1
|
Lee DY, Oh JS, Kim JW, Lee SH, Kim BJ, Koh JM, Kim JS, Ryu JS. Imaging bone turnover assessment through volumetric density-adjusted standardized uptake value using quantitative bone SPECT/CT in osteoporosis. EJNMMI Res 2024; 14:75. [PMID: 39182210 PMCID: PMC11345349 DOI: 10.1186/s13550-024-01137-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 08/12/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Serum bone turnover markers offer limited insight into metabolic activity at the individual vertebra level in osteoporosis. This study introduces a novel image-derived bone turnover marker for individual vertebrae to address this limitation, utilizing volumetric density-adjusted quantitative bone single-photon emission computed tomography/computed tomography (SPECT/CT) with [99mTc]Tc-DPD. This retrospective study included 177 lumbar vertebrae from 55 postmenopausal South Korean women. The mean standardized uptake value (SUVmean, g/cm3) and volumetric bone mineral density (vBMD, mg/cm3) were determined within a 2-cm³ volume of interest in the trabecular portion of each vertebra using quantitative SPECT and CT. The density-adjusted mean standardized uptake value (dSUVmean) was calculated by dividing the SUVmean by the vBMD and multiplying by 1,000. RESULTS SUVmean correlated positively with vBMD (r = 0.60, p < 0.001). Conversely, dSUVmean correlated negatively with vBMD (ρ = -0.66, p < 0.001), highlighting the inverse relationship between bone mass and turnover after density adjustment of SUVmean. Patients with major osteoporotic fractures had lower vBMD (62.5 ± 29.4 vs. 92.3 ± 27.4 mg/cm³, p = 0.001) but higher dSUVmean (100.8 ± 60.7 vs. 62.6 ± 17.5, p = 0.001) compared to those without fractures, reinforcing the association between fracture prevalence, low bone mass, and high bone turnover. CONCLUSION Volumetric density-adjusted quantitative bone SPECT/CT offers a novel image-derived bone turnover marker for assessing bone turnover in osteoporosis. This method provides a precise assessment of fragility at the individual vertebra level, which may enhance personalized osteoporosis management.
Collapse
Affiliation(s)
- Dong Yun Lee
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jungsu S Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Hun Lee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom-Jun Kim
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Koh
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Sook Ryu
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Popa M, Cursaru A, Cretu B, Iordache S, Iacobescu GL, Spiridonica R, Serban B, Cirstoiu C. Enhancing Osteoporosis Management: A Thorough Examination of Surgical Techniques and Their Effects on Patient Outcomes. Cureus 2024; 16:e59681. [PMID: 38836146 PMCID: PMC11149898 DOI: 10.7759/cureus.59681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/06/2024] Open
Abstract
Managing osteoporotic fractures in older individuals is a difficult task in orthopedic surgery. It requires a careful approach that combines advanced diagnostic methods, customized surgical treatments, and comprehensive rehabilitation strategies. This article presents the results of an analysis carried out at the University Emergency Hospital, Bucharest. The analysis specifically examines the treatment of osteoporotic fractures using different osteosynthesis techniques. Although diagnostic tools like dual-energy X-ray absorptiometry (DXA) and Fracture Risk Assessment Tool (FRAX) have improved, a considerable number of fractures still happen in people who do not have obvious osteoporosis. This emphasizes the importance of using additional diagnostic measures such as high-resolution peripheral quantitative computed tomography (HR-pQCT) and quantitative computed tomography (QCT) to improve the accuracy of predictions. The study demonstrates the intricate nature of surgical decision-making and the significance of adjusting techniques to meet the specific needs of each patient. An instance of osteosynthesis failure resulting from the inappropriate choice of method highlighted the crucial significance of a thorough preoperative assessment. The discussion highlights the importance of early mobilization and rehabilitation in reducing the risks associated with prolonged immobilization and improving patient recovery. This paper strongly supports the use of evidence-based and patient-centered methods in the management of osteoporotic fractures. It emphasizes the importance of utilizing the most recent advancements in diagnostic and surgical technologies. Promising advancements in orthopedic medicine lie in the future, particularly in the integration of interdisciplinary research and personalized medicine. These advancements have the potential to enhance patient outcomes in this population that is at high risk.
