BMD Tests Research Articles

Validation of Three Tools for Estimating the Risk of Primary Osteoporosis in an Elderly Male Population in Beijing.

This cross-sectional study estimated three clinical tools including the Osteoporosis Self-Assessment Tool for Asians (OSTA), Body Mass Index (BMI), and Beijing Friendship Hospital Osteoporosis Self-assessment Tool for Elderly Male (BFH-OSTM) for identifying primary osteoporosis and found optimal cut-off values in an elderly Han Beijing male population. We conducted a cross-sectional study, enrolling 400 community-dwelling elderly Han Beijing males aged ≥50 from 8 medical institutions. Osteoporosis was diagnosed as a T-score of -2.5 standard deviations or lower than that of the average young adult in different diagnostic criteria [lumbar spine (L1-L4), femoral neck, total hip, WHO]. BFH-OSTM, OSTA, and BMI were assessed for predicting OP by receiver operating characteristic (ROC) curves. Sensitivity, specificity, and areas under the ROC curves (AUC) were determined. Ideal thresholds for the omission of screening BMD were proposed. The prevalence of osteoporosis ranged from 9.25% to 19.0% according to different diagnostic criteria. The present study indicated the highest discriminating ability was BFH-OSTM in different criteria. The AUCs of OSTA and BMI were 0.748 and 0.770 in WHO criteria, which suggested limiting predictive value for identifying OP in elderly Beijing males. The AUC of BFH-OSTM to predict OP based on WHO criteria was 0.827, yielding a sensitivity of 65.8% and specificity of 82.7%, respectively. With a cost of missing 6.5% of osteoporosis patients, BFH-OSTM could reduce 73.5% of participants in screening BMD tests. BFH-OSTM may be a simple and effective tool for identifying OP in the elderly male population in Beijing to omit BMD screening reasonably.

A comparative evaluation of mikrolatest kit broth microdilution and VITEK2 in assessing colistin susceptibility to Gram-negative bacterial isolates

Introduction and Aim: The increasing resistance in colistin is a major concern. The aim of the study was to compare the methods to identify the prevalence of colistin resistance and antibiotic susceptibility patterns of colistin resistant strains isolates from blood, urine and sputum samples at all ICUs including NICU and PICU and wards.
 
 Materials and Methods: A total of 1458 consecutive Gram-negative isolates were tested for colistin susceptibility by standard broth microdilution method, Mikrolatest method and VITEK 2 automation system. Intrinsically colistin resistant organisms including Proteus sps, Providencia sps, Serratia sps., and Morganella morganii were excluded. Enterobacteriaceae (e.g., Escherichia coli, Klebsiella), Pseudomonas aeruginosa and Acinetobacter baumanii were included. The sensitivity, specificity, positive predictive value, negative predictive value of Vitek-2, BMD and Mikrolatest methods were compared. 
 
 Results: Sixteen (1.09%) colistin?resistant isolates were reported over 24 months. K. pneumoniae constituted 8(50%), E. coli 6 (37.5%) and Enterobacter cloacae 2 (12.5%) of the 16 resistant isolates. The sensitivity, specificity, positive predictive value, negative predictive value of Mikrolatest compared with that of VITEK2 were 87.5% vs 56.25%, 90.84% vs 82.65%, 9.58% vs 3.47%and 99.8% vs 99.3%, respectively for resistant isolates. Mikrolatest shared good Category agreement of 1.24% with BMD Essential agreement was 1.5%. Comparing MICs of BMD with other tests, essential agreement was the lowest for the VITEK2, while the Mikrolatest MIC showed essential agreement greater than 1.5%. No errors and 100% categorical agreement (for E. coli, K. pneumoniae) were observed while comparing colistin susceptibility test results of the Mikrolatest MIC and BMD tests. The difference between the two methods in assessing colistin resistance were not statistically significant (P=0.89). Blood[37.5%] and pus[37.5%] samples recorded as the common sources of the isolate, followed by Urine [12.5%], and respiratory [12.5%) samples.
 
