (p = 0.02) rate among long-term survivors (20%) compared to candidates (6%). The longitudinal study documented acceleration (p = 0.025) of bone loss after transplantation with a decline of 13.4% (femoral neck), 12.7% (hip) and 2.1% (spine). Alendronate reduced (p < 0.05) but did not prevent bone loss. In conclusion, intestinal transplant recipients are at risk of osteoporosis secondary to bone loss before and after transplantation. Accordingly, current management includes comprehensive preventive measures with prompt therapeutic intervention utilizing intravenous bisphosphonates or subcutaneous human PTH.
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Affiliation(s)
- J. Resnick
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - N. Gupta
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - J. Wagner
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - G. Costa
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - R. J. Cruz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - L. Martin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - D. A. Koritsky
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - S. Perera
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA,Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - L. Matarese
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - K. Eid
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - B. Schuster
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - M. Roberts
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - S. Greenspan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - K. Abu-Elmagd
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, Corresponding author: Kareem M. Abu-Elmagd,
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Patel R, Blake GM, Panayiotou E, Fogelman I. Clinical evaluation of a phalangeal bone mineral density assessment system. J Clin Densitom 2010; 13:292-300. [PMID: 20554233 DOI: 10.1016/j.jocd.2010.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 03/11/2010] [Accepted: 04/03/2010] [Indexed: 11/22/2022]
Abstract
Because osteoporosis is common and usually managed in primary care, there is a requirement for cheap and convenient methods of measuring bone mineral density (BMD). AccuDEXA (Lone Oak Medical Technologies, Doylestown, PA) is a tabletop dual-energy X-ray absorptiometry (DXA) device that performs BMD measurements of the hand in the middle phalanges of the third finger. The aims of this study were to (1) evaluate the use of AccuDEXA in UK women; (2) investigate the concordance between AccuDEXA T-scores and DXA T-scores for central (spine and hip) sites; (3) investigate the comparative response of AccuDEXA measurements to clinical risk factors for osteoporosis. Measurements of phalangeal and central BMD were performed in 620 women referred by their family doctors for bone densitometry (group 1) and 159 healthy female volunteers (group 2). For 65 women in group 2, aged 39 yr or younger, the mean Z-scores for AccuDEXA and the central sites calculated from US reference ranges were consistent with the expected value of 0, whereas for the 62 group 2 women, aged 50 yr or older, the mean Z-scores for AccuDEXA and the central sites were in the range 0.4-0.7 and were statistically significantly different from 0. In both group 1 and group 2, the AccuDEXA T-scores in older and younger women were systematically higher than those in the central sites by up to 1 unit. Of the 157 women aged 50 yr or older, with osteoporosis, based on their central DXA results, only 34 (22%) had an AccuDEXA T-score less than or equal to -2.5, whereas 76 (48%) had osteopenia and 47 (30%) were normal based on their AccuDEXA T-scores. When assessed by the effect of clinical risk factors on Z-scores, both AccuDEXA and central BMD were affected to a similar extent. We conclude that the conventional World Health Organisation T-score criteria for the diagnosis of osteoporosis should not be applied to AccuDEXA measurements in UK women. Clinical risk factors for low BMD were found to affect AccuDEXA measurements to a similar extent as central BMD measurements. AccuDEXA measurements could, therefore, provide an alternative method for identifying individuals with low bone mass, provided care is taken in interpreting T-scores, perhaps, through the use of device-specific thresholds.
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Affiliation(s)
- Rajesh Patel
- Department of Biosurgery and Surgical Technology, Division of Surgery, Academic Bone Densitometry Unit, Imperial College London, London, UK.
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13
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A comparison of quantitative ultrasound of the calcaneus with dual-energy x-ray absorptiometry in hospitalized orthopaedic trauma patients. J Orthop Trauma 2010; 24:176-80. [PMID: 20182254 DOI: 10.1097/bot.0b013e3181b8b036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Osteoporosis remains underdiagnosed in orthopaedic trauma patients. Recently, protocols have emerged to identify and treat osteoporosis in this population. Our purpose was to compare the usefulness of quantitative ultrasound of calcaneus (QUS) with dual-energy x-ray absorptiometry (DXA) for identifying orthopaedic trauma patients at risk for osteoporotic fractures. DESIGN A retrospective review of an osteoporosis screening protocol comparing QUS and DXA. SETTING Regional trauma center. PATIENTS Three hundred sixty consecutive hospitalized orthopaedic trauma patients treated by a single surgeon. INTERVENTION QUS T-score and DXA bone mineral density T-scores (hip or radius) were obtained relative to U.S. normative data. MAIN OUTCOME MEASUREMENTS QUS and DXA data were statistically compared to analyze their relationship. Potential thresholds for osteoporosis risk were subsequently defined. RESULTS Testing was successfully performed with heel QUS in 350 patients and with DXA in 129 patients. One hundred twenty-six patients underwent testing with both modalities. According to World Health Organization criteria, 17% of patients tested with DXA had osteoporosis. A good predictive relationship between hip bone mineral density, as estimated by calcaneal QUS, and direct DXA measurement was seen (Pearson's r correlation coefficient of 0.53; area under the curve of 0.84 with 95% confidence interval=0.75-0.90; P=0.0001). QUS T-score cutoffs of greater than -0.9 resulted in 90% sensitivity (defining low osteoporosis risk) and a threshold of -1.6 or less resulted in a specificity of 80% (defining high osteoporosis risk). CONCLUSIONS Substantial logistical difficulties are inherent in attempting to obtain DXA scans in orthopaedic trauma patients at our regional trauma center. For those patients who did undergo DXA, a strong predictive relationship was seen between hip bone mineral density and QUS parameters. QUS thresholds in defining low- and high-risk subjects for osteoporosis in this population using this device are proposed. QUS is a simple, reliable, and relatively inexpensive tool for evaluating osteoporosis risk in orthopaedic trauma patients.
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Havill LM, Levine SM, Newman DE, Mahaney MC. Osteopenia and osteoporosis in adult baboons (Papio hamadryas). J Med Primatol 2008; 37:146-53. [PMID: 18642436 DOI: 10.1111/j.1600-0684.2007.00270.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Little is known about the degree to which baboons, an important animal model in skeletal research, spontaneously experience age-related osteopenia and osteoporosis. METHODS We measured bone mineral density (BMD) in 667 baboons, assigned T-scores to older animals based on sex-specific young adult reference groups, and compared reproductive history in older females with low BMD to those with normal BMD. RESULTS Approximately 25% of older baboon females were osteopenic. No females or males were osteoporotic. Neither parity nor interbirth interval spine clearly distinguished low vs. normal BMD groups. Intersite correspondence in low BMD was highest between sites in the same region rather than sites of the same bone type. CONCLUSION As with humans, osteopenia is common among older females. The absence of osteoporotic animals may be due to colony maintenance resulting in truncation of the aged population and selection for healthier animals in the oldest ranges.