Collapse
Affiliation(s)
- Mihnea Popa
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Adrian Cursaru
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Cretu
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Sergiu Iordache
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Georgian L Iacobescu
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Razvan Spiridonica
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Bogdan Serban
- Orthopaedics and Trauma, University of Medicine and Pharmacy Carol Davila, Bucharest, ROU
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| | - Catalin Cirstoiu
- Orthopedics and Traumatology Department, University Emergency Hospital, Bucharest, ROU
| |
Collapse
|
3
|
Shevroja E, Reginster JY, Lamy O, Al-Daghri N, Chandran M, Demoux-Baiada AL, Kohlmeier L, Lecart MP, Messina D, Camargos BM, Payer J, Tuzun S, Veronese N, Cooper C, McCloskey EV, Harvey NC. Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporos Int 2023; 34:1501-1529. [PMID: 37393412 PMCID: PMC10427549 DOI: 10.1007/s00198-023-06817-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/31/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Trabecular bone score (TBS) is a grey-level textural measurement acquired from dual-energy X-ray absorptiometry lumbar spine images and is a validated index of bone microarchitecture. In 2015, a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) published a review of the TBS literature, concluding that TBS predicts hip and major osteoporotic fracture, at least partly independent of bone mineral density (BMD) and clinical risk factors. It was also concluded that TBS is potentially amenable to change as a result of pharmacological therapy. Further evidence on the utility of TBS has since accumulated in both primary and secondary osteoporosis, and the introduction of FRAX and BMD T-score adjustment for TBS has accelerated adoption. This position paper therefore presents a review of the updated scientific literature and provides expert consensus statements and corresponding operational guidelines for the use of TBS. METHODS An Expert Working Group was convened by the ESCEO and a systematic review of the evidence undertaken, with defined search strategies for four key topics with respect to the potential use of TBS: (1) fracture prediction in men and women; (2) initiating and monitoring treatment in postmenopausal osteoporosis; (3) fracture prediction in secondary osteoporosis; and (4) treatment monitoring in secondary osteoporosis. Statements to guide the clinical use of TBS were derived from the review and graded by consensus using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS A total of 96 articles were reviewed and included data on the use of TBS for fracture prediction in men and women, from over 20 countries. The updated evidence shows that TBS enhances fracture risk prediction in both primary and secondary osteoporosis, and can, when taken with BMD and clinical risk factors, inform treatment initiation and the choice of antiosteoporosis treatment. Evidence also indicates that TBS provides useful adjunctive information in monitoring treatment with long-term denosumab and anabolic agents. All expert consensus statements were voted as strongly recommended. CONCLUSION The addition of TBS assessment to FRAX and/or BMD enhances fracture risk prediction in primary and secondary osteoporosis, adding useful information for treatment decision-making and monitoring. The expert consensus statements provided in this paper can be used to guide the integration of TBS in clinical practice for the assessment and management of osteoporosis. An example of an operational approach is provided in the appendix. This position paper presents an up-to-date review of the evidence base, synthesised through expert consensus statements, which informs the implementation of Trabecular Bone Score in clinical practice.
Collapse
Affiliation(s)
- Enisa Shevroja
- Interdisciplinary Center for Bone Diseases, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Jean-Yves Reginster
- World Health Organization Collaborating Center for Epidemiology of Musculoskeletal Health and Aging, Liège, Belgium
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU Sart Tilman B23, 4000 Liège, Belgium
| | - Olivier Lamy
- Interdisciplinary Center for Bone Diseases, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Nasser Al-Daghri
- Biochemistry Department, College of Science, King Saud University, 11451 Riyadh, Kingdom of Saudi Arabia
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20, College Road, Singapore, 169856 Singapore
| | | | - Lynn Kohlmeier
- Spokane Strides for Strong Bones, Medical Director, West Coast Bone Health CME TeleECHO, Spokane, WA USA
| | | | - Daniel Messina
- IRO Medical Research Center, Buenos Aires and Rheumatology Section, Cosme Argerich, Buenos Aires, Argentina
| | - Bruno Muzzi Camargos
- Rede Materdei de Saúde - Hospital Santo Agostinho - Densitometry Unit Coordinator, Belo Horizonte, Brazil
| | - Juraj Payer
- 5th Department of Internal Medicine, Comenius University Faculty of Medicine, University Hospital, Bratislava, Slovakia
- Ružinovská 6, 82101 Bratislava, Slovakia
| | - Sansin Tuzun
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Nicola Veronese
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D’Alessandro”, University of Palermo, 90127 Palermo, Italy
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, SO16 6YD UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Eugene V. McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, SO16 6YD UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
4
|
Gates M, Pillay J, Nuspl M, Wingert A, Vandermeer B, Hartling L. Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools. Syst Rev 2023; 12:51. [PMID: 36945065 PMCID: PMC10029308 DOI: 10.1186/s13643-023-02181-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care. METHODS For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach. RESULTS We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated. CONCLUSION An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.