 Conclusion: Automated VITEK, Mikrolatest MIC methods give variable susceptibility results and colistin should be prescribed only after Mikrolatest and BMD. K. pneumoniae and E. coli, the Mikrolatest showed better performance for isolates with ? 0.5 or ? 16 µg/mL MICs. For P. aeruginosa isolates, colistin resistant isolates must be confirmed Colistin resistance among Gram-negative bacteria, especially K. pneumoniae, is emerging in Indian hospitals. Re-evaluation is required of the methods available to address the numerous technical challenges associated with colistin susceptibility testing, and to determine which method yields the most meaningful results. These studies will provide critical information on the appropriate selection of colistin therapy, as well as evaluating novel and upcoming compounds with structure and properties similar to the Polymyxin.

Bone densitometry categories as a salient distracting feature in the modern clinical pathways of osteoporosis care: A retrospective 20-year cohort study.

It is unknown as to what factors typically drive osteoporosis therapy decisions in real-world practice. Retrospective, 20-year cohort study within the government health system of Manitoba including all women having bone densitometry (BMD) tests between 1996 and 2017. Osteoporosis prescription data was linked to registry data on fractures, clinical risk factors and BMD tests. We defined 6 possible treatment decisions by prescription data: no treatment, starting, stopping, continuing, drug hiatus and re-starting. For each decision, we tested the association between salient patient factors (age, glucocorticoid use, recent fracture, BMD hip or spine T-score≤-2.5, FRAX major osteoporotic fracture probability ≥20%) using multivariable logistic regression. The factors were rank-ordered by decreasing Wald χ2 statistic to determine the relative importance. There were 64,181 women, 33.8% of whom started osteoporosis therapy. For patients who begin therapy after a first BMD, the rank-ordered multivariable logistic regression factor most strongly associated was the T-score≤-2.5 [OR of 7.59(95%CI 7.19-8.01, p<0.001)]. This was followed by glucocorticoid use [OR 2.89(95%CI 2.59-3.22, p<0.001)]. Increasing age and recent fracture (within 2years) were weak predictors of therapy and high FRAX score associated with reduced odds of therapy [OR 0.80 (95%CI 0.74-0.88, p<0.001)]. T-scores were the strongest factor predicting therapy stop/continuation/re-starting; age and prior fracture had weak or no associations. Despite recommendations for fracture-risk-based approach to osteoporosis therapy, BMD T-score continues to be the dominant factor in actual practice. Age, prior fracture or global fracture risk are much less associated; it is possible that BMD T-score categories are therefore acting as a clinically salient distracting factor.

How frequent is osteogenesis imperfecta in patients with idiopathic osteoporosis?: Case reports.

Rationale:The term idiopathic osteoporosis itself is quite a non-specific disease label, which fails to address the etiological understanding. Bone mineral density alone is not a reliable parameter to detect patients at high risk of fracture. The diversity of the clinical phenotypes of discolored teeth, blueness of the sclera, back and joint pain, cardiovascular disease, Diabetes type II, hearing problems and a long list of orthopedic problems are have to be considered.Patients concerns:Our study has been designed in accordance with the clinical and radiological phenotype of eleven index cases with the provisional diagnosis of OI, which was followed by genotypic confirmation. This was followed by the invitation of siblings, parents, grandparents and other relatives to participate in the interviews, and to discuss the impact of the diagnosis. Proper collaboration with these families facilitated the process to identify other subjects with a history of fractures and other deformities/disabilities which were seemingly correlated to heritable connective tissue disorder. In total, 63 patients (27 children and 36 parents/grandparents and relatives) were enrolled in the study. Two groups of children were not included in our study. We excluded children with incomplete documentation and children who manifested de novo mutation. The term idiopathic osteoporosis (IOP) has been given to these families in other Institutes and was considered as a definite diagnosis. IOP was solely based on T scores, BMD and certain laboratory tests. Surprisingly, no single adult patient underwent clinical and or radiological phenotypic characterization.Diagnoses:A constellation of significant disease associations with osteoporotic fracture risk have been encountered. The index cases showed mutations in COL1A1 (17q21.31.q22) and COL1A2 (7q22.1), the genes encoding collagen type I. The phenotype/genotype confirmation in 11 children was the key factor to boost our research and to re-consult each family. Comprehensive clinical and radiological phenotypic documentation has been applied to most of other family subjects who principally received the diagnosis of IOP.Interventions:All adult patients had normal serum calcium and only three patients showed an average of low serum phosphate of 0.7–0.61 mmol/l. Serumcrosslaps in six parents was in the average of (2.9–3.8 nM) and PTH levels were normal in all patients (the average showed 8.73 pg/ml).Outcomes:Our efforts to minimize and constrain the usage of the term idiopathic osteoporosis and to understand the sequence of pathological events that occurred in these families were emphasized. These efforts evolved into a remarkable and unique constellation of clinical findings. Strikingly, fracture represented a portion in a series of skeletal and extra-skeletal deformities and abnormalities which are all correlated to connective tissue disorder. This was achieved mainly through comprehensive phenotype/genotype confirmation, followed by scrutinizing the records of each family, clinical examination of the adults and revising the archives of our Hospitals and other Institutes.Lessons:The sequence of diverse pathological events recorded within each family would be almost incomprehensible without a proper etiological understanding of the natural history of each child/family deformity that led to their occurrences. We wish to stress that, our current study is just an attempt to cover only a tiny fraction of the tip of the iceberg and to profoundly explore one of the most under-estimated causes of idiopathic osteoporosis.

