Densitometer type and impact on risk assessment for osteoporosis.

Studies have shown a high correlation between measurements of bone mineral density (BMD) obtained on differentdual-energy X-ray absorptiometry machines. Challenger osteodensitometers (Diagnostic Medical System [DMS],Montpellier, France) are becoming widely used but little is known about their clinical performance. The aim of this study was to compare BMD measurements and the resulting patient classification based on T-scores obtained on a DMS Challenger device to those obtained on Hologic 4500A (Bedford, MA) device. Fifty-three volunteers were studied.The BMD of the spine and of the hip were simultaneously measured on both densitometers. BMD values obtained on the Challenger were significantly higher than those obtained with the Hologic QDR4500 (p<0.001). The correlations coefficients between the Hologic QDR4500 and the DMS Challenger measured BMDs were r=0.70 at the femoral neck, r=0.70 at the trochanter, and r=0.83 at the spine (p<0.001). Among the 35 postmenopausal women, there was discordance in the WHO T-score-based classification in 28 subjects (80%) at the spine, 18 subjects (52%) at the femoral neck, and 14 subjects (42%) at the trochanter. The intermachine agreement was low: The kappa score was -0.10 at the spine, 0.2 at the femoral neck, and 0.3 at the trochanter. In conclusion, this study cautions against the use of non established densitometers that leads to underdiagnosis of patients and, subsequently, to inappropriate treatment strategies.     

Urinary-based tumor markers enhance microhematuria risk stratification according to baseline bladder cancer prevalence

IntroductionThe 2020 AUA microhematuria (MH) guideline stratifies patients into low, intermediate and high-risk for urologic malignancy based on established risk-factors for urothelial carcinoma. Notably, urine-based tumor markers (UBTMs) were not included in the risk classification. We evaluated the impact of incorporating UBTMs (cytology and multiple commercially available UBTMs) into this risk stratification.MethodsWe performed a systematic review of performance characteristics of UBTMs for the detection of bladder cancer during hematuria evaluation, pooled the reported sensitivity and specificity, and calculated positive and negative likelihood ratios (LR). These were then applied to the estimated pre-test probability for the diagnosis for each AUA risk strata: low-risk 0.5%, intermediate-risk 1.0%, and high-risk (2%-3%) in order to calculate a post-test probability of bladder cancer in the event of a positive or negative test.ResultsThe pooled sensitivity for urinary cytology and commercially available UBTMs was 68% and 58%-95%, respectively while the specificity was estimated at 91% and 34%-90%, respectively. The positive LRs of UBTMs ranged from 2.1-7.67 and negative LRs ranged from 0.07-0.48. A negative UBTM was associated with a post-test probability of cancer for low, intermediate, and high-risk patients of 0-0.2%, 0.2%-0.5%, and 0.4%-1.1%, respectively. In the setting of a positive UBTM, the post-test probability of cancer for low, intermediate, and high-risk patients was 1.1%-3.7%, 2.1%-7.8%, 4.2%-19.2%, respectively.ConclusionPending prospective validation, UBTMs may be able to enhance risk stratification and inform shared decision-making over clinical factors alone and allow for re-classification of patients into higher or lower risk categories.     

Automated osteoporosis risk assessment by dentists: a new pathway to diagnosis

General dental practitioners use a vast amount of panoramic radiography in their routine clinical work, but valuable information about patients' osteoporotic status is not collected. There are many reasons for this, but one of the prime reasons must be the disruption involved in clinical routine with lengthy manual radiographic assessment. We have developed computer software, based on active shape modeling that will automatically detect the mandibular cortex on panoramic radiographs, and then measure its width. Automatic or semi-automatic measurement of the cortical width will indicate the osteoporotic risk of the patient. The aim of our work was to assess the computer search technique's ability to measure the mandibular cortical width and to assess its potential for detection of osteoporosis of the hip, spine and femoral neck. Mandibular cortical width was measured using the manually initialized (semi-automatic) method and, when assessed for diagnosing osteoporosis at one of the three measurement sites, gave an area under the ROC curve (A(z))=0.816 (95% CI=0.784 to 0.845) and for the automatically initialized searches, A(z)=0.759 (95% CI=0.724 to 0.791). The difference between areas=0.057 (95% Confidence interval=0.025 to 0.089), p<0.0001. For diagnosing osteoporosis at the femoral neck, mandibular cortical width derived from the manually initialized fit gave an area under the ROC curve (A(z))=0.835 (95% CI=0.805 to 0.863) and for the automatically initialized searches A(z)=0.805 (95% CI=0.773 to 0.835). The difference in A(z) values between active shape modeling search methods=0.030 (95% CI=-0.010 to 0.070), and this was not significant, p=0.138. We concluded that measurement of mandibular cortical width using active shape modeling is capable of diagnosing skeletal osteoporosis with good diagnostic ability and repeatability.     

