Femoral Dual-energy X-ray Absorptiometry Research Articles

Bone strain index for fracture risk assessment in older men-the prospective STRAMBO study.

Bone strain index (BSI) is a noninvasive index of bone strength assessed on lumbar spine and femur dual energy X-ray absorptiometry scans using the finite-element method. In this study, we assess the link of the lumbar spine and hip BSI with fracture risk in older men. Prospective cohort study. A cohort of 825 men aged ≥60 was followed up for 12 years. Lumbar spine and hip bone mineral density, BSI, Fracture Risk Assessment Tool (FRAX) for major osteoporotic fractures (MOPFx), and lumbar spine trabecular bone score (TBS) were assessed at baseline. Overall, 159 men had 198 incident fractures. After adjustment for FRAX and prior falls, a higher BSI was associated with a higher fracture risk, eg, trochanter BSI: (HR = 1.34 per standard deviation (SD) increase, 95% CI: 1.14-1.58, P < .001). Patterns were similar for MOPFx, vertebral, nonvertebral, and multiple fractures. The fracture risk was higher in the highest vs the lowest BSI quartiles. The associations were the strongest for the BSI of the lumbar spine and trochanter. When the TBS and BSI were analyzed jointly, their respective contributions to fracture prediction varied according to the fracture and the site of the BSI, eg, both the TBS and the trochanter BSI contributed to the MOPFx prediction (TBS: HR = 1.38/SD decrease, 95%CI: 1.04-1.84, P < .05; BSI: HR = 1.49/SD increase, 95% CI: 1.16-1.91, P < .005). The BSI at both the lumbar and the femoral sites was associated with a higher fracture risk independently of FRAX and prior falls in older men followed prospectively for 12 years.

Ultrasound in Bone Quality Screening: From the Perspective of Osteoporosis

ABSTRACT Background: Among Brazilians, 4.4% of population has osteoporosis, and the characteristic population with the disease is women above 45 years. Monitoring bone mineralization from an early age becomes a preventive factor essential for those with a family history of osteoporosis or vulnerable population to develop osteoporosis. It is essential to use techniques that are affordable and easily available with high reliability. Quantitative ultrasound (QUS) can be one of these techniques. Objectives: The objective of the study was to analyze the importance of phalanx ultrasound (US) as a tracking element of the bone quality, accurately establish the diagnostic tests as bone quality, define a nomogram of bone quality, build bone quality normality curve, and establish the pathological risk cutoff score according to the age group. Method: In this descriptive, analytical, cross-sectional study, 125 women who met the inclusion criteria were selected. They were divided into four groups according to their age: group 1 (G1): 30 to 39 years; group 2 (G2): 40 to 49 years; group 3 (G3): 50 to 59 years; and group 4 (G4): 60 years and above. All the participants underwent phalanx US and dual-energy X-ray absorptiometry (DEXA). The Ultrasound Bone Profile Index (UBPI) was found, and the phalanx US and sensitivity of the same technique were determined. Result: UBPI at the phalanx was compared with DEXA, and the sensitivity of the test was found to be 80% for G1 and 100% for G2, G3, and G4. Regarding femur DEXA, the sensitivity of the test was 90% for G1 and 100% for G2, G3, and G4. There was a significant inverse correlation observed between age and bone quality. This result includes an early decrease in bone quality, starting in the fertile period of women. The cutoff score for pathological risk was as follows: G1: 0.68 ± 0.23; G2: 0.64 ± 0.28; G3: 0.54 ± 0.37; and G4: 0.32 ± 0.30. Conclusion: Phalanx US proved to be a highly effective method as an osteoporosis tracking element in terms of bone quality evaluation, hence can be used as a screening tool for early diagnosis among the female population.