Low-trauma fractures and bone mineral density testing in adults with and without intellectual and developmental disabilities: a population study.

Individuals with IDD are at increased risk for developing osteoporosis which contributes to high rates of low-trauma fracture. Low-trauma fractures can lead to significant pain and further decrease mobility. It is therefore important to effectively manage osteoporosis, for example, by monitoring BMD in persons with IDD. The objective of this study was to examine the rates of low-trauma fracture and BMD testing among a population-based cohort of people with IDD and compare them to those without IDD. Using administrative data, we created a cohort of adults with IDD between the ages of 40 and 64. They were compared to a random 20% sample of those without IDD. The number of low-trauma fractures and BMD tests in each group were determined for Ontario residents between April 1, 2009 and March 31, 2010. Adults with IDD were approximately three times more likely to experience a low-trauma fracture than adults without IDD. The largest disparity in prevalence of low-trauma fractures between those with and without IDD was for men, older adults (60-64years old) and those living in rural or lower-income neighbourhoods. Post low-trauma fracture, there was no significant difference in the likelihood of receiving a BMD test between individuals with and without IDD. The findings of this study have a number of important implications related to early detection, prevention and proper management of osteoporosis and low-trauma fractures among persons with IDD.

Bone-density testing interval and transition to osteoporosis in patients with rheumatoid arthritis.

Although BMD testing is routinely performed in RA patients, the interval between BMD tests has not been determined. We retrospectively recruited 360 consecutive female patients with RA, who underwent repeated BMD testing, with a mean age of 53.7 ± 10.2years and a mean follow-up duration of 7.4 ± 5.0years. We stratified the study participants into five groups based on their baseline T-score range. The testing interval was defined as the estimated time for 10% of patients in each subgroup to transition to osteoporosis. Competing-risk analyses were performed with sensitivity analysis by menopausal status and risk factors for transition to osteoporosis. At baseline, 15% of screened patients had osteoporosis, and during follow-up, that proportion increased to 24.8%. The estimated BMD testing interval for 10% of patients to develop osteoporosis was 9.6years for those with normal BMD, 7.6years for those with mild osteopenia, 4.7years for those with moderate osteopenia, and 2.1years for those with severe osteopenia. No significant risk factor for transition to osteoporosis was identified in this cohort. Our data indicate that osteoporosis will develop in less than 10% of female RA patients during rescreening intervals of approximately 9years for those with normal bone density at baseline, 7years for those with mild osteopenia, 4years for those with moderate osteopenia, and 2years for those with severe osteopenia at baseline. BMD interval in RA patients could be adjusted according to their baseline BMD T-scores.