不同骨质疏松风险评估工具的筛检效果评价

目的通过对7种骨质疏松风险评估工具的对比,评价其社区与临床应用价值,为预防和筛查骨质疏松提供科学依据。方法共纳入299名40周岁以上的中老年人,其中女性均已绝经,应用双能X线骨密度仪测量其骨密度值并诊断是否患有骨质疏松症,计算各个工具得分,比较变量、灵敏度、特异度和曲线下面积(area under the curve,AUC)。结果绝经后妇女的各个工具得分均有统计学意义(P0.05),亚洲人骨质疏松自评工具(osteoporosis self-assessment tool for asian, OSTA)的灵敏度为96.3%,特异度为6.3%,AUC为0.710;骨质疏松风险评估工具(osteoporosis risk assessment instrument, ORAI)的灵敏度为90.1%,特异度为12.7%, AUC为0.661;骨质疏松风险简单评估(simple calculated osteoporosis risk estimation, SCORE)的灵敏度为25.9%,特异度为81.9%, AUC为0.686;骨质疏松危险指数(osteoporosis index of risk, OSIRIS)的灵敏度为90%,特异度为30.8%, AUC为0.734;骨质疏松预筛选风险评估(osteoporosis prescreening risk assessment, OPERA)的灵敏度为38.2%,特异度为84%, AUC为0.658;美国骨质疏松基金会快速诊断法(National Osteoporosis Foundation, NOF)的灵敏度为90.4%,特异度为26.6%, AUC为0.652。仅NOF筛检的中老年男性骨质疏松具有统计学意义(P0.05),NOF的灵敏度为93.5%,特异度为25.8%, AUC为0.697;而男性骨质疏松症风险评估(male osteoporosis risk estimation score, MORES)筛检的灵敏度为74.1%,特异度为29.0%,AUC为0.575,不具有统计学意义(P=0.190)。结论 OSTA的灵敏度最高,且仅有2个变量,使用最为简便,适合筛检大样本人群;OSIRIS灵敏度和特异度均较好,用于临床筛检更为准确;ORAI和NOF灵敏度较高,适合筛检阳性人群;SCORE和OPERA特异度较好,适合筛检阴性人群;NOF可用于筛检中老年男性骨质疏松。     

Vertebral fractures in osteoporosis: a new method for clinical assessment.

Vertebral fractures are the most common consequence of osteoporosis, and are an important risk factor for subsequent fractures. Patients with reduced bone mineral density (BMD) and vertebral fractures have significantly increased risk for future fractures, indicating great potential for the combined use of fracture assessment and BMD in risk evaluation. Despite the established importance of fractures, however, vertebral assessment is not typically performed in the clinical evaluation of patients at risk for osteoporosis. Radiographs are the accepted standard for assessment of fractures, but are rarely obtained in osteoporosis assessment for a variety of practical reasons, including cost, radiation dose, and the lack of office-based radiological facilities. Clinical assessment of fractures is difficult because most are asymptomatic. Consequently, this strong risk factor for osteoporotic fractures is often overlooked. High-resolution lateral spine images, obtained on advanced fan-beam dual X-ray absorptiometry (DXA) systems, provide a practical, low-radiation dose, point-of-care methodology for assessment of vertebral fractures, and have the potential to address this important clinical need. In this article, we review the importance of vertebral fractures and the methods of assessing them. We also review clinical data supporting the feasibility of visual evaluation of lateral spine images obtained using a fan-beam DXA system, and discuss the potential positive impact of this new methodology on clinical patient evaluation.     