Collapse
Affiliation(s)
- Michelle Gates
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| | - Jennifer Pillay
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| | - Megan Nuspl
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| | - Aireen Wingert
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| | - Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| | - Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9 Canada
| |
Collapse
|
5
|
Lee KA, Kim HJ, Kim HS. Comparison of predictive value of FRAX, trabecular bone score, and bone mineral density for vertebral fractures in systemic sclerosis: A cross-sectional study. Medicine (Baltimore) 2023; 102:e32580. [PMID: 36637920 PMCID: PMC9839281 DOI: 10.1097/md.0000000000032580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Assessing fracture risk is important for managing patients with systemic sclerosis (SSc). Vertebral fracture (VF) is the most common fracture and is associated with future VF and non-VF. We aimed to evaluate the predictive value of FRAX, trabecular bone score (TBS), and bone mineral density (BMD) for VFs, compared to rheumatoid arthritis (RA) patients and postmenopausal women, and to identify risk factors for VFs in SSc. In this cross-sectional study, prevalent VFs, 10-year probability of major osteoporotic fracture by FRAX (FRAX-MOF), TBS, and BMD were assessed in women with SSc (n = 69) and RA (n = 58), and postmenopausal women (n = 38). Risk factors for osteoporosis, modified Rodnan total skin score (mRSS), organ involvement, and patterns of nailfold capillaroscopy (NFC) were also evaluated. The accuracy of BMD (T-score ≤ -2.5), TBS and FRAX-MOF, with and without TBS adjustment, to detect prevalent VF was assessed by determining the area under the receiver operating characteristic (ROC) curve. Patients with SSc (14.5%) and RA (17.2%) had significantly more VFs than postmenopausal women (0%) (P = .031). Non-significant differences were observed in TBS and BMD of all groups. The FRAX-MOF were higher in RA (9.2%) than SSc group (6.1%) and postmenopausal women (5.5%) (P < .001). Based on the ROC curve, TBS-adjusted FRAX-MOF (0.803) showed largest area under curve (AUC) to detect the prevalent VFs, followed by FRAX-MOF (0.796), TBS (0.765), and BMD (0.588) in the SSc group. In the RA group, FRAX-MOF had the largest AUC (0.896), followed by TBS-adjusted FRAX-MOF (0.863), TBS (0.736), and BMD (0.686). The cutoffs for FRAX-MOF and TBS-adjusted FRAX-MOF for detecting VFs were 8.95% and 9.7% for SSc, and 14.5% and 14% for RA. No association between VFs and SSc subtypes, organ involvement, mRSS or NFC patterns was found. FRAX-MOF, with or without TBS, had better predictive value for VFs than BMD and TBS in SSc. However, FRAX-MOF underestimated the probability of VFs in SSc compared with RA.