Diagnosis of Osteoporotic Spinal Fractures

scans are sufficient for diagnosis of OSFs. However, other clinical and radiographic clues should be considered for prediction of the prognosis and differential diagnosis. Materials and Methods: Review of the relevant literature. Results: Clinical clues including morphometric changes in the vertebral body are sufficient for diagnosis of OSFs. BMD testing is helpful for diagnosis of osteoporosis. However, simple radiographs and BMD tests do not present sufficient information on the prognosis of OSFs. The location of the involved segments, morphological characteristics, and other co-morbidities should be taken into consideration in the initial management of OSFs. Moreover, pathologic conditions leading to spinal fractures should be taken into account in some clinical situations. Conclusions: With increasing reports of complicated OSFs or other pathologic fractures, other diagnostic modalities and clinical factors should be considered in predicting the prognosis of OSFs and differentiating OSFs from other pathologic conditions.

Temporal changes of microarchitectural and mechanical parameters of cancellous bone in the osteoporotic rabbit.

This study was aimed at elucidating the temporal changes of microarchitectural and mechanical parameters of cancellous bone in the osteoporotic rabbit model induced by ovariectomy (OVX) combined with glucocorticoid (GC) administration. Osteoporotic (OP) group received bilateral OVX combined with injections of GC, while sham group only received sham operation. Cancellous bone quality in vertebrae and femoral condyles in each group was assessed by DXA, μCT, nanoindentation, and biomechanical tests at pre-OVX and 4, 6, and 8 weeks after injection. With regard to femoral condyles, nanoindentation test could detect significant decline in tissue modulus and hardness at 4 weeks. However, BMD and microarchitecture of femoral condylar cancellous bone changed significantly at 6 weeks. In vertebrae, BMD, microarchitecture, nanoindentation, and biomechanical tests changed significantly at 4 weeks. Our data demonstrated that temporal changes of microarchitectural and mechanical parameters of cancellous bone in the osteoporotic rabbit were significant. The temporal changes of cancellous bone in different anatomical sites might be different. The nanoindentation method could detect the changes of bone quality at an earlier stage at both femoral condyle and vertebra in the osteoporotic rabbit model than other methods (μCT, BMD).

FRI0434 Anterior chest wall pain in recent inflammatory back pain. data from the desir cohort.

BackgroundAnterior chest wall pain (ACW) may be suggestive of spondyloarthritis (SpA), but little is known about this clinical feature in recent inflammatory back pain (IBP).ObjectivesTo determine the prevalence of ACW...

SAT0264 Impact of uveitis on the phenotype of patients with recent inflammatory back pain. Data from the desir cohort

BackgroundInfluence of uveitis on clinical, epidemiological and imaging features in patients with inflammatory back pain (IBP) related to spondyloarthritis (SpA) needs to be known.ObjectivesTo determine the prevalence of uveitis in...

The Long-Term Impact of a Performance Improvement Continuing Medical Education Intervention on Osteoporosis Screening

The purpose of this study is to determine whether a performance improvement continuing medical education (PI CME) initiative that utilizes quality improvement (QI) principles is effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. A health care center participated in a PI CME program designed to increase appropriate osteoporosis screening. There were eight 1-hour educational sessions for this activity over a 9-month period. Thirteen providers completed all 3 stages of the PI CME program. A variety of other clinicians, in addition to the 13 providers, participated in the educational sessions. Data were collected at the beginning and end of the PI CME activity and at three intervals during the 5 years after the completion of the activity. The percentage of tests for osteoporosis ordered and performed increased significantly from Stage A to Stage C of the PI CME activity and continued to increase after the completion of the PI CME activity. Follow-up data at 4 and 40 months (for ordering and performing osteoporosis screening) and 49 months (for performing the screening only) reflect the impact of the PI CME activity plus the continuing QI interventions. The percentage of BMD tests ordered continued to increase substantially over the post-PI CME periods: 4 and 40 months (F(3,46) = 4.04, p < .05). Similarly, the percentage of BMD tests performed continued to increase at 4, 40, and 49 months after the conclusion of the PI CME activity (F(4,55) = 12.55, p < .0001). The data indicate that PI CME utilizing QI principles can be effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. Further research is needed to determine the extent to which such changes can be directly attributed to this type of intervention.

P91 Care of HIV+ women aged 50 and over: can we do better?

BackgroundThe prevalence of ageing HIV infected females continues to increase due to greater survival, delayed diagnosis and new infections; management of specific issues in this group becomes more challenging.Aims/ObjectiveTo identify...