FRAX在绝经后骨质疏松症中骨折风险评估的Meta分析

目的 系统评价未使用骨密度检测时,通过FRAX工具评估绝经后骨质疏松症(PMOP)中骨折发生概率的应用准确性。方法 系统检索CNKI、CBM、VIP、WanFang、PubMed、Embase、Cochrane 图书馆,开展方法学质量评估,同时借助软件Stata16.0和Metadisc实施Meta分析。所纳入文献合计12篇,涉及研究为14个。结果 Meta分析结果表明,FRAX敏感度为84.68%,特异性为63.18%。合并SROC曲线绘制,最终得到诊断的准确率为85%,P<0.05,准确率接近骨密度检测方法。其中,髋部骨折概率对于骨密度评估方法的敏感度为81.9%,特异性为65.02%。使用FRAX评估时,诊断的准确率为83%,P<0.05;主要部位骨折概率对于骨密度评估方法的敏感度为73.5%;特异性为72.71%,使用FRAX评估时得到诊断的准确率为81%,P<0.05。 结论 FRAX工具是一种可靠的应用于绝经后骨质疏松症中的骨折评估方法。     

应用FRAX筛查骨质疏松高危人群的方法研究

目的应用骨折风险评估工具(FRAX)预测不同骨质疏松性骨折危险因子及股骨颈骨密度(BMD)情况下10年骨折风险性的差异,探讨筛查骨质疏松高危人群的方法。方法应用FRAX的中国大陆子模型软件,综合年龄、性别、体重指数,计算单一危险因子或多重危险因子在联合或不联合BMD的条件下预测骨折风险性。结果随着BMD下降、骨折危险因子增多,10年骨质疏松性骨折风险增大。不同骨折危险因子和BMD配对时骨折风险性不同,当BMD未达骨质疏松诊断标准而合并部分危险因子时的骨折风险性大于BMD的T值达-2.5SD但无危险因子时的骨折风险性。结论 FRAX模型使原来单凭BMD转向综合各类危险因子评估长期骨质疏松性骨折风险性,在无条件行BMD检测地区可用以筛查骨质疏松高危人群。     

Glucocorticoid-induced osteoporosis: assessment and treatment.

Supraphysiologic levels of glucocorticoids result in substantial bone loss, particularly at sites rich in trabecular bone. This results in fractures, typically in the vertebrae and ribs, in up to one third of long-term steroid users. Patients requiring long-term steroid treatment or with incurable Cushing's syndrome should have a bone density measurement, preferably at the spine. They should be offered specific prophylaxis against bone loss if their bone density is in the lower part of the young normal range, or below. Treatment should consist of sex hormone replacement in hypogonadal subjects, a bisphosphonate, or possibly a vitamin D metabolite. These medications can be used in combination. Correction of vitamin D deficiency, provision of calcium supplementation, cessation of smoking, and the provision of adequate exercise are sensible adjunctive interventions. Attention to the issue of steroid osteoporosis before fractures occur will substantially reduce the skeletal morbidity attendant upon the use of these lifesaving medications.     

绝经后妇女骨质疏松风险简易筛选方法

目的寻找一种经济、简便、科学、实用并易推广的骨质疏松高危人群的筛查方法,来预测骨质疏松的风险。方法对314例绝经后妇女进行骨质疏松相关危险因素简易问卷调查及髋部骨密度测定。通过单元线性回归分析寻找与股骨颈BMD值有显著相关性的变量,并通过多元线性回归分析,将各变量的回归系数标准化。根据筛选指数工作特征曲线(ROC),计算曲线下面积(AUC),找出最有意义的变量,组成最简单的筛选指数模式。结果经单元线性回归分析找出与股骨颈BMD有显著相关性的变量共12个,再通过多元线性回归分析,最后进入回归方程的有意义变量共有2个,即年龄,目前体重,最后得出筛选指数计算公式为筛选指数=INT(2×体重/10)-INT(3×年龄/10)。以-6作为筛选指数对骨量异常筛选的临界值,灵敏度为90.0%,特异度为49.3%。阳性预测值为54.5%,阴性预测值为88.3%。结论以年龄和体重作为骨质疏松风险的筛选指数筛选效度好,且简单、方便,而又经济。但此方法只能作为骨质疏松高危人群的筛查方法,不能代替骨密度检查作为骨质疏松症的诊断方法。必须考虑是否存在骨质疏松相关危险因素,以确定哪些妇女需要进一步进行骨密度检查,使高危人群得到及时治疗。     