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Affiliation(s)
- L M Havill
- Department of Genetics, Southwest Foundation for Biomedical Research, San Antonio, TX 78245-0549, USA.
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Fink HA, Harrison SL, Taylor BC, Cummings SR, Schousboe JT, Kuskowski MA, Stone KL, Ensrud KE. Differences in site-specific fracture risk among older women with discordant results for osteoporosis at hip and spine: study of osteoporotic fractures. J Clin Densitom 2008; 11:250-9. [PMID: 18296090 PMCID: PMC2724071 DOI: 10.1016/j.jocd.2007.12.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Revised: 12/20/2007] [Accepted: 12/20/2007] [Indexed: 11/30/2022]
Abstract
To examine the fracture pattern in older women whose bone mineral density (BMD) T-score criteria for osteoporosis at hip and spine disagree, hip and spine BMD were measured in Study of Osteoporotic Fractures participants using dual energy X-ray absorptiometry (DXA). Hip osteoporosis was defined as T-score <or=-2.5 at femoral neck or total hip, and spine osteoporosis as T-score <or=-2.5 at lumbar spine. Incident clinical fractures were self-reported and centrally adjudicated. Incident radiographic spine fractures were defined morphometrically. Compared to women with osteoporosis at neither hip nor spine, those osteoporotic only at hip had a 3.0-fold age- and weight-adjusted increased risk for hip fracture (95% confidence interval [CI]: 2.4-3.6), and smaller increases in risk of nonhip nonspine (hazard ratios [HR]=1.6), clinical spine (odds ratio [OR]=2.2), and radiographic spine fractures (OR=1.5). Women osteoporotic only at spine had a 2.8-fold increased odds of radiographic spine fracture (95% CI: 2.1-3.8), and smaller increases in risk of clinical spine (OR=1.4), nonhip nonspine (HR=1.6), and hip fractures (HR=1.2). Discordant BMD results predict different fracture patterns. DXA fracture risk estimation in these patients should be site specific. Women osteoporotic only at spine would not have been identified from hip BMD measurement alone, and may have a sufficiently high fracture risk to warrant preventive treatment.
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Affiliation(s)
- Howard A. Fink
- Geriatric Research Education & Clinical Center, VA Medical Center, Minneapolis, MN
- Center for Chronic Disease Outcomes Research, VA Medical Center, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Stephanie L. Harrison
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, CA
| | - Brent C. Taylor
- Center for Chronic Disease Outcomes Research, VA Medical Center, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Steven R. Cummings
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, CA
- University of California, San Francisco, CA
| | - John T. Schousboe
- Park Nicollet Clinic, Minneapolis, MN
- Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Michael A. Kuskowski
- Geriatric Research Education & Clinical Center, VA Medical Center, Minneapolis, MN
| | - Katie L. Stone
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, CA
| | - Kristine E. Ensrud
- Center for Chronic Disease Outcomes Research, VA Medical Center, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
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Oral Bisphosphonate-Induced Osteonecrosis: Risk Factors, Prediction of Risk Using Serum CTX Testing, Prevention, and Treatment. J Oral Maxillofac Surg 2007; 65:2397-410. [DOI: 10.1016/j.joms.2007.08.003] [Citation(s) in RCA: 542] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 06/01/2007] [Accepted: 08/15/2007] [Indexed: 02/05/2023]
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Gudmundsdottir SL, Indridason OS, Franzson L, Sigurdsson G. Age-related decline in bone mass measured by dual-energy X-ray absorptiometry and quantitative ultrasound in a population-based sample of both sexes: identification of useful ultrasound thresholds for osteoporosis screening. J Clin Densitom 2005; 8:80-6. [PMID: 15722591 DOI: 10.1385/jcd:8:1:080] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 08/31/2004] [Accepted: 08/31/2004] [Indexed: 11/11/2022]
Abstract
Quantitative ultrasound (QUS) can be used as a screening tool for low bone mineral density (BMD), but clinical guidelines have not been set. The aim of this population-based, cross-sectional study was to compare age-related changes in bone mass measured by QUS (Lunar, Achilles Plus) and dual-energy X-ray absorptiometry (DXA) in a random sample of 1630 individuals (1041 females, 589 males) 30-85 yr of age. Individuals with DXA T-scores < or =-2.5 at the femoral neck or total hip were identified and receiver operating curves (ROCs) were used to calculate cutoff points for QUS. Sensitivity, specificity, and kappa statistics were calculated. Age-related bone loss was significantly larger with QUS than DXA at all sites in women. For men, the curves were similar for QUS and DXA in the hip. Similar correlations were found between QUS and DXA in different age groups of both sexes (0.36-0.60). For women aged 50-65 yr, a QUS T-score >-1.0 was found to be the most applicable for identifying normal BMD. In the 70-85 yr age group, a T-score <-2.5 for women and a T-score <-0.5 for men seemed reasonable cutoffs for identifying normal BMD (sensitivity: 86-93%; specificity: 28-44%; discordance: 33-73%). Calcaneal QUS cannot be used for the diagnosis of osteoporosis according to WHO criteria, but it can be of use to exclude osteoporosis in 30-40% of our cases.
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Affiliation(s)
- Sigridur L Gudmundsdottir
- Department of Endocrinology & Metabolism, Landspitali-University Hospital, Fossvogur, IS-108 Reykjavik, Iceland
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Vokes TJ, Gillen DL, Lovett J, Favus MJ. Comparison of T-scores from different skeletal sites in differentiating postmenopausal women with and without prevalent vertebral fractures. J Clin Densitom 2005; 8:206-15. [PMID: 15908709 DOI: 10.1385/jcd:8:2:206] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Revised: 12/16/2004] [Accepted: 12/16/2004] [Indexed: 11/11/2022]
Abstract
It is not clear how bone mineral density (BMD) measurements from several regions of lumbar spine and proximal femur should be utilized in assessing fracture risk. We examined how well the newest ISCD recommendations differentiate subjects with and without prevalent vertebral fractures in 187 postmenopausal women presenting for routine bone densitometry. The association between T-scores from proximal femur and lumbar spine sites and the probability of having a vertebral fracture was modeled via logistic regression with adjustment for age. The lowest T-score of any hip or spine sites (the current ISCD recommendation) and the proximal femur measurements, particularly the femoral neck and total hip, displayed the strongest association with the probability of vertebral fractures.Subjects with a T-score < -2.5 at multiple hip sites had a higher probability of having a vertebral fracture. The sensitivity and specificity associated with particular T-score cutoff values varied greatly depending on the site of measurement.Consequently, T-score values from different sites that had comparable sensitivity/specificity for detecting the presence of vertebral fractures differed by as much as 1.5 T-score units. This finding implies that a single cutoff value, such as -2.5, might not be clinically acceptable when applied to T-scores from different sites.