FRAX® with and without Bone Mineral Density

The use of FRAX, particularly in the absence of BMD, has been the subject of some debate and is the focus of this review. The clinical risk factors used in FRAX have high validity as judged from an evidence-based assessment and identify a risk that is responsive to pharmaceutical intervention. Moreover, treatment effects, with the possible exception of alendronate, are not dependent on baseline BMD and strongly suggest that FRAX identifies high-risk patients who respond to pharmaceutical interventions. In addition, the selection of high-risk individuals with FRAX, without knowledge of BMD, preferentially selects for low BMD. The prediction of fractures with the use of clinical risk factors alone in FRAX is comparable to the use of BMD alone to predict fractures and is suitable, therefore, in the many countries where DXA facilities are sparse. In countries where access to BMD is greater, FRAX can be used without BMD in the majority of cases and BMD tests reserved for those close to a probability-based intervention threshold. Whereas the efficacy for agents to reduce fracture risk has not been tested prospectively in randomized controlled trials in patients selected on the basis of FRAX probabilities, there is compelling evidence that FRAX with or without the use of BMD provides a well-validated instrument for targeting patients most likely to benefit from an intervention.

BMD, clinical risk factors and their combination for hip fracture prevention

This study examined the effects of the use of clinical risk factors (CRFs) alone, BMD alone or the combination using the FRAX tool for the detection of women at risk of hip fracture. BMD tests alone selected women at higher risk and a greater number of hip fracture cases were identified compared to the use of CRFs alone. The combined use of CRFs and BMD identified fewer women above a threshold risk than the use of BMD alone, but with a higher hip fracture risk and thus had the more favourable positive predictive value (PPV) and number needed to treat (NNT). Algorithms have recently become available for the calculation of hip fracture probability from CRFs with and without information on femoral neck BMD. The aim of this study was to examine the effects of the use of CRFs alone, BMD alone or their combination using the FRAX tool for the detection of women at risk of hip fracture. Data from 10 prospective population based cohorts, in which BMD and CRFs were documented, were used to compute the 10-year probabilities of hip fracture calibrated to the fracture and death hazards of the UK. The effects of the use of BMD tests were examined in simulations where BMD tests were used alone, CRFs alone or their combined use. The base case examined the effects in women at the age of 65 years. The principal outcome measures were the number of women identified above an intervention threshold, the number of hip fracture cases that would be identified, the positive predicted value and the NNT to prevent a hip fracture during a hypothetical treatment with an effectiveness of 35% targeted to those above the threshold fracture risk. We also examined BMD values in women selected for treatment. Sensitivity analysis examined the effect of age and limited use of BMD resources. BMD tests alone selected women at higher risk of hip fracture than the use of CRFs alone (6.1% versus 5.3%). BMD tests alone also identified a greater number of hip fracture cases (219/1,000) compared to the use of CRFs alone (140/1,000). The combined use of CRFs and BMD identified fewer women above a threshold risk than the use of BMD alone (168/1,000 versus 219/1,000, respectively), but with a higher hip fracture risk (PPV, 8.6% versus 6.1%), and consequently a lower number needed to treat (NNT) (33 versus 47). In sensitivity analyses, the PPV and NNT were always better for the combination than either BMD or CRFs alone across all ages studied (50-70 years). The use of FRAX in combination with BMD increases the performance characteristics of fracture risk assessment.

Population Trends in BMD Testing, Treatment, and Hip and Wrist Fracture Rates: Are the Hip Fracture Projections Wrong?