应用骨折风险因子评估工具（FRAX )诊治 骨质疏松症

世界卫生组织(WHO)推荐的骨折风险因子评估工具(FRAX)已经被越来越多的国家采用作为诊疗骨质疏松症的常规手段,而不是单纯使用骨密度及T值作为诊断标准.本文从FRAX的概念、使用方法、预测的准确性、FRAX的种族差异、干预阈值设定以及对治疗效果评价、对骨折发生几率预测结果的影响以及与其他工具对比等方面进行了详尽说明,并列举了FRAX工具的优缺点以及目前国际骨质疏松基金会(IOF)官方文件的相关规定.中国老年学学会骨质疏松委员会推荐国内同道们进一步关注及更广泛在临床工作中使用FRAX评估工具来进行准确评估骨质疏松症,并推荐使用FRAX代替单纯检测BMD所进行的骨质疏松相关研究.     

Vertebral fracture assessment in healthy men: prevalence and risk factors

IntroductionVertebral fracture assessment (VFA) is a technology that can reliably and accurately diagnose vertebral fractures with greater patient convenience, less radiation exposure, and lower cost than standard spine radiography.ObjectiveTo study prevalence and risk factors of vertebral fractures using VFA in healthy men.MethodsThe study cohort consists of a population of 216 healthy men aged between 50 and 79 (mean age, weight and BMI of 63.8 years, 73.3 kg and 25.7 kg/m², respectively). Lateral VFA images and scans of the lumbar spine and proximal femur were obtained by two technologists using a GE Healthcare Lunar Prodigy densitometer. Vertebral fractures were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.ResultsNinety-three percent of vertebrae from T4–L4 and 98% from T8–L4 were adequately visualized on VFA. Vertebral fractures were detected in 29.6% (64/216) of these men: 34/216 (15.7%) had grade 1 and 30/216 (13.8%) had grades 2 or 3. Twenty one of men with VFA-identified fracture (32.8%) had only a single vertebral fracture, while the other 67.2% had two or more. Fractures were most common in the mid-thoracic spine and at the thoraco-lumbar junction. As would be expected, the prevalence of VFA-detected fractures increased with age and as BMD declined. This group of men had a statistically significant lower weight, height, calcium consumption and T-score than those without a VFA-identified vertebral fracture. Regression analysis showed that presence of vertebral fracture was mainly related to the osteoporotic status (OR: 9.0; 95% CI: 3.5–22.8).ConclusionVFA allows evaluation of the majority of vertebral bodies in men. Vertebral fractures are common in healthy men and are related to low BMD.     

Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA

Summary Application of the WHO fracture prediction algorithm in conjunction with an updated US economic analysis indicates that osteoporosis treatment is cost-effective in patients with fragility fractures or osteoporosis, in older individuals at average risk and in younger persons with additional clinical risk factors for fracture, supporting existing practice recommendations. Introduction The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment. Methods The WHO fracture prediction algorithm was calibrated to the US population using national age-, sex- and race-specific death rates and age- and sex-specific hip fracture incidence rates from the largely white population of Olmsted County, MN. Fracture incidence for other races was estimated by ratios to white women and men. The WHO algorithm estimated the probability (%) of a hip fracture (or a major osteoporotic fracture) over 10 years, given specific age, gender, race and clinical profiles. The updated economic model suggested that osteoporosis treatment was cost-effective when the 10-year probability of hip fracture reached 3%. Results It is cost-effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared to postmenopausal white women. Conclusions This analysis generally endorsed existing clinical practice recommendations, but specific treatment decisions must be individualized. An estimate of the patient’s 10-year fracture risk should facilitate shared decision-making. The authors comprise the National Osteoporosis Foundation Guide Committee.     