CT required to perform robotic-assisted total hip arthroplasty can identify previously undiagnosed osteoporosis and guide femoral fixation strategy

Osteoporosis can determine surgical strategy for total hip arthroplasty (THA), and perioperative fracture risk. The aims of this study were to use hip CT to measure femoral bone mineral density (BMD) using CT X-ray absorptiometry (CTXA), determine if systematic evaluation of preoperative femoral BMD with CTXA would improve identification of osteopenia and osteoporosis compared with available preoperative dual-energy X-ray absorptiometry (DXA) analysis, and determine if improved recognition of low BMD would affect the use of cemented stem fixation. Retrospective chart review of a single-surgeon database identified 78 patients with CTXA performed prior to robotic-assisted THA (raTHA) (Group 1). Group 1 was age- and sex-matched to 78 raTHAs that had a preoperative hip CT but did not have CTXA analysis (Group 2). Clinical demographics, femoral fixation method, CTXA, and DXA data were recorded. Demographic data were similar for both groups. Preoperative femoral BMD was available for 100% of Group 1 patients (CTXA) and 43.6% of Group 2 patients (DXA). CTXA analysis for all Group 1 patients preoperatively identified 13 osteopenic and eight osteoporotic patients for whom there were no available preoperative DXA data. Cemented stem fixation was used with higher frequency in Group 1 versus Group 2 (28.2% vs 14.3%, respectively; p = 0.030), and in all cases where osteoporosis was diagnosed, irrespective of technique (DXA or CTXA). Preoperative hip CT scans which are routinely obtained prior to raTHA can determine bone health, and thus guide femoral fixation strategy. Systematic preoperative evaluation with CTXA resulted in increased recognition of osteopenia and osteoporosis, and contributed to increased use of cemented femoral fixation compared with routine clinical care; in this small study, however, it did not impact short-term periprosthetic fracture risk.

The role of opportunistic quantitative computed tomography in the evaluation of bone disease and risk of fracture in thalassemia major.

Dual-energy X-ray absorptiometry (DXA) remains the cornerstone for osteoporosis evaluation in Thalassemia major. However, several drawbacks have been observed in this unique setting. We sought to determine the correlation between quantitative CT (QCT) and DXA-derived parameters; secondarily, we aimed to investigate the role of the two techniques in predicting the risk of fracture. We retrospectively included patients with β-thalassemia major who had undergone both lumbar and femoral DXA examinations, and CT scans including the lumbar spine, performed for disparate diagnostic issues, within 4 months from the DXA. CT data were examined employing a phantom-less QCT method for bone mineral density (BMD) assessment. We also retrieved any spontaneous or fragility fractures occurring from 1 year before up to 5 years after the date of DXA scans. The 43 patients were included. QCT measures were significantly higher than those determined by DXA. The gap between QCT and DXA values was strongly associated with patient age. The most powerful predictive variable for risk of fracture was the ACR classification based on volumetric BMD obtained by QCT. DXA provided more negative measures than those determined by QCT. However, QCT seemed to evaluate thalassaemic osteopathy better than DXA, since volumetric BMD was a stronger predictor of fracture.

Reproducibility and Accuracy of the Radiofrequency Echographic Multi-Spectrometry for Femoral Mineral Density Estimation and Discriminative Power of the Femoral Fragility Score in Patients with Primary and Disuse-Related Osteoporosis.

We aimed to investigate the reproducibility and accuracy of Radiofrequency Echographic Multi-Spectrometry (REMS) for femoral BMD estimation and the reproducibility and discriminative power of the REMS-derived femoral fragility score. 175 patients with primary and disuse-related osteoporosis were recruited: one femoral Dual-energy X-ray Absorptiometry (DXA) scan and two femoral REMS scans were acquired. No significant test—retest differences were observed for all REMS-derived variables. The diagnostic concordance between DXA and REMS was 63% (Cohen’s kappa = 0.31) in patients with primary osteoporosis and 13% (Cohen’s kappa: −0.04) in patients with disuse-related osteoporosis. No significant difference was observed between REMS and DXA for either femoral neck BMD (mean difference between REMS and DXA: −0.015 g/cm2) or total femur BMD (mean difference: −0.004 g/cm2) in patients with primary osteoporosis. Significant differences between the two techniques were observed in patients with disuse-related osteoporosis (femoral neck BMD difference: 0.136 g/cm2; total femur BMD difference: 0.236 g/cm2). Statistically significant differences in the fragility score were obtained between the fractured and non-fractured patients for both populations. In conclusion, REMS showed excellent test-retest reproducibility, but the diagnostic concordance between DXA and REMS was between minimal and poor. Further studies are required to improve the REMS—derived estimation of femoral BMD.