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Affiliation(s)
- Tamara J Vokes
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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20
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Identification of Low Bone Mass in a Developmental Center: Finger Bone Mineral Density Measurement in 562 Residents. J Am Med Dir Assoc 2004. [DOI: 10.1016/s1525-8610(04)70004-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Elliott ME, Binkley N. Evaluation and measurement of bone mass. Epilepsy Behav 2004; 5 Suppl 2:S16-23. [PMID: 15123007 DOI: 10.1016/j.yebeh.2003.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2003] [Accepted: 11/21/2003] [Indexed: 11/30/2022]
Abstract
Patients taking antiepileptic drugs (AEDs) have an increased risk for osteoporosis and osteoporotic fractures. Bone mineral density (BMD) is the best predictor of fracture risk. Measurement of BMD allows the identification of patients at risk before they suffer a fracture. The current "gold standard" for the measurement of BMD and diagnosis of osteopenia and osteoporosis is dual-energy X-ray absorptiometry. Clinicians should be familiar with the ways in which bone mass measurements are reported and should understand how to use BMD measurements in making treatment decisions and monitoring treatment. They should also be aware of current controversies, including the role of peripheral versus central BMD measurements and the use of different reference databases for different patient groups. Laboratory assessment to identify secondary causes of osteoporosis, such as low vitamin D status in patients taking AEDs, is useful, but the role of markers of bone turnover in clinical practice has not been well defined.
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Affiliation(s)
- Mary E Elliott
- University of Wisconsin School of Pharmacy, 777 Highland Avenue, Madison, WI 53705, USA.
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22
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Abstract
OBJECTIVE To review the literature concerning the utility of point-of-care (POC) testing devices for the diagnosis and management of osteoporosis. DATA SOURCES Articles were identified from a MEDLINE search (1993–June 2003). Additional references were obtained from cross-referencing the bibliographies of selected articles. STUDY SELECTION AND DATA EXTRACTION After evaluation of clinical trials and select review articles, articles comparing peripheral dual-energy absorptiometry (pDXA) or quantitative ultrasound (QUS) with central DXA (cDXA) measurements were emphasized in this analysis. DATA SYNTHESIS Sensitivity for detecting osteoporosis by QUS or pDXA varies widely (range 35–75%). Using adjusted T-score cutoffs increases sensitivity to 85–95%, at the price of reducing device specificity to 23–49%. Many states require a radiology technician to perform pDXA tests. CONCLUSIONS POC testing with peripheral devices should only be considered in areas with limited access to cDXA or for women who initially refuse cDXA testing. T scores of −1.0 or less with POC testing typically require further evaluation via cDXA. Many states require pDXAs to be performed by certified radiology technologists, making QUS use more feasible for pharmacists. POC testing should not be used for assessing response to osteoporosis therapy.
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Affiliation(s)
- Renee M DeHart
- McWhorter School of Pharmacy, Medical Center East Family Practice Residency Program, Samford University, Birmingham, AL 35229-7027, USA.
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Picard D, Brown JP, Rosenthall L, Couturier M, Lévesque J, Dumont M, Ste-Marie LG, Tenenhouse A, Dodin S. Ability of peripheral DXA measurement to diagnose osteoporosis as assessed by central DXA measurement. J Clin Densitom 2004; 7:111-8. [PMID: 14742895 DOI: 10.1385/jcd:7:1:111] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2002] [Revised: 04/08/2003] [Accepted: 05/13/2003] [Indexed: 11/11/2022]
Abstract
In order to evaluate the utility of peripheral measurement of bone mineral density (BMD) in the diagnosis of osteoporosis, we measured BMD at the spine and femoral neck with central dual-energy X-ray absorptiometry (DXA), at phalanx with AccuDXA (Schick) as well as proximal and distal forearm with pDXA (Norland) in 835 women ranging in age from 20 to 85 yr. In receiver operating characteristic (ROC) curves, where a positive case was defined as a T-score < or = -2.5 either on spine or femoral neck, the areas under the curve were not significantly different between sites. At a T-score of -2.5 as determined by each peripheral apparatus, sensitivity and specificity were, respectively, 0.39 and 0.95 for phalanx and 0.75 and 0.85 for proximal forearm whereas they were 0.42 and 0.96 for distal forearm. Using optimal absolute BMD cutoff values improved the results. Sensitivity and specificity were, respectively, 0.79 and 0.83 for phalanx at an absolute BMD value of 0.436 and 0.84 and 0.79 for proximal forearm at a value of 0.703, whereas they were 0.90 and 0.75 for distal forearm at a value of 0.208. Combining the two forearm measurements improves the results slightly. At cutoff values of 0.641 and 0.252, respectively for proximal and distal forearms, sensitivity was 0.83 and specificity was 0.84. Therefore, a peripheral measurement of BMD together with a good clinical evaluation of the osteoporosis risk profile of the patient, can be an interesting tool for the diagnosis of osteoporosis in areas where central DXA is not available.
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Affiliation(s)
- D Picard
- Department of Nuclear Medicine, Hôpital Saint-Luc, Université de Montréal, Montreal, Québec, Canada.
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Kiebzak GM, Lewiecki EM, Petak SM. Impact of using the ultradistal radius region of interest on diagnostic classification. J Clin Densitom 2004; 7:143-52. [PMID: 15181258 DOI: 10.1385/jcd:7:2:143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Revised: 09/05/2003] [Accepted: 10/03/2003] [Indexed: 11/11/2022]
Abstract
World Health Organization (WHO) criteria using T-scores for classifying patients as normal, osteopenic, or osteoporotic are based on bone mineral density (BMD, g/cm2) of the lumbar spine and hip and bone mineral content (BMC) (BMC, g) at the distal and midradius. There is no consensus on whether other forearm regions of interest (ROIs) can be used with the WHO criteria. Because the ultradistal radius region of interest (UDR) has a greater ratio of trabecular to cortical bone than midshaft portions of the radius, it is possible that more patients would be classified as osteoporotic if the UDR is measured. The objective of this study was to determine the prevalence of osteoporosis when using T-scores from the UDR in addition to PA lumbar spine, proximal femur (hip), and the radius 33% ROI. Retrospective data were obtained from three centers with differing patient demographics, thus reducing bias as a result of patient characteristics. Data were used only from patients who had a spine, hip, and forearm scan on the same day. Central dual-energy X-ray absorptiometry (DXA) systems included a GE Lunar DPX-L, DPX IQ, and Prodigy and a Hologic Delphi. Hologic data were for the ultradistal radius + ulna ROI (UDRU). Diagnostic classification (using the WHO T-score criteria) was made excluding and including the UDR and UDRU T-scores, in addition to lumbar spine (L2-L4 or L1-L4), hip (femoral neck, greater trochanter, or total), and the radius 33% ROI. The lowest T-score from any ROI determined the classification. For all GE Lunar patients (n = 409 women; age range: 20-96 yr), the distribution of normal, osteopenic, osteoporotic not using the UDR was 94 (23%), 170 (42%), and 145 (36%), respectively. The distribution when using the UDR was 67 (16%), 137 (33%), and 205 (50%), respectively. The difference in the ratio of normal + osteopenic versus osteoporotic when excluding and including the UDR T-scores was significant (p < 0.0001; two-tailed Fisher's exact test). For all Hologic patients (n = 153 women; age range: 44-93 yr), the distributions were 32 (21%), 66 (43%), and 55 (36%) not using and 31 (20%), 64 (42%), and 58 (38%), respectively, using the UDRU (not statistically significantly different). The group mean T-scores were lowest for the UDR compared to the spine and hip with GE Lunar but not Hologic patients.