The assessment of osteoporosis risk factors in Iranian women compared with Indian women

Background  

Osteoporosis is an important public health problem in older adults. It is more common in postmenopausal women and not only gives rise to morbidity but also markedly diminishes the quality of life in this population. There is lack of information about the risk factor of osteoporosis in developing countries. In this study we aimed to assess the risk factors for osteoporosis in postmenopausal women from selected BMD centers of two developing Asian countries (Iran and India).     

上海地区老年人骨质疏松危险因素知晓率及其患病率的研究

目的调查上海地区60岁以上老年人,对其骨质疏松危险因素的知晓率及其患病率进行研究,进而加强骨质疏松症及其并发症防治教育宣传工作。方法对来我院及多家区中心医院就诊的840例60岁以上患者进行骨质疏松危险因素知晓问卷调查,并行腰椎骨密度检查。将840例检测结果按不同性别每间隔10岁为一年龄组,应用SPSS 20.0软件分析骨密度测量值、骨质疏松症患病率,及其危险因素患病率。结果上海地区60岁以上老年人对传统的骨质疏松危险因素知晓率较高,如低骨密度(100%)、缺钙(100%)、高龄(96.5%)、偏食(96.1%)、缺乏锻炼(85.1%)等;而对于临床偏专业性的危险因素知晓率较低,如吸烟/饮酒(36.5%)、肥胖(25.1%)、家族骨折史(14.9%)、跌倒/跌倒倾向(10.2%)、糖尿病(7.5%)、独居(6.7%)等。上海地区60岁以上老年人骨质疏松症患病危险因素由高到低依次为跌倒(51.7%)、高龄(43.4%)、独居者(34.1%)、糖尿病等基础疾病(30.5%)、低骨密度者(27.6%)、既往或者家族骨折史(22.8%)、超重(17.1%)、缺乏身体锻炼(13%)、嗜酒吸烟者(11.6%)。结论上海地区60岁以上老年人骨质疏松症患病率较高,对骨质疏松的高危因素认知程度普遍较低,两者呈负相关;亟需积极开展骨质疏松防治宣传教育工作。     

The mandibular cortex on radiographs as a tool for osteoporosis risk assessment: the OSTEODENT Project.

The aim of this study was to measure the accuracy of porosity of the mandibular cortex on dental panoramic radiographs (DPRs) in diagnosis of osteoporosis, alone and in combination with a clinical risk index. Six hundred seventy-one women (45-70yr) were recruited in the study, and dual-energy X-ray absorptiometry of the hip and lumbar spine was performed. A clinical index of osteoporosis risk (OSIRIS) and a DPR were obtained for each subject. The cortical appearance on the DPR was classified using the mandibular cortical index (MCI) by 5 observers. receiver operating characteristic (ROC) curve analysis was performed with calculation of area under the ROC curve (AUC) and sensitivity and specificity at various thresholds. Complete data were available for 653 subjects, of whom 21.6% had osteoporosis. The AUC for OSIRIS was 0.838. When used alone as the diagnostic test, MCI AUC for the 5 observers ranged from 0.560 to 0.670, significantly less than OSIRIS. Intraobserver and interobserver repeatability of MCI assessment was inconsistent. We conclude that MCI has limited value for osteoporosis diagnosis, being most appropriate as a method of fortuitous case-finding.     