Prediction of osteoporosis from simple hip radiography using deep learning algorithm

Despite being the gold standard for diagnosis of osteoporosis, dual-energy X-ray absorptiometry (DXA) could not be widely used as a screening tool for osteoporosis. This study aimed to predict osteoporosis via simple hip radiography using deep learning algorithm. A total of 1001 datasets of proximal femur DXA with matched same-side cropped simple hip bone radiographic images of female patients aged ≥ 55 years were collected. Of these, 504 patients had osteoporosis (T-score ≤ − 2.5), and 497 patients did not have osteoporosis. The 1001 images were randomly divided into three sets: 800 images for the training, 100 images for the validation, and 101 images for the test. Based on VGG16 equipped with nonlocal neural network, we developed a deep neural network (DNN) model. We calculated the confusion matrix and evaluated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We drew the receiver operating characteristic (ROC) curve. A gradient-based class activation map (Grad-CAM) overlapping the original image was also used to visualize the model performance. Additionally, we performed external validation using 117 datasets. Our final DNN model showed an overall accuracy of 81.2%, sensitivity of 91.1%, and specificity of 68.9%. The PPV was 78.5%, and the NPV was 86.1%. The area under the ROC curve value was 0.867, indicating a reasonable performance for screening osteoporosis by simple hip radiography. The external validation set confirmed a model performance with an overall accuracy of 71.8% and an AUC value of 0.700. All Grad-CAM results from both internal and external validation sets appropriately matched the proximal femur cortex and trabecular patterns of the radiographs. The DNN model could be considered as one of the useful screening tools for easy prediction of osteoporosis in the real-world clinical setting.

Gender-Dependent Characteristics of Serum 1,25-Dihydroxyvitamin D/25-Hydroxyvitamin D Ratio for the Assessment of Bone Metabolism.

ObjectivesVitamin D deficiency, which is common worldwide, increases the risks of falls and fractures and can lead to increased morbidity and mortality. However, the clinical utility and relevance of vitamin D activation remain unknown. The aim of the present study was to clarify the clinical usefulness of serum 1,25-dihydroxyvitamin D (1,25D)/25-hydroxyvitamin D (25D) ratio for assessment of the extent of bone metabolism.MethodsWe retrospectively screened data for 87 patients whose serum 1,25D and 25D levels were measured. Eight patients who were taking vitamin D preparations were excluded, and data for 79 patients (33 males and 46 females) were analyzed. Since menopausal status can be associated with serum vitamin D level, we divided the patients by gender and divided the female patients into two groups at the age of 50 years.ResultsThe median serum 1,25D/25D ratio was significantly lower in males than in females, with the most considerable difference in all males [4.1 (interquartile range: 2.3-5.8) × 10−3] versus elderly females (aged ≧50 years) [7.9 (3.3-10.1) × 10−3). Main disorders were endocrine (30.6%), inflammatory (18.5%), and bone-related (16.7%) disorders. The ratios of serum 1,25D/25D had significant negative correlations with femoral dual-energy X-ray absorptiometry % young adult mean (DEXA %YAM) (R=−0.35) and lumbar DEXA %YAM (R=−0.32). Significant correlations were found between the 1,25D/25D ratio and serum levels of inorganic phosphate (iP), parathyroid hormone, and alkaline phosphatase (ALP). The 1,25D/25D ratio had gender-specific characteristics: the ratio was significantly correlated with age in males (R=−0.49), while it was significantly correlated with BMI in females (R=0.34).ConclusionsThe results of this study suggested that vitamin D activity is negatively correlated with bone mineral density, being reduced in aged males but enhanced in obese females.

Evaluation of femoral head bone quality by Hounsfield units: a comparison with dual-energy X-ray absorptiometry.