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Affiliation(s)
- Gary M Kiebzak
- Center for Orthopaedic Research and Education, St. Luke's Episcopal Hospital, 6720 Bertner Avenue, Houston, TX 77030, USA.
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Rothenberg RJ, Boyd JL, Holcomb JP. Quantitative ultrasound of the calcaneus as a screening tool to detect osteoporosis: different reference ranges for caucasian women, african american women, and caucasian men. J Clin Densitom 2004; 7:101-10. [PMID: 14742894 DOI: 10.1385/jcd:7:1:101] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Accepted: 05/09/2003] [Indexed: 11/11/2022]
Abstract
The interpretation of results measured by quantitative ultrasound (QUS) of the heel depends on the population studied. We measured estimated bone mineral density (BMD) of the heel using the Hologic Sahara sonometer. People were studied at county fairs, health fairs, and churches. Subjects were not on treatments that would affect bone density, other than calcium supplementation. This included 823 Caucasian women, 131 African American women, and 301 Caucasian men. In contrast to women, for Caucasian men the squared term for age was not significant, and a straight line of decline was the best fit for estimated BMD. African American women had a standard deviation larger than that reported by Hologic for Caucasian women. We compared a history of self-reported fractures with a subject's estimated BMD. An estimated BMD of 0.57 gm/cm2 included 75% of all fractures. This cutoff point was associated with increased fracture prevalence in subjects over age 50, relative risk of 1.4. This result corresponds to the Hologic data T-score of -0.2. When used as a screening tool for osteoporosis fracture risk, an estimated BMD of 0.57 gm/cm2 seems reasonable in those subjects over age 50.
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Affiliation(s)
- R J Rothenberg
- Northeastern Ohio University College of Medicine and Forum Health Care, Youngstown, OH 44501, USA
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Abstract
UNLABELLED The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. INTRODUCTION The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. MATERIALS AND METHODS Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). RESULTS A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. CONCLUSIONS A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.
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Affiliation(s)
- Clifford J Rosen
- Maine Center for Osteoporosis Research and Education, St. Joseph Hospital, Bangor, Maine 04401, USA.
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Pedrazzoni M, Girasole G, Bertoldo F, Bianchi G, Cepollaro C, Del Puente A, Giannini S, Gonnelli S, Maggio D, Marcocci C, Minisola S, Palummeri E, Rossini M, Sartori L, Sinigaglia L. Definition of a population-specific DXA reference standard in Italian women: the Densitometric Italian Normative Study (DINS). Osteoporos Int 2003; 14:978-82. [PMID: 14530829 DOI: 10.1007/s00198-003-1521-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2003] [Accepted: 09/05/2003] [Indexed: 10/26/2022]
Abstract
Osteoporosis is currently defined on the basis of the T-score by dual-energy X-ray absorptiometry (DXA). Despite its limitations, this definition is applied worldwide. However, the normal values provided by manufacturers may not be fully representative of specific local populations. So far, there are no normative data in the Italian population using Hologic densitometers. The Densitometric Italian Normative Study (DINS) is an ongoing multi-center study that aims to establish reference values for bone densitometry with dual-energy X-ray absorptiometry (DXA) in the male and female Italian population. In this paper we report the results of the lumbar vertebrae (L2-L4) and proximal femur in 1,622 women aged 20-79 years. Bone mineral density (BMD) was determined using dual-energy X-ray absorptiometry (DXA) on Hologic bone densitometers (Hologic, Waltham, Mass.). Most of the subjects were examined with a QDR 4500. The BMD of the lumbar vertebrae was virtually constant between 20 and 49 years (test for trend: P=0.66); the BMD values between 20-45 in premenopausal women (mean 1.036; SD 0.109 g/cm(2)) were thus defined as the peak bone mass values, significantly lower compared to the Hologic reference curve (mean 1.079, SD 0.11 g/cm(2)). The mean BMD values of the femoral neck were virtually identical to those of the NHANES study in the first 3 decades; after the age of 50 the BMD values were slightly greater than those of the NHANES subject. The subject classification according to the WHO criteria was similar using the DINS and NHANES reference values for the femur; for the spine, the Hologic reference values classified a larger proportion of women as osteoporotic (21 vs. 16%) or osteopenic (42 vs. 38%) compared to DINS.
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Affiliation(s)
- M Pedrazzoni
- Dipartimento di Medicina Interna e Scienze Biomediche, Università di Parma, Via Gramsci 14, 43100, Parma, Italy.
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Hans D, Hartl F, Krieg MA. Device-specific weighted T-score for two quantitative ultrasounds: operational propositions for the management of osteoporosis for 65 years and older women in Switzerland. Osteoporos Int 2003; 14:251-8. [PMID: 12730788 DOI: 10.1007/s00198-002-1358-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2002] [Accepted: 11/12/2002] [Indexed: 10/20/2022]
Abstract
The World Health Organization (WHO) criteria for the diagnosis of osteoporosis are mainly applicable for dual X-ray absorptiometry (DXA) measurements at the spine and hip levels. There is a growing demand for cheaper devices, free of ionizing radiation such as promising quantitative ultrasound (QUS). In common with many other countries, QUS measurements are increasingly used in Switzerland without adequate clinical guidelines. The T-score approach developed for DXA cannot be applied to QUS, although well-conducted prospective studies have shown that ultrasound could be a valuable predictor of fracture risk. As a consequence, an expert committee named the Swiss Quality Assurance Project (SQAP, for which the main mission is the establishment of quality assurance procedures for DXA and QUS in Switzerland) was mandated by the Swiss Association Against Osteoporosis (ASCO) in 2000 to propose operational clinical recommendations for the use of QUS in the management of osteoporosis for two QUS devices sold in Switzerland. Device-specific weighted "T-score" based on the risk of osteoporotic hip fractures as well as on the prediction of DXA osteoporosis at the hip, according to the WHO definition of osteoporosis, were calculated for the Achilles (Lunar, General Electric, Madison, Wis.) and Sahara (Hologic, Waltham, Mass.) ultrasound devices. Several studies (totaling a few thousand subjects) were used to calculate age-adjusted odd ratios (OR) and area under the receiver operating curve (AUC) for the prediction of osteoporotic fracture (taking into account a weighting score depending on the design of the study involved in the calculation). The ORs were 2.4 (1.9-3.2) and AUC 0.72 (0.66-0.77), respectively, for the Achilles, and 2.3 (1.7-3.1) and 0.75 (0.68-0.82), respectively, for the Sahara device. To translate risk estimates into thresholds for clinical application, 90% sensitivity was used to define low fracture and low osteoporosis risk, and a specificity of 80% was used to define subjects as being at high risk of fracture or having osteoporosis at the hip. From the combination of the fracture model with the hip DXA osteoporotic model, we found a T-score threshold of -1.2 and -2.5 for the stiffness (Achilles) determining, respectively, the low- and high-risk subjects. Similarly, we found a T-score at -1.0 and -2.2 for the QUI index (Sahara). Then a screening strategy combining QUS, DXA, and clinical factors for the identification of women needing treatment was proposed. The application of this approach will help to minimize the inappropriate use of QUS from which the whole field currently suffers.