Collapse
Affiliation(s)
- Kyung-Ann Lee
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, South Korea
| | - Hyun-Joo Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, South Korea
| | - Hyun-Sook Kim
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University School of Medicine, Seoul, South Korea
- * Correspondence: Hyun-Sook Kim, Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, South Korea (e-mail: )
| |
Collapse
|
6
|
Kong SH, Jo AJ, Park CM, Park KI, Yun JE, Kim JH. Chronic airway disease as a major risk factor for fractures in osteopenic women: Nationwide cohort study. Front Endocrinol (Lausanne) 2023; 14:1085252. [PMID: 37025406 PMCID: PMC10070847 DOI: 10.3389/fendo.2023.1085252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/07/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION The study aimed to demonstrate the risk factors for fractures and to develop prediction models for major osteoporotic and hip fractures in osteopenic patients using the nationwide cohort study in South Korea. METHODS The study was a retrospective nationwide study using the national screening program for transitional ages from the National Health Insurance Services database in Korea from 2008 to 2019. Primary outcomes were incident fracture events of major osteoporotic and hip fractures. Major osteoporotic and hip fracture events were defined as diagnostic and procedural codes. Patients were followed until the fragility fractures, death, or 2019, whichever came first. RESULTS All participants were 66-year-old females, with a mean body mass index was 25.0 ± 3.1 kg/m2. During a median follow-up of 10.5 years, 26.9% and 6.7% of participants experienced major osteoporotic and hip fractures. In multivariate analysis, a history of fracture, chronic airway disease, falls, diabetes mellitus and cerebrovascular diseases were significant risk factors for major osteoporotic (hazard ratio [HR] 2.35 for a history of fracture; 1.17 for chronic airway disease; 1.10 for falls; 1.12 for diabetes mellitus; 1.11 for cerebrovascular disease) and hip fractures (HR 1.75 for a history of fracture; 1.54 for diabetes mellitus; 1.27 for cerebrovascular disease; 1.17 for fall; 1.15 for chronic airway disease). The performances of the prediction models were area under the receiver operating curve of 0.73 and 0.75 for major osteoporotic and hip fractures. CONCLUSION The study presented prediction models of major osteoporotic and hip fractures for osteopenia patients using simple clinical features.
Collapse
Affiliation(s)
- Sung Hye Kong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ae Jeong Jo
- Department of Information Statistics, Andong National University, Kyongbuk, Republic of Korea
| | - Chan Mi Park
- Department of Health Technology Assessment, National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Republic of Korea
| | - Kyun Ik Park
- Department of Health Technology Assessment, National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Republic of Korea
| | - Ji Eun Yun
- Department of Health Technology Assessment, National Evidence-Based Healthcare Collaborating Agency (NECA), Seoul, Republic of Korea
- *Correspondence: Ji Eun Yun, ; Jung Hee Kim,
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- *Correspondence: Ji Eun Yun, ; Jung Hee Kim,
| |
Collapse
|
7
|
Chuang TL, Chuang MH, Wang YF, Koo M. Comparison of Trabecular Bone Score-Adjusted Fracture Risk Assessment (TBS-FRAX) and FRAX Tools for Identification of High Fracture Risk among Taiwanese Adults Aged 50 to 90 Years with or without Prediabetes and Diabetes. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121766. [PMID: 36556968 PMCID: PMC9787568 DOI: 10.3390/medicina58121766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Background and Objectives: The burden of osteoporosis is projected to increase. Identification and prompt intervention for osteoporotic fractures are important. Adjusting the Fracture Risk Assessment (FRAX®) tool with trabecular bone score (TBS) could improve risk prediction. However, little is known about whether TBS-adjusted FRAX® would change the proportion of individuals qualified for osteoporosis intervention. Therefore, the aim of the present study was to compare the proportions of Taiwanese adults who qualified for intervention, according to the FRAX® and TBS-adjusted FRAX®, with stratification by sex, age group, and glucose regulation status. Materials and Methods: A medical record review on adults 50−90 years who had undergone a general health examination in a regional hospital in Taiwan was conducted. FRAX® and TBS-adjusted FRAX® were calculated. FRAX® cut-points of ≥ 20% for major osteoporotic fracture and ≥3% for hip fracture were adopted to identify individuals qualified for osteoporosis intervention. Individuals were classified as prediabetes and diabetes if their HbA1c was 5.7−6.4% and >6.4%, respectively. Results: A total of 8098 individuals with a mean age of 61.0 years were included. The proportion of men qualified for intervention for hip fracture was significantly lower according to TBS-adjusted FRAX® (17.2%) compared with FRAX® (20.7%) (p < 0.001), with a similar pattern across all three age groups and in those with prediabetes. In contrast, the proportion of women qualified for intervention for major osteoporotic fracture was significantly higher according to TBS-adjusted FRAX® (4.6%) compared with FRAX® (3.7%) (p < 0.001), particularly among those with prediabetes 60−69 years. Conclusions: TBS-adjusted FRAX® led to small but significant changes in the proportions of individuals qualified for intervention in specific age groups and glucose regulation status.