Osteoporosis is associated with decreases in bone mineral density (BMD) and is diagnosed using dual-energy X-ray absorptiometry (DXA). Computed tomography (CT), performed in routine practice, can also be used to evaluate bone quality without additional cost. To determine whether Hounsfield units (HU), a standardized CT attenuation coefficient, measured from the femoral head correlated with DXA-measured BMD. We evaluated 82 patients (14 men, 68 women; mean age, 67 years) undergoing femoral DXA and CT (non-enhanced abdominopelvic and hip scans) with 130 kV to determine whether HU correlated with T-scores. HU were measured by two radiologists using the largest spherical region of interest including the medullary bone of the femoral head from the junction point of the most caudal section of the femoral head with the femoral neck in 5-mm axial sections. The correlations of both sides' HU values with their ages and DXA femur T-score were evaluated. HU values obtained from both femoral heads showed significant variation between the osteoporotic and non-osteoporotic groups (both P = 0.000) and strongly correlated with each other and DXA femur T-scores (left r = 0.75, right r = 0.73, respectively). In ROC curve analysis, predictive power of left HU values in identifying patients with osteoporotic femur DXA T-score was 0.905, and for right HU values it was 0.924. Osteoporosis cutoff values were 198 HU and 204 HU for the left and right hips, respectively. HU obtained from CT performed in routine practice correlated with the DXA scores, thus providing an alternative method to determine regional bone quality without additional cost. This may be useful when choosing a fixation method, especially in trauma cases with already-performed abdominopelvic or pelvic CT in emergency services.

Characteristics of Serum Ratios of 1,25-Dihydroxyvitamin D to 25-Hydroxyvitamin D for Assessment of Bone Metabolism

Vitamin D is obtained in the body by food intake or by production from 7-dehydrocholesterol by exposure of the skin to ultraviolet B radiation. It is first metabolized in the liver to 25-hydroxyvitamin D (25D), which is a major circulating metabolite. In the kidney, 25D is subsequently metabolized to the hormonally active form, 1,25-dihydroxyvitamin D (1,25D), via 1α-hydroxylase encoded by the CYP27B1 gene. 1,25D has a cellular effect through the vitamin D receptor, which leads to calcium absorption in the gut, bone metabolism, and parathyroid function. A recent study showed that a low vitamin D status is common worldwide and is associated with various diseases including kidney, heart, and liver failure, secondary hyperparathyroidism, osteomalacia, inflammatory bowel disease, granuloma-forming disorders (sarcoidosis and tuberculosis), and cancer. Vitamin D deficiency also increases the risks of falls, fractures, bone loss, sarcopenia, leading to worse outcomes of illness severity, morbidity, and mortality. The 1,25D/25D ratio is considered to be a useful tool for diagnosis of ocular sarcoidosis; however, its clinical utility and relevance to pathophysiology of evaluation of the ratio 1,25D/25D which indicates vitamin D activation have remained unknown. To clarify the clinical usefulness of markers for vitamin D activation, 87 patients in whom serum 25D and 1,25D level was measured were retrospectively reviewed in the present study. Data for 79 patients (33 males and 46 females) were analyzed after exclusion of 8 patients taking vitamin D. The median serum 1,25D/25D ratio was significantly lower in males than in females: 4.1 (IQR: 2.3–5.8) x 10−3 versus 6.8 (3.0–9.8) x 10−3. However, individual levels of 25D and 1,25D were not different in males and females. The major categories of main disorders were endocrine (30.6 %), inflammatory (18.5 %), and bone-related (16.7 %) disorders. The ratios of serum 1,25D/25D had significant negative correlations with femoral dual energy X-ray absorptiometry % young adult mean (DEXA %YAM) (R=-0.35) and lumbar DEXA %YAM (R=-0.32). Significant correlations were found between 1,25D/25D ratio and serum levels of inorganic phosphate (R=-0.34), intact parathyroid hormone (R=0.64) and alkaline phosphatase (R=0.46) in all patients. Of interest, the 1,25D/25D ratio had gender-specific characteristics: the ratio had a significant correlation with age in males (R=0.49), while it had a significant correlation with body mass index (BMI) in females (R=0.34). Collectively, the results revealed that the ratio of serum 1,25D/25D as a marker for activation of vitamin D had relevance to clinical parameters, especially bone turnover, with gender-specific features. It is suggested that the existence of a gender-specific difference of aging males and obese females regarding the activation of vitamin D that is functionally linked to bone metabolism.