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Affiliation(s)
- D Hans
- Division of Nuclear Medicine, Geneva University Hospital, Geneva, Switzerland.
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Gnudi S, Malavolta N. Comparison between T-score-based diagnosis of osteoporosis and specific skeletal site measurements: prognostic value for predicting fracture risk. J Clin Densitom 2003; 6:267-73. [PMID: 14514997 DOI: 10.1385/jcd:6:3:267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2002] [Revised: 03/25/2003] [Accepted: 04/24/2003] [Indexed: 11/11/2022]
Abstract
T-score-based diagnosis of osteoporosis might lead to diagnostic misclassification when using multiple-site bone mineral density (BMD) measurements. To compare the diagnostic concordance of T-score-based diagnosis of osteoporosis among different skeletal sites and its correlation to osteoporotic fracture, we studied 1200 postmenopausal women with (441) and without (759) fragility fracture after measuring BMD at the femoral neck, Ward's triangle, trochanter, and spine. Agreement rates of T-score-based diagnosis of osteoporosis were statistically different between pairs of measurements taken at different skeletal sites (McNemar test, p < 0.001). Fragility fractures poorly matched T-score-based diagnosis of osteoporosis (Cohen and Younden indexes <0.4). Technique inaccuracies support these discrepancies as also shown by the large range of T-score values (from -2 to -3) with similar abilities to predict fractures by ROC curve area comparison. Concordance rates between T-score and fragility fracture diagnosis of osteoporosis (marginal homogeneity test, p < 0.001) were also different across the various measurement sites. Our data show that the T-score leads to diagnostic inconsistencies among different skeletal sites and low concordance with fragility fracture based diagnosis of osteoporosis. Integration of the T-score with multiple risk assessment from clinical sources should be tested to better diagnose osteoporosis and related fracture risk.
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Affiliation(s)
- Saverio Gnudi
- Modulo Dipartimentale di Medicina Interna, Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40100 Bologna.
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Yang NP, Lin T, Wang CS, Chou P. Community-based survey of low quantitative ultrasound values of calcaneus in Taiwan. J Clin Densitom 2003; 6:131-41. [PMID: 12794235 DOI: 10.1385/jcd:6:2:131] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2002] [Accepted: 07/31/2002] [Indexed: 11/11/2022]
Abstract
This study investigated prevalence and associated-factors of low quantitative ultrasound (QUS) values by screening calcaneal QUS parameters--broadband ultrasound attenuation (BUA) and speed of sound (SOS)--in population samples of three different Taiwanese communities. The study included 6,322 subjects (2,631 male and 3,691 female), aged 31 yr old or more in Shih-Pai (a metropolitan area in northern Taiwan),Yu-Chi (a mountain area in central Taiwan), and A-Lein (a seaside area in southern Taiwan). The overall response rate was 50.2%. The correlation between BUA and SOS was 0.684, p<0.001. From those who responded, we selected 403 subjects aged 31-40 yr as the reference (the young group), and their BUA was 65.34+/-7.91 dB/MHz. The t-score was calculated from the BUA data of our reference group. The percentile of -2.5<t-score<-1.0 and t-score< or =-2.5 in male subjects was 21.4 and 2.9%, respectively, and in female subjects 24.2 and 14.1%, respectively. The BUA of urban area subjects was higher than that of rural area subjects in almost all age-strata, and overweight was noted to be a protective factor. The effect of age-adjusted odds ratio (AOR) on low QUS values in females was significantly increased every 10 yr from 1.55, 5.13, 13.81, 34.29, to 38.14. This survey showed that age-related decreases in calcaneal ultrasonometry, indicating prevalence of low QUS values, were more obvious in female than male subjects. Overall 38.3% of the female Taiwanese had low QUS values, and this is approximately equivalent to the lifetime risk of fracture at the hip, spine, or distal forearm in Caucasian women. The specific t-score designation, as World Health Organization (WHO) criteria, applied to calcaneal QUS are reasonable when the reference group is selected from the same population.
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Affiliation(s)
- Nan-Ping Yang
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Taiwan, ROC
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31
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Pearson D, Masud T, Sahota O, Earnshaw S, Hosking D. A comparison of calcaneal dual-energy X-ray absorptiometry and calcaneal ultrasound for predicting the diagnosis of osteoporosis from hip and spine bone densitometry. J Clin Densitom 2003; 6:345-52. [PMID: 14716047 DOI: 10.1385/jcd:6:4:345] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Accepted: 06/16/2003] [Indexed: 11/11/2022]
Abstract
Peripheral densitometry is increasingly being used in the management of osteoporosis, but the optimal diagnostic thresholds have not been defined. The aim of this study was to determine the optimal T-score for peripheral dual-energy X-ray absorptiometry (pDXA) of the heel using a GE Lunar PIXI and quantitative ultrasound (QUS) of the heel using a GE Lunar Achilles Plus when compared with dual-energy X-ray absorptiometry (DXA) of central sites (spine, femoral neck, or total hip). Ninety-nine women (mean age 69 +/- 8, range 33-86 yr) referred from the metabolic bone clinic were studied. The optimal T-score for pDXA from ROC analysis was -1.7 and for QUS was -2.5. The pDXA T-score that defined the same prevalence of osteoporosis at any central site was also -1.7 and for QUS was -2.4. These results are similar to the manufacturer's recommendations. There is no significant difference in performance between the PIXI and QUS.
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Affiliation(s)
- Derek Pearson
- Nottingham City Hospital NHS Trust, University Hospital NHS Trust, Nottingham, UK.
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Abstract
In the face of increasing use of all types of bone densitometry in the diagnosis and management of osteoporosis, the limitations of the World Health Organization criteria for the diagnosis of osteoporosis based on bone density measurements have become apparent. Controversy has arisen about whether these criteria should be used for the diagnosis of osteoporosis. Using densitometry to monitor changes in bone density as a measure of therapeutic efficacy has been criticized. It has been suggested that changes in bone density are not surrogates for reduction in fracture risk and that regression to the mean invalidates serial testing. There is both truth and fallacy in these controversies. The resolutions are critical to the role of densitometry in clinical practice.
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Affiliation(s)
- Sydney Lou Bonnick
- Institute for Women's Health, Texas Woman's University, Denton, Texas 76204, USA.