Collapse
Affiliation(s)
- Tzyy-Ling Chuang
- Department of Nuclear Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi 622401, Taiwan
- Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien 970374, Taiwan
| | - Mei-Hua Chuang
- Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien 970374, Taiwan
- Faculty of Pharmacy, National Yang-Ming Chiao Tung University, Taipei 112304, Taiwan
- MacKay Junior College of Medicine, Nursing, and Management, New Taipei City 11260, Taiwan
| | - Yuh-Feng Wang
- Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei 112021, Taiwan
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu 300102, Taiwan
| | - Malcolm Koo
- Graduate Institute of Long-Term Care, Tzu Chi University of Science and Technology, Hualien 970302, Taiwan
- Correspondence: ; Tel.: +886-3-857-2158 (ext. 2206)
| |
Collapse
|
8
|
Favarato MHS, Almeida MFD, Lichtenstein A, Martins MDA, Junior MF. Risk of osteoporotic fracture in women using the FRAX tool with and without bone mineral density score in patients followed at a tertiary outpatient clinic ‒ An observational study. Clinics (Sao Paulo) 2022; 77:100015. [PMID: 35290857 PMCID: PMC8918849 DOI: 10.1016/j.clinsp.2022.100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/21/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Fragility fractures increase morbidity and mortality. Adding assessment of clinical risk factors independently or as a previous step to Bone Densitometry (BD) should provide better accuracy in fracture risk prediction. FRAX tool might be used to stratify patients in order to rationalize the need for BD and risk classification. The primary objective of this study is to describe and perform comparisons between the estimated risk of fractures in 10 years using the FRAX calculator based on clinical factors with and without BD results for women aged 40 or more with clinical diseases monitored in tertiary care service in internal medicine. METHODS Cross-sectional. Women over 40 years with BD in the previous year. After medical chart review, identification of risk factors and risk estimations using FRAX-BRAZIL with (FRAX BDI) and without (FRAX BDNI) the inclusion of T-score. RESULTS 239 women. Age 65 ± 10.35 years. BMI 29.68 ± 6.27kg/m2. RISK FACTORS 32(13.4%) previous fractures; 23 (9.6%) current smoking; 78 (32.6%) corticosteroids use; 44 (18.4%) rheumatoid arthritis; 38 (15.9%) secondary causes; FRAX scores were higher when BD was not included. Spearman correlation coefficients between FRAX BDNI and FRAX BDI for major fractures r = 0.793 (95% CI 0.7388‒0.836). For hip fractures r = 0.6922 (95% CI 0.6174‒0.75446) CONCLUSION: Using FRAX to estimate 10-year fracture risk without BD data might be a reliable tool for screening, even for patients with a high prevalence of risk factors, improving accessibility and equity in health systems. The present study's data suggest an overestimation of fracture risk with FRAX BDNI, suggesting that it is safe to be widely used as a screening tool.
Collapse
Affiliation(s)
- Maria Helena Sampaio Favarato
- Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Maria Flora de Almeida
- Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Arnaldo Lichtenstein
- Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Milton de Arruda Martins
- Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Mario Ferreira Junior
- Serviço de Clínica Geral e Propedêutica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| |
Collapse
|
9
|
Association of Trabecular Bone Score-Adjusted Fracture Risk Assessment Tool with Coronary Artery Calcification in Women. Diagnostics (Basel) 2022; 12:diagnostics12010178. [PMID: 35054344 PMCID: PMC8775109 DOI: 10.3390/diagnostics12010178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Abstract
The trabecular bone score (TBS) was found to be significantly associated with moderate coronary artery calcification (CAC). The aim of this study was to further explore the association between TBS-adjusted Fracture Risk Assessment Tool (FRAX) and CAC score in women. The electronic medical record database of a regional teaching hospital in southern Taiwan yielded women who received both coronary computed tomography and bone mineral density (BMD) measurement during their general health examination. Health history, anthropomorphic measurements, laboratory results, BMD, and T-scores were obtained. TBS values were calculated from database spine dual-energy X-ray absorptiometry files. Linear regression analyses tested the association between CAC score and 10-year probability of major osteoporotic fracture (MOF) and hip fracture (HF) determined by TBS-adjusted FRAX. Of the 116 women (mean age 55.8 years) studied, 24.1% had osteoporosis. Simple linear regression showed a significant association of CAC score with an increase in MOF and HF risk as measured by TBS-adjusted FRAX. In multiple linear regression adjusted for potential confounders, CAC score remained significantly associated with TBS-adjusted FRAX for right MOF (p = 0.002), left MOF (p = 0 006), right HF (p = 0.005), and left HF (p = 0.015). In conclusion, clinicians should be vigilant to the potential increased risk of coronary events among women with increased TBS-adjusted FRAX for MOF and HF.