Deep Learning in DXA Image Segmentation

Many existing techniques to acquire dual-energy X-ray absorptiometry (DXA) images are unable to accurately distinguish between bone and soft tissue. For the most part, this failure stems from bone shape variability, noise and low contrast in DXA images, inconsistent X-ray beam penetration producing shadowing effects, and person-to-person variations. This work explores the feasibility of using state-of-the-art deep learning semantic segmentation models, fully convolutional networks (FCNs), SegNet, and U-Net to distinguish femur bone from soft tissue. We investigated the performance of deep learning algorithms with reference to some of our previously applied conventional image segmentation techniques (i.e., a decision-tree-based method using a pixel label decision tree [PLDT] and another method using Otsu’s thresholding) for femur DXA images, and we measured accuracy based on the average Jaccard index, sensitivity, and specificity. Deep learning models using SegNet, U-Net, and an FCN achieved average segmentation accuracies of 95.8%, 95.1%, and 97.6%, respectively, compared to PLDT (91.4%) and Otsu’s thresholding (72.6%). Thus we conclude that an FCN outperforms other deep learning and conventional techniques when segmenting femur bone from soft tissue in DXA images. Accurate femur segmentation improves bone mineral density computation, which in turn enhances the diagnosing of osteoporosis.

Multidetector Computed Tomography in Patients with Femoral Neck Fracture for Assessing Osteoporosis: Comparison with Dual Energy X-Ray Absorptiometry

PurposeTo evaluate the ability of the Hounsfield unit (HU) measurement of the femoral neck during multidetector computed tomography (MDCT) for assessing osteoporosis compared with dual-energy X-ray absorptiometry (DXA).Materials and MethodsForty-two patients with femoral neck fractures who underwent MDCT and DXA from July to December 2016 were included in this study. HU measurements were made of the cancellous portions of the normal contralateral femoral neck on MDCT. Bone mineral density (BMD) and T-scores were obtained at the femur DXA. Correlations of HU values with BMD and T-scores were analyzed using Spearman's correlation test.ResultsThe mean BMD and T-score of the femoral neck were 0.650 g/cm2 and −2.4, respectively. The mean HU values for the normal, osteopenia, and osteoporosis groups were 131.9, 98.9, and 41.3, respectively. HU values at the femoral neck were positively correlated with BMD (r2 = 0.670; p < 0.001) and T-scores (r2 = 0.676; p < 0.001).ConclusionThe HU values of the femoral neck on MDCT are significantly correlated with BMD and T-scores of femur DXA. The HU values may serve as a diagnostic tool for the screening of regional bone quality when MDCT is performed for other reasons.

Correlation between MCI/Sapori screening tools and DXA results and between MCI/Sapori and Frax tool for estimating fracture risk

Background: Peripheral Dual-energy X-ray absorptiometry (DXA) can be applied to identify low bone mineral density (BMD) patients, however, DXA is not sufficiently available in many countries. Thus, the use of simpler and cheaper screening tools than DXA to detect low BMD become indispensable. Objectives: The objective of this study was to correlate São Paulo osteoporosis risk index (Sapori) and mandibular cortical index (MCI) screening tools with the femur DXA results of patients in our sample of Brazilian women. A secondary objective was to assess which of these screening tools better correlates with the results of the Frax tool. Material and Methods: Exams of women who had undergone panoramic radiographic examination at the beginning of dental treatment and peripheral DXA for screening osteoporosis from 2010 to 2014 were included. The MCI was evaluated, and Sapori and Frax were calculated with their available online software tools. Spearman correlation was performed to analyse the level of correlation between femur T-scores (and MCI and Sapori values, as well to perform the level of correlation between Frax and MCI and Sapori values. Results: The spearman correlation comparing the numerical T-score values and the categorical values of MCI (rs=-0.274), and of Sapori (rs=-0.470), showed a statistically significant inverse correlation for both equations (p&lt;0.01). The Spearman equation comparing the values obtained with Frax and MCI did not show a statistically signifcant correlation (p&gt;0.01). But the equation comparing the values obtained with Frax and Sapori showed a positive, moderate and statistically significant correlation between them (rs=0.460). Conclusion: MCI is not a reliable screening tool to identify women with low BMD or Osteoporosis, whereas more optimistic results were observed for the Sapori.