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Boyd JL, Holcomb JP, Rothenberg RJ. Physician treatment of osteoporosis in response to heel ultrasound bone mineral density reports. J Clin Densitom 2002; 5:375-81. [PMID: 12665638 DOI: 10.1385/jcd:5:4:375] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2001] [Revised: 01/31/2002] [Accepted: 02/27/2002] [Indexed: 11/11/2022]
Abstract
Optimal information that should be included in ultrasound (US) heel bone mineral density (BMD) reports is not known. If additional information about further evaluation of patients with low heel BMD were included in reports, would responses for treatment improve? We screened people at health fairs using the Sahara heel US machine. For those with a T-score of </= 1.0, letters were sent to their primary care physician notifying them of the result. Physicians were randomly assigned to (1) a standard letter, which recommended central bone density screening (dual X-ray absorptiometry [DXA]) and treatment if the BMD was low; or (2) an extended letter, which also outlined treatment strategies based on recommended subsequent central DXA scan results for a T-score of < 1.50 and also if < 2.00. The extended letter only increased the frequency of DXA testing from 30.1 to 37.2% (not a significant increase). Of 88 people with heel BMD </= 1.00 and not previously on any treatment, 25 of 45 (56%) were treated (calcium, estrogens, bisphosphonates, or calcitonin or a combination) after physicians received a standard letter and 30 of 43 (70%) after an extended letter (one-sided p = 0.084). Of people with T </= 1.9, and initially taking nothing more than calcium, 5 of 36 (13.9%) received additional treatment after physicians received a standard letter vs 9 of 41 (22.0%) after an extended letter (one-sided p = 0.180). For those with T </= 1.0 because of the screen 25 of 197 (12.7%) received additional treatment. One hundred forty-six of 194 (75%) individuals and received treatment with calcium or other medications, and 74 of 173 (43%) of individuals before screening and 141 of 195 (72%) after physicians received letters took calcium. Physicians regarded calcium alone as adequate treatment in many cases. There was no marked increase in treatment when additional information was provided to physicians regarding evaluation and treatment for low US heel BMD results.
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Affiliation(s)
- Joan L Boyd
- Department of Health Professions, Youngstown State University, Ohio, USA
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Vallarta-Ast N, Krueger D, Binkley N. Densitometric diagnosis of osteoporosis in men: effect of measurement site and normative database. J Clin Densitom 2002; 5:383-89. [PMID: 12665639 DOI: 10.1385/jcd:5:4:383] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2001] [Revised: 02/15/2002] [Accepted: 02/22/2002] [Indexed: 02/01/2023]
Abstract
Controversy exists regarding which sites to measure, and the appropriate reference database to use, for densitometric diagnosis of osteoporosis in men. While hip and spine bone mineral density (BMD) measurement is routine, spinal osteoarthritis often elevates measured BMD in older men. Additionally, the use of male reference data is standard practice; however, recent reports suggest that a female database may be more appropriate. This study evaluated the effect of sites measured, and normative database utilized, on the densitometric diagnosis of osteoporosis in men. Spine, femur, and ultradistal radial BMD T-scores were determined in 595 male veterans using the GE Lunar male normative database. Subsequently, World Health Organization diagnostic criteria were applied, identifying 282 men with osteoporosis (T-score </= 2.5). The combination of femoral (lowest of neck or total) with the ultradistal radius site was more sensitive (p < 0.0001) for diagnosing osteoporosis than femur plus lumbar spine. When scans from 129 subjects with documented fractures were analyzed using female normative data, fewer (p < 0.0001) met an arbitrary threshold for receiving pharmacologic osteoporosis therapy. In conclusion, BMD measurement at only the spine and hip leads to underdiagnosis of osteoporosis in men. This situation will be exacerbated by utilization of a female normative database; more men with prior fracture may be categorized as not meeting a pharmaceutical intervention threshold.
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Cherney DD, Laymon MS, McNitt A, Yuly S. A study on the influence of calcified intervertebral disk and aorta in determining bone mineral density. J Clin Densitom 2002; 5:193-8. [PMID: 12110763 DOI: 10.1385/jcd:5:2:193] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2001] [Revised: 10/11/2001] [Accepted: 10/12/2001] [Indexed: 11/11/2022]
Abstract
This study utilized dual-energy X-ray absorptiometry (DXA) to determine the association that age-related calcinosis of the aorta and intervertebral disks have in determining bone mineral density (BMD). Eight cadavers were chosen at random and were scanned with DXA before and after the removal of the aorta and intervertebral disks. Our results showed that the removal of sclerotic aortas decreased the vertebral BMD an average of 4.64% and the removal of two lumbar intervertebral disks further decreased BMD an average of 11.93%. These results were deemed significant at the 0.01 level using a Friedman two-way analysis of variance by ranks. It can be concluded that the presence of aortic arteriosclerotic lesions and intervertebral disk chondrocalcinosis add a significant contribution to BMD.
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Affiliation(s)
- David D Cherney
- Department of Physical Therapy, Azusa Pacific University, Azusa, CA 91702-7000, USA
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Elliott ME, Meek PD, Kanous NL, Schill GR, Weinswig PA, Bohlman JP, Zimpel CL, Jensen BC, Walters DR, Sutter SL, Peterson AN, Peterson RM, Binkley NC. Osteoporosis screening by community pharmacists: use of National Osteoporosis Foundation resources. JOURNAL OF THE AMERICAN PHARMACEUTICAL ASSOCIATION (WASHINGTON, D.C. : 1996) 2002; 42:101-10; quiz 110-1. [PMID: 11833500 DOI: 10.1331/108658002763538134] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the feasibility of establishing an osteoporosis screening program in rural community pharmacies based on information and resources provided by the National Osteoporosis Foundation (NOF), to survey primary care providers regarding the usefulness of this screening program, and to recommend strategies for pharmacists interested in working with patients at risk for osteoporosis. DESIGN AND PARTICIPANTS Pharmacists and/or nurses enrolled women 65 years of age and older into the study, measured calcaneal bone density, administered a questionnaire to ascertain subjects' osteoporosis risk factors, and provided NOF literature to subjects. With their agreement, women's bone mass data and risk factor assessments were provided to primary care providers along with NOF's Physician's Guide to Prevention and Treatment of Osteoporosis. These providers were surveyed as to whether they found this information useful. SETTING Five independent community pharmacies in rural Wisconsin. RESULTS We enrolled and tested 133 women. Of these, 122 (92%) agreed to have information mailed to their primary health care providers. These 57 providers were surveyed and 24 (42%) responded; of these 24, 20 (83%) found the information they received useful. CONCLUSION A community pharmacy-based osteoporosis screening program using NOF materials was well accepted by physicians. NOF resources and recommendations can provide a strong foundation for such programs.
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Affiliation(s)
- Mary E Elliott
- School of Pharmacy, University of Wisconsin-Madison, 53705, USA.