海口地区各年龄段人群骨密度变化及中老年骨质疏松患病率调查

目的分析海口地区常住居民各年龄段人群骨密度(bone mineral density,BMD)值变化情况,并调查分析中老年骨质疏松患病率。方法采用多阶段抽样法抽取海口地区常住居民2 176名,采用双能X线检测腰椎正位BMD、左髋部BMD,并根据性别、年龄分组对骨质疏松患病率进行分析,统计中老年(年龄≥46岁)骨质疏松患病率。结果 BMD值随年龄增加呈下降趋势,51岁以上男性BMD值同年龄段内女性,且组间差异有统计学意义(P0.05);男性在66～70岁年龄段BMD明显增加,其中L1～4最明显;女性51～55岁年龄段内BMD值下降最明显。海口地区城市女性Ward’s、Troch的BMD高于农村女性(P0.05)。海口地区中老年人骨质疏松总发生率为58.17%,中老年人骨质疏松发生率随年龄增加呈上升趋势;相同年龄段内,男性骨质疏松发生率低于女性,男性在66～70岁、76～80岁两个年龄段内骨质疏松发生率略下降。骨折发生率随年龄增加呈上升趋势,同年龄段内男性骨折发生率低于女性,女性76～80岁年龄段内骨折发生率最高;脊柱骨折发生率最高,81岁及以上年龄骨折发生率呈下降趋势。结论海口地区常住居民BMD随年龄增加下降,中老年骨质疏松发生率较高,且随年龄增加上升,女性骨质疏松发生率显著高于男性,因此应加强中老年群体干预与健康教育。     

3253例围绝经及绝经后女性骨质疏松风险评估工具的应用

目的 比较分析FRAX(不含BMD模型)、BMD、BMI、OSTA指标对北京南郊地区围绝经期及绝经后女性骨质疏松风险的预测评估价值。方法 选取2017年1月至2022年6月在大兴区中西医结合医院行骨密度检查的围绝经期及绝经后女性3 253例,收集患者年龄、身高、体重、骨密度T值等数据,分析FRAX(不含BMD模型)、BMD、BMI和OSTA 4种指标在各年龄层和不同骨量之间的差异,绘制不同指标诊断骨量减少或骨质疏松的ROC曲线,比较各指标预测的准确性。结果 随着年龄增加,BMD、OSTA减低,FRAX-MOF、FRAX-HF增加;(2)骨量越小,BMD、OSTA越低,FRAX-MOF、FRAX-HF越高;(3)FRAX-MOF、FRAX-HF诊断骨质疏松的AUC值分别为0.811和0.810,较OSTA(AUC=0.799)有更好的诊断效能(P<0.001);(4);FRAX-MOF、FRAX-HF诊断骨量减少的AUC值分别为0.770和0.767,较OSTA(AUC=0.748)有更好的诊断效能(P<0.001),OSTA指数特异性较高(83.0%),临界值为0.10。结...     

Cardiovascular risk assessment according to a national calibrated score risk index in psoriatic arthritis patients without clinically evident cardiovascular disease or classic atherosclerosis risk factors

ObjectiveTo assess cardiovascular (CV) risk in psoriatic arthritis (PsA) patients without clinically evident CV disease or classic atherosclerosis risk factors according to the SCORE chart following the EULAR recommendations.MethodsEighty PsA patients without previous CV events or atherosclerosis risk factors and eighty matched controls were included. Information on demographic, anthropometric and clinical-serological data of disease was assessed. The national calibrated Systematic Coronary Risk Evaluation (SCORE) index was calculated and the association between this SCORE and clinical-serological data of these patients was analyzed.ResultsPsA patients had higher acute phase reactants as well as higher SCORE mean values than healthy controls (1.99 ± 3.52 vs. 1.0 ± 1.74; P = 0.028). According to SCORE definitions, 71 (89%) patients had low-intermediate CV risk and 9 (11%) were above the threshold of high risk. In the control group, 76 (95%) had low-intermediate risk and four (5%) had high CV risk. However, there were no differences in CV risk stratification between both groups (P = 0.148). PsA patients with high-very high CV risk had longer disease duration (P = 0.001) and higher levels of triglycerides (P = 0.009). PsA patients showed a significant correlation between SCORE values and disease duration (β = 0.185; P = 0.0001) and the average annual levels of C reactive protein (CRPa), β = 2.38; P = 0.014.ConclusionCV risk assessment in PsA patients without clinically evident CV disease or classic atherosclerosis risk factors may be underestimated by using only the SCORE chart. In these patients, disease duration and the CRPa may help to establish a better stratification of the actual CV risk.