Collapse
|
10
|
Comparison of HU histogram analysis and BMD for proximal femoral fragility fracture assessment: a retrospective single-center case-control study. Eur Radiol 2021; 32:1448-1455. [PMID: 34647175 DOI: 10.1007/s00330-021-08281-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the feasibility of HU histogram analysis (HUHA) to assess proximal femoral fragility fractures with respect to BMD. METHODS This retrospective study included 137 patients with femoral fragility fractures who underwent hip CT and 137 control patients without fractures who underwent abdominal CT between January 2018 and February 2019. HUHA was calculated with the 3D volume of interest from the femoral head to the lesser trochanter. HUHAfat (percentage of negative HU values) and HUHAbone (percentage of HU values ≥ 125 HU) were assumed to be fat and bone components, respectively. Statistical significance was assessed using the area under the receiver operating characteristic curve (AUC), Spearman correlation (ρ), and odds ratio. RESULTS HUHAfat was strongly positively correlated (ρ = 0.56) and BMD was moderately negatively correlated with fragility fractures (ρ = - 0.37). AUC of HUHAfat (0.82, 95% CI [0.77, 0.87]) significantly differed from that of BMD (0.69, 95% CI [0.63, 0.75]) (p < .001). The cutoff value was 15.8% for HUHAfat (sensitivity: 90.4%; specificity: 67.7%) and 0.709 g/cm2 for BMD (sensitivity: 87.5%; specificity: 51.5%), with higher HUHAfat and lower BMD values indicating fragility fractures. The odds ratio of HUHAfat was 19.5 (95% CI [9.9, 38.2], p < .001), which was higher than that of BMD, 7.4 (95% CI [4.0, 13.6], p < .001). CONCLUSION HUHAfat revealed better performance than BMD and demonstrated feasibility in assessing proximal femoral fragility fractures. KEY POINTS • HUHAfat showed a strong positive correlation (Spearman ρ = 0.56, p < .001), and BMD showed a moderate negative correlation (Spearman ρ = - 0.37, p < .001) with proximal femoral fragility fractures. • HUHAfat (AUC = 0.82) performed significantly better than BMD in assessing proximal femoral fragility fractures (AUC = 0.69) (p < .001). • The odds ratio of HUHAfat for proximal femoral fragility fractures was higher than that of BMD (19.5 and 7.4, respectively; p < .001).
Collapse
|
11
|
Kong SH, Hong N, Kim JW, Kim DY, Kim JH. Application of the Trabecular Bone Score in Clinical Practice. J Bone Metab 2021; 28:101-113. [PMID: 34130362 PMCID: PMC8206609 DOI: 10.11005/jbm.2021.28.2.101] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/18/2021] [Indexed: 01/28/2023] Open
Abstract
The trabecular bone score (TBS) was introduced as an indirect index of trabecular microarchitecture, complementary to bone mineral density (BMD), and is derived using the same dual energy X-ray absorptiometry images. Recently, it has been approved for clinical use in Korea. Therefore, we conducted a comprehensive review to optimize the use of TBS in clinical practice. The TBS is an independent predictor of osteoporotic fractures in postmenopausal women and men aged >50 years. The TBS is potentially useful in monitoring the skeletal effects of anabolic agents but not of antiresorptive agents. In postmenopausal women with type 2 diabetes mellitus, the TBS assesses osteoporotic fracture risk not captured by BMD. However, high body mass index and soft tissue thickness can cause underestimation of the TBS; however, this limitation has been improved in recent versions of the TBS software. However, a high precision error and low reproducibility limit the use of TBS. This review may provide information on the application of the TBS in clinical practice based on reliable evidence.
Collapse
Affiliation(s)
- Sung Hye Kong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Namki Hong
- Division of Endocrinology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin-Woo Kim
- Department of Orthopedic Surgery, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Deog Yoon Kim
- Department of Nuclear Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|