Large cortical bone pores in the tibia are associated with proximal femur strength.

Alterations of structure and density of cortical bone are associated with fragility fractures and can be assessed in vivo in humans at the tibia. Bone remodeling deficits in aging women have been recently linked to an increase in size of cortical pores. In this ex vivo study, we characterized the cortical microarchitecture of 19 tibiae from human donors (aged 69 to 94 years) to address, whether this can reflect impairments of the mechanical competence of the proximal femur, i.e., a major fracture site in osteoporosis. Scanning acoustic microscopy (12 μm pixel size) provided reference microstructural measurements at the left tibia, while the bone vBMD at this site was obtained using microcomputed tomography (microCT). The areal bone mineral density of both left and right femoral necks (aBMDneck) was measured by dual‐energy X‐ray absorptiometry (DXA), while homogenized nonlinear finite element models based on high-resolution peripheral quantitative computed tomography provided hip stiffness and strength for one-legged standing and sideways falling loads. Hip strength was associated with aBMDneck (r = 0.74 to 0.78), with tibial cortical thickness (r = 0.81) and with measurements of the tibial cross-sectional geometry (r = 0.48 to 0.73) of the same leg. Tibial vBMD was associated with hip strength only for standing loads (r = 0.59 to 0.65). Cortical porosity (Ct.Po) of the tibia was not associated with any of the femoral parameters. However, the proportion of Ct.Po attributable to large pores (diameter > 100 μm) was associated with hip strength in both standing (r = -0.61) and falling (r = 0.48) conditions. When added to aBMDneck, the prevalence of large pores could explain up to 17% of the femur ultimate force. In conclusion, microstructural characteristics of the tibia reflect hip strength as well as femoral DXA, but it remains to be tested whether such properties can be measured in vivo.

Low physical performance determined by chair rising test muscle mechanography is associated with prevalent fragility fractures.

Although the interaction between muscle and bone has been demonstrated in various aspects, the clinical focus in the diagnosis of musculoskeletal disorders mainly lies on the skeletal assessments. Accordingly, the association between muscle function, bone mineral density (BMD), and fragility fractures remains to be further elucidated with a feasible muscle assessment in a clinical setting. Patient data (2076 patients, 1538 women, 538 men) were evaluated retrospectively from a large dual energy X-ray absorptiometry (DXA) database as well as from chair rising test (CRT) that was performed on a muscle mechanograph. To determine potential predictors of the CRT time and maximum force, a multivariate regression analysis was performed including age, DXA T-score, and body composition indices. Furthermore, CRT results were compared between non-fracture and fracture cases. We determined independent predictors for CRT time such as age, femoral DXA T-score, and total fat mass, whereas CRT force was only influenced by total lean mass. Both women and men with previous fragility fractures displayed a longer CRT time (women p = 0.009, men p = 0.001) and lower CRT force (women p < 0.001, men p < 0.001) than those with no fractures, while no clear differences in CRT results could be detected between normal BMD, osteopenia, and osteoporosis based on DXA T-scores. Our study demonstrates that in addition to the associations between chair rising time and femoral T-score assessed by DXA, low muscle strength is associated with previous fragility fractures.

Quantitative computed tomographic evaluation of bone mineral density in beagle dogs: comparison with dual-energy x-ray absorptiometry as a gold standard.

This study aimed to demonstrate the higher accuracy and reproducibility of quantitative computed tomography (QCT) compared with dual-energy X-ray absorptiometry (DXA) as a gold standard for measuring canine bone mineral density (BMD). Seven middle-aged beagle dogs underwent lumbar vertebral and bilateral femoral DXA and QCT scans. BMD (mg/cm2) was measured at the vertebral body from L2 to L6, femoral neck, and proximal and distal femoral diaphyses. The BMD values were measured 3 times and compared. The BMD value on QCT was higher than that on DXA for femoral BMD but not for vertebral BMD. The correlation was strong for the lumbar vertebrae (r=0.66) and was strongest for L3 (r=0.85). No correlation was found for the femoral neck (P=0.35), and only moderate correlations were found for the proximal and distal femoral diaphyses (r=0.43 and r=0.40, respectively). The limits of agreement were narrower for vertebral BMD than for femoral BMD, and L3 had the narrowest limits of agreement. The intraclass correlation (ICC) was higher for DXA than for QCT at all lumbar and femoral sites measured, but the ICC of QCT was higher than 0.7. In conclusion, L3 can be used to monitor changes in BMD, and relative values and sequential monitoring of femoral BMD can also be useful because of the high reproducibility of QCT measurements. QCT would be a useful technique for evaluation of BMD in veterinary practice.