A worldwide epidemic of hip fractures has been predicted. Time trends in BMD testing, bone-sparing medications and hip and wrist fractures in the province of Ontario, Canada, were examined. From 1996 to 2001, BMD testing and use of bone-sparing medications increased each year, whereas despite the aging of the population, wrist and hip fracture rates decreased. If patients with osteoporosis are being diagnosed and effective treatments used with increasing frequency in the population, rates of hip and wrist fractures will remain stable or possibly decrease. We report here time trends in BMD testing, prescriptions for bone-sparing medications, hip and wrist fracture rates, and population projections of fracture rates to 2005 in the province of Ontario, Canada. Ontario residents have universal access to Medicare. To examine time trends in BMD testing, all physician claims for DXA from 1992 to 2001 were selected from the Ontario Health Insurance Plan (OHIP) database. Trends in prescribing were examined from 1996 to 2003 using data from the Ontario Drug Benefit plan, which provides coverage to persons > or = 65 years of age. Actual numbers of hip and wrist fractures were determined for 1992-2000 and population projections for 2001-2005 using time-series analysis. Wrist fractures were identified in the OHIP database and hip fractures through hospital discharge abstracts. From 1992 to 2001, the number of BMD tests increased 10-fold. There has been a steady increase in the number of persons filling prescriptions for antiresorptives (12,298 in 1996 to 225,580 in 2003) and the majority were for etidronate. For women, the rate of decline for wrist fractures is greater than that for hip fractures. The rate of hip fracture was fairly constant around 41 per 10,000 women > or = 50 years between 1992 and 1996. In 1997, the hip fracture rate began to decrease, and the population projections suggest that this downward trend will continue to a rate of 33.1 per 10,000 in 2005. Our findings suggest that fracture rates may be on the decline, despite the aging of the population, because of increased patterns of diagnosis and treatment for osteoporosis.

Requirements for DXA for the management of osteoporosis in Europe

The availability of dual energy X-ray absorptiometry (DXA) varies markedly in different countries. There is, however, little information to indicate the optimal requirements for this technology. The principal aim of this study was to estimate the requirements for DXA in Europe for the assessment and treatment of osteoporosis. Three assessment scenarios were chosen. The first envisaged screening of all women with DXA at the age of 65 years. A second scenario comprised a screening programme based on the identification of clinical risk factors with the selective addition of BMD tests in those close to an intervention threshold. The third scenario envisaged a case finding strategy where women aged 65 years were identified on the basis of risk factors and referred for DXA. Requirements for women aged more than 65 years were amortised over a 10-year period. A secondary aim was to estimate the number and cost of osteoporotic fractures in Europe. The requirements for DXA in assessment ranged from 4.21 to 11.21 units/million of the population. The most efficient assessment scenario was the use of clinical risk factors with the selective use of BMD. With this scenario, an additional 6.39 units/million would be required to monitor treatment giving a total requirement of 10.6 units/million. In 2000, the number of osteoporotic fractures was estimated at 3.79 million, of which 0.89 million were hip fractures (179,000 hip fractures in men and 711,000 in women). The total direct costs were estimated at 31.7 billion Euros (21.165 billion UK pounds), which were expected to increase to 76.7 billion Euros (51.1 billion UK pounds) in 2050 based on the expected changes in the demography of Europe.

Optimization of BMD measurements to identify high risk groups for treatment--a test analysis.

The aim of this study was to develop a methodology to optimize the role of BMD measurements in a case finding strategy. We studied 2113 women > or = 75 years of age randomly selected from Sheffield, UK, and adjacent regions. Baseline assessment included hip BMD and clinical risk factors. Outcomes included death and fracture in women followed for 6723 person-years. Poisson models were used to identify significant risk factors for all fractures and for death with and without BMD and the hazard functions were used to compute fracture probabilities. Women were categorized by fracture probability with and without a BMD assessment. A 10-year fracture probability threshold of 35% was taken as an intervention threshold. Discordance in categorization of risk (i.e., above or below the threshold probability) between assessment with and without BMD was examined by logistic regression as probabilities of re-classification. Age, prior fracture, use of corticosteroids, and low body mass index were identified as significant clinical risk factors. A total of 16.8% of women were classified as high risk based on these clinical risk factors. The average BMD in these patients was approximately 1 SD lower than in low-risk women; 21.5% of women were designated to be at high risk with the addition of BMD. Fifteen percent of all women were reclassified after adding BMD to clinical risk factors, most of whom lay near the intervention threshold. When a high probability of reclassification was accepted (without a BMD test) for high risk to low risk (p1< or = 0.8) and a low probability accepted for low to high risk (P2 < or = 0.2), BMD tests would be required in only 21% of the population. We conclude that the use of clinical risk factors can identify elderly women at high fracture risk and that such patients have a low average BMD. BMD testing is required, however, in a minority of women--a fraction that depends on the probabilities accepted for classification and the thresholds of risk chosen. These findings need to be validated in other cohorts at different ages and from different regions of the world.