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37
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Hamdy RC, Petak SM, Lenchik L. Which central dual X-ray absorptiometry skeletal sites and regions of interest should be used to determine the diagnosis of osteoporosis? J Clin Densitom 2002; 5 Suppl:S11-8. [PMID: 12464707 DOI: 10.1385/jcd:5:3s:s11] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although central measurement of bone mass by dual X-ray absorptiometry (DXA) is viewed by many as the "gold standard" for the diagnosis of osteoporosis in patients without previous fragility fracture, controversy remains on how best to use central DXA as a tool for diagnosis. Questions concerning the measurement of bone mass of the central skeleton were addressed at the International Society for Clinical Densitometry Position Development Conference. An expert panel agreed on the following positions: First, the diagnosis of osteoporosis should be based on the lowest T-score of either the PA spine or hip. Second, both the PA spine and hip should be measured. Third, whenever possible, bone mineral density (BMD) of the first four lumbar vertebrae should be measured. Fourth, DXA manufacturers should use L1-L4 as the default region of interest for their printouts. Fifth, BMD of either hip may be measured. Sixth, the lowest T-score of the three sites total hip, femoral neck, or trochanter should be considered. Seventh, Ward's area should not be used for diagnostic purposes; DXA manufacturers should not include this region in the default printout. Eighth, BMD of the forearm should be measured if the hip or spine cannot be accurately measured. Finally, lateral spine BMD should not be used to diagnose osteoporosis.
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38
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Njeh CF, Saeed I, Grigorian M, Kendler DL, Fan B, Shepherd J, McClung M, Drake WM, Genant HK. Assessment of bone status using speed of sound at multiple anatomical sites. ULTRASOUND IN MEDICINE & BIOLOGY 2001; 27:1337-1345. [PMID: 11731047 DOI: 10.1016/s0301-5629(01)00437-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Studies in vitro and in vivo have shown that quantitative ultrasound (QUS) is a valid tool for the assessment of bone status. Current QUS methods using the transmission technique are limited to one peripheral bone site. A new system, Sunlight Omnisense (Omnisense, Sunlight Medical Ltd., Rehovot, Israel), measures speed of sound (SOS, in m/s) along the surface of the bone based on an axial transmission technique. The Omnisense can measure SOS at several anatomical sites. This study evaluated the SOS at different anatomical sites in a healthy population. A total of 334 adult women from three research centers in the USA and Canada with a mean (+/- SD) age of 48.8 (+/- 17.4) years were enrolled in this study. SOS was measured at the proximal third phalanx, distal one third radius, midshaft tibia, and fifth metatarsal. The mean SOS (+/- SD) values for the phalanx, radius, tibia and metatarsal were 3984 (+/- 221), 4087 (+/- 147), 3893 (+/- 150) and 3690 (+/- 246) m/s, respectively. Each anatomical site SOS was significantly different (p < 0.001) from that of the other sites. SOS at the different anatomical sites was modestly, but significantly, correlated (r = 0.31 to 0.56, p < 0.001). Similar correlation coefficients were obtained for the T scores. The mean T scores for subjects over the age of 60 years were -1.94, -2.01, -0.97 and -1.42 for the phalanx, radius, tibia and metatarsal, respectively. The age of peak SOS and the rate of change thereafter varied with anatomical site, implying that the prevalence of osteopenia and osteoporosis was site-dependent if only one T score cut-off point was used. Comparing individuals, 10% to 17% of patients had T scores that differed by more than a factor of 2 between sites. Weight and age were some of the contributing factors to this heterogeneity. The Omnisense provides an opportunity to assess bone status at different anatomical sites. Whether or not combining measurements from all these anatomical sites will improve osteoporosis management still needs to be determined.
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Affiliation(s)
- C F Njeh
- Osteoporosis and Arthritis Research Group, Department of Radiology, University of California San Francisco, 350 Parnassus Avenue, Suite 607, San Francisco, CA 94143-1349, USA.
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Jirkovská A, Kasalický P, Boucek P, Hosová J, Skibová J. Calcaneal ultrasonometry in patients with Charcot osteoarthropathy and its relationship with densitometry in the lumbar spine and femoral neck and with markers of bone turnover. Diabet Med 2001; 18:495-500. [PMID: 11472470 DOI: 10.1046/j.1464-5491.2001.00511.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS To assess calcaneal ultrasonometry in Charcot osteoarthropathy (CO) and to compare it with densitometry measured by dual energy X-ray absorptiometry (DEXA) and with bone remodelling markers. PATIENTS AND METHODS A group of 16 diabetic patients in the acute stage of CO with a mean age (+/- SD) of 51 +/- 13 years was compared with 26 sex- and age-matched control subjects. Both calcaneal quantitative ultrasound (QUS) parameter stiffness and bone mineral density (BMD) measured in lumbar spine and femoral neck by DEXA were compared. Collagen type I cross-linked C-telopeptides (ICTP) were used for assessment of bone resorption. RESULTS Patients with acute CO had significantly lower stiffness of the calcaneus in the Charcot and non-Charcot foot (both P < 0.001) and significantly lower femoral neck BMD (P < 0.05) in comparison with the control group. The T-score of stiffness was significantly lower in the Charcot foot compared with the non-Charcot foot (-3.00 +/- 1.39 vs. -2.36 +/- 1.12; P < 0.01) and significantly lower than the mean T-score of BMD in the lumbar spine (-0.57 +/- 1.28; P < 0.001) and femoral neck (-1.58 +/- 1.24; P < 0.05). A significant difference in ICTP (8.49 +/- 4.37 vs. 3.92 +/- 2.55 ng/ml; P < 0.001) between patients with CO and the control group was found, and a significant correlation was demonstrated between ICTP and the T-score of stiffness (r = -0.73; P < 0.01). CONCLUSION The lower calcaneal QUS parameter stiffness in the Charcot foot in comparison with the control group, with the non-Charcot foot and with BMD in the lumbar spine and femoral neck, and its association with increased bone resorption indicate that calcaneal ultrasonometry may be useful in diagnosing the acute stage of CO and in assessing the risk of foot fracture. Diabet. Med. 18, 495-500 (2001)
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Affiliation(s)
- A Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Videnská 1958/9, CZ-140 00 Prague 4, Czech Republic.
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40
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41
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Jørgensen HL, Warming L, Bjarnason NH, Andersen PB, Hassager C. How does quantitative ultrasound compare to dual X-ray absorptiometry at various skeletal sites in relation to the WHO diagnosis categories? CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 2001; 21:51-9. [PMID: 11168297 DOI: 10.1046/j.1365-2281.2001.00298.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The World Health Organisation (WHO) has proposed a set of guidelines for the diagnosis of osteoporosis in adult women based on a measurement of bone mineral density (BMD) expressed as the number of SD below young adult mean (t-score). In this study, we investigated the number of subjects classified as either osteopenic or osteoporotic according to these guidelines using dual X-ray absorptiometry (DXA), at the hip, at the spine and at the lower forearm and quantitative ultrasound (QUS), at the heel. A total of 247 men, 209 postmenopausal women and 195 premenopausal women were included in the study. Furthermore, the study provides the first normative data showing the influence of sex, age and menopause on broadband ultrasound attenuation (BUA) and speed of sound (SOS), as measured by the DTU-one imaging ultrasound scanner. The difference between the number of patients classified into either diagnosis group by the investigated parameters is large ranging from 25.9% of the women being diagnosed as osteopenic by BUA at the heel to 43.0% by BMD at the femoral neck. For men, the same range is from 20.5% by BUA to 44.1% by BMD at the femoral neck. For the classification into the osteoporotic group, the range is from 2.5% by intertrochanteric BMD to 24.4% by BMD at Ward's triangle for women and from 0% by SOS to 29.0% by BMD at Ward's triangle for men. Using total hip BMD as the reference parameter to categorize the subjects as normal, osteopenic or osteoporotic, the agreement of the other parameters with this classification is assessed in terms of sensitivity and specificity. We conclude that there are significant differences in the classification of osteoporosis/osteopenia depending on the site measured and the technique used for the bone mass assessment. Furthermore, we suggest that development of technique and site specific cut-off values may increase the accuracy of the classification of osteoporosis/osteopenia in both men and women.