Definition of Italian Specific DXA References for Diagnosis of Osteoporosis: Preliminary Data from the Osteoporosis Registry of Magenta Rheumatology School (OSTEOREMA)

Background : Osteoporosis is the most common metabolic bone disease and dual energy X ray absorptiometry (DXA) scans is the gold standard to evaluate individuals at risk of osteoporosis. Up to date, studies focused on population specific DXA values among general population are lacking. Primary aim of this study was to obtain lumbar and femoral DXA values of Italy adult females based on a nationally representative sample aged 20 years and older, attempting to obtain a national specific normative bone mineral density (BMD) levels curve. Methods : demographic and anthropometric data of females aged 20 years and older that performed their first DXA (QDR 9000 Hologic, Waltham, Mass.) in our Hospital between 2006 and 2015 were extracted from our local registry using a random sampling technique. Criteria for patient choice were: absence of known risk factors of Osteoporosis (e.g. smoke, alcohol), metabolic disease that affects bone (e.g. diabetes), a normal BMI between 18.5 to 24.5, previous fractures, any medication for treatment of osteoporosis or corticosteroids, spondylosis radiologically relevant. Our database was compared to Caucasian normal values incorporated into Hologic’s scan analysis software, that we proven were comparable in terms of BMI, gender and age. Results : DXA scan of 15335 women were extracted and analysed. Mean age was 64.2 ± 12.8 years (range 20.8 to 90). Mean BMI was 22.4± 5.1 (range 20.1 to 24.3). Mean menopause age was 41.3±5 (range 31-54). Mean menarche age was 16.3±5 (range 11-17). The lumbar and femoral BMD were substantially constant between 25 and 35 years (test for trend using ANOVA: P =0.31); these data collected in premenopausal women (mean 1.043± 0.12 g/cm 2 for lumbar spine and 0.97± 0.136 g/cm 2 for femoral neck) were thus defined as the reference peak bone mass values, significantly lower compared to the Hologic reference values (mean 1.079±0.11 g/cm 2 , p<0.05). The frequency of osteopenia and osteoporosis were so significantly different depending on whether you use the manufacturer criteria rather than those derived from collected data (X square p=0,01). Conclusions : our data suggest that the reference curves for the lumbar spine and femoral neck are significantly different from the current normative data reported by the manufacturer for the Italian population.

Bone health measures in glucocorticoid-treated ambulatory boys with Duchenne muscular dystrophy

Osteoporosis is a major problem in boys with Duchenne Muscular Dystrophy (DMD), attributable to muscle weakness and glucocorticoid therapy. Consensus regarding bone health assessment and management is lacking. Lumbar spine areal bone mineral density (defined as bone mass per area of bone) by dual-energy X-ray absorptiometry (DXA) is frequently the primary measure used, but has limitations for boys with DMD. We retrospectively studied 292 ambulant glucocorticoid-treated boys with DMD categorized by functional mobility score, FMS 1, 2 or 3. We assessed DXA whole body and lumbar spine areal bone mineral density and content Z-scores adjusted for age and height, lateral distal femur areal bone mineral density Z-scores, frequency of fractures, and osteoporosis by International Society for Clinical Densitometry 2013 criteria. Whole body and femoral DXA indices decreased, while spine fractures increased, with declining motor function. Lumbar spine areal bone mineral density Z-scores appeared to improve with declining motor function. Bone mineral content Z-scores were consistently lower than corresponding bone mineral density Z-scores. Our findings highlight the complexity of assessing bone health in boys with DMD. Bone health indices worsened with declining motor function in ambulant boys, but interpretation was affected by measure and skeletal site examined. Whole body bone mineral content may be a valuable measure in boys with DMD. Lumbar spine areal bone mineral density Z-score as an isolated measure could be misleading. Comprehensive management of osteoporosis in boys with DMD should include vertebral fracture assessment.