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Affiliation(s)
- H L Jørgensen
- Department of Clinical Biochemistry, Hvidovre Hospital, Hvidovre, Denmark; Center for Clinical and Basic Research, Ballerup, Denmark
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42
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Shields AT, Chesnut CH. Diagnosis of postmenopausal osteoporosis: reviews in endocrine and metabolic disorders. Rev Endocr Metab Disord 2001; 2:23-33. [PMID: 11704977 DOI: 10.1023/a:1010050823176] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- A T Shields
- Department of Radiology, University of Washington Medical Center, Osteoporosis Research Group, 1107 NE 45th Street, Suite 440, Seattle, WA 98105-4631, USA
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43
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Affiliation(s)
- L J Melton
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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44
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Boyd JL, Rothenberg R, Holcomb J. The effects of bone density testing at health fairs on awareness and treatment of osteoporosis. ACTA ACUST UNITED AC 2000; 13:330-2. [PMID: 14635303 DOI: 10.1002/1529-0131(200010)13:5<330::aid-anr13>3.0.co;2-b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- J L Boyd
- Department of Mathematics, Youngstown State University, Youngstown, OH 44555-3327, USA
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45
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Phillipov G, Holsman M, Phillips PJ. The clinical role of quantitative ultrasound in assessing fracture risk and bone status. Med J Aust 2000; 173:208-11. [PMID: 11008596 DOI: 10.5694/j.1326-5377.2000.tb125604.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Quantitative ultrasound (QUS) analysis of calcaneal bone is useful to quantify fracture risk, and in monitoring response to treatment and identifying bone changes associated with disease and medication. However, diagnosis of osteoporosis by QUS measurements remains contentious, but the problems are due to the limitations of the present T-scores rather than the technique. QUS offers the potential for the widespread detection of low bone mass and subsequent management and prevention of fracture.
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Affiliation(s)
- G Phillipov
- Osteoporosis Centre, North Western Adelaide Health Service, Queen Elizabeth Hospital, SA.
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Masud T, Francis RM. The increasing use of peripheral bone densitometry. BMJ (CLINICAL RESEARCH ED.) 2000; 321:396-8. [PMID: 10938032 PMCID: PMC1127781 DOI: 10.1136/bmj.321.7258.396] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
Ultrasound has been proposed as a low-cost, radiation-free method for osteoporosis assessment in postmenopausal women. Large prospective studies have shown that ultrasound parameters can be used for fracture risk estimate in this population, providing that adequate quality control is performed. The places of both ultrasound and the current gold standard method for bone assessment, dual energy x-ray absorptiometry, are still to be determined. Further studies are needed on the diagnosis of osteoporosis using ultrasound, because current diagnostic thresholds, designed by the World Health Organization, do not apply to this-new technology. Monitoring of skeletal changes and treatment effects by ultrasound cannot be recommended.
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Affiliation(s)
- C Roux
- Centre d'Evaluation des Maladies Osseuses, Département de Rhumatologie, Hôpital Cochin, Université René Descartes, Paris, France.
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Mulder JE, Michaeli D, Flaster ER, Siris E. Comparison of bone mineral density of the phalanges, lumbar spine, hip, and forearm for the assessment of osteoporosis in postmenopausal women. J Clin Densitom 2000; 3:373-81. [PMID: 11175918 DOI: 10.1385/jcd:3:4:373] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The objective of this study was to compare peripheral bone mineral density (BMD) of the phalanges with BMD of the lumbar spine, total hip, femoral neck, and forearm and to determine the clinical value of measuring a single peripheral site (phalanges) in identifying postmenopausal women with osteoporosis. BMD was measured by dual energy X-ray absorptiometry using the accuDEXA((R)) (ADXA-finger) (Schick, New York, NY) and the QDR-4500 (DXA-lumbar spine, hip, forearm) (Hologic, Waltham, MA). Correlation coefficients between ADXA and DXA of the lumbar spine, total hip, femoral neck and one third radial site ranged from 0.53 to 0.73. The sensitivity of an ADXA T-score of -2.5 in identifying patients with a DXA T-score of < or = -2.5 at the femoral neck was 35%. An ADXA T-score cut point of -1.0 improved the sensitivity of ADXA in identifying patients with a femoral neck T-score of < or = -2.5 (85%), but the specificity declined from 88 to 49%. There was substantial discordance in the diagnosis of osteoporosis when a single site was measured, regardless of technique. Within the limitations of single-site measurements, BMD measured by ADXA has adequate sensitivity to identify women with low BMD at the femoral neck, if an appropriate T-score criterion is used.
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Affiliation(s)
- J E Mulder
- Department of Medicine, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
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Stoch SA, Wysong E, Connolly C, Parker RA, Greenspan SL. Classification of osteoporosis and osteopenia in men is dependent on site-specific analysis. J Clin Densitom 2000; 3:311-7. [PMID: 11175910 DOI: 10.1385/jcd:3:4:311] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2000] [Revised: 08/25/2000] [Accepted: 08/25/2000] [Indexed: 11/11/2022]
Abstract
To examine the diagnosis of osteoporosis and osteopenia in men based on bone density measurements at single or multiple sites using central and peripheral measurements, we studied 206 ambulatory, community-dwelling men over age 50. Bone mineral density of the hip, PA spine, forearm, and finger were assessed by dual-energy X-ray absorptiometry. The diagnosis of osteoporosis based on a single measurement ranged from 1% using the trochanter to 39% using Ward's triangle. Twenty-one percent of men had osteoporosis if the diagnosis was based on at least one osteoporotic value at three central sites (PA spine, total hip, femoral neck). Among these men using T-scores provided by the manufacturers, 51% of osteoporotic patients would be misclassified as normal using the accuDEXA((R)) (finger), and 37% of osteoporotic men would be misclassified as normal using the PA spine. We conclude depending on the number and selection of sites there is considerable variability in the classification and misclassification of osteoporosis and osteopenia in men.
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Affiliation(s)
- S A Stoch
- Division of Bone and Mineral Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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