A computer-aided system for automatic extraction of femur neck trabecular bone architecture using isotropic volume construction from clinical hip computed tomography images.

Hip fractures due to osteoporosis are increasing progressively across the globe. It is also difficult for those fractured patients to undergo dual-energy X-ray absorptiometry scans due to its complicated protocol and its associated cost. The utilisation of computed tomography for the fracture treatment has become common in the clinical practice. It would be helpful for orthopaedic clinicians, if they could get some additional information related to bone strength for better treatment planning. The aim of our study was to develop an automated system to segment the femoral neck region, extract the cortical and trabecular bone parameters, and assess the bone strength using an isotropic volume construction from clinical computed tomography images. The right hip computed tomography and right femur dual-energy X-ray absorptiometry measurements were taken from 50 south-Indian females aged 30-80 years. Each computed tomography image volume was re-constructed to form isotropic volumes. An automated system by incorporating active contour models was used to segment the neck region. A minimum distance boundary method was applied to isolate the cortical and trabecular bone components. The trabecular bone was enhanced and segmented using trabecular enrichment approach. The cortical and trabecular bone features were extracted and statistically compared with dual-energy X-ray absorptiometry measured femur neck bone mineral density. The extracted bone measures demonstrated a significant correlation with neck bone mineral density (r > 0.7, p < 0.001). The inclusion of cortical measures, along with the trabecular measures extracted after isotropic volume construction and trabecular enrichment approach procedures, resulted in better estimation of bone strength. The findings suggest that the proposed system using the clinical computed tomography images scanned with low dose could eventually be helpful in osteoporosis diagnosis and its treatment planning.

Bone Mineral Density Is Positively Related to Carotid Intima-Media Thickness: Findings From a Population-Based Study in Adolescents and Premenopausal Women.

ABSTRACTOsteoporosis and cardiovascular disease (CVD) are both common causes of morbidity and mortality. Previous studies, mainly of people older than 60 years, suggest a relationship between these conditions. Our aim was to determine the association between bone characteristics and CVD markers in younger and middle‐aged individuals. Women (n = 3366) and their adolescent offspring (n = 4368) from the UK population‐based cohort study, Avon Longitudinal Study of Parents and Children (ALSPAC), were investigated. We measured total body (TB) and hip bone mineral density (BMD), TB bone area (BA) and bone mineral content (BMC) by dual‐energy X‐ray absorptiometry (DXA), and carotid intima‐media thickness (cIMT) by high‐resolution ultrasound. Arterial distensibility was calculated as the difference between systolic and diastolic arterial diameters. Linear regression determined associations between bone exposures and cIMT (in adolescents) and both cIMT and arterial distensibility (in women), generating partial correlation coefficients. Mean (SD) age of women was 48 (4.2) years, body mass index (BMI) was 26.2 (5.0) kg/m2, and 71% were premenopausal. In confounder‐adjusted analyses (age, height, lean mass, fat mass, menopause, smoking, estrogen replacement, calcium/vitamin D supplementation, and education) TB and hip BMD were both positively associated with cIMT (0.071 [0.030, 0.112], p = 0.001; 0.063 [0.025, 0.101], p = 0.001, respectively). Femoral neck BMD and TB BMD, BMC, and BA were positively associated with arterial distensibility. Mean (SD) age of adolescents was 17 (0.4) years, BMI was 23 (4.1) kg/m2, and 44.5% were male. Total hip and TB measurements were positively associated with cIMT, with similar magnitudes of association to those found in their mothers. In contrast to most published findings, we identified weak positive associations between BMD and cIMT in predominantly premenopausal women and their adolescent offspring. We found greater femoral neck BMD and TB DXA measurements to be associated with reduced arterial stiffness. Rather than a relationship with preclinical atherosclerosis, in these relatively young populations, we speculate our associations between BMD, cIMT, and arterial distensibility may reflect a shared relationship between bone and vascular growth and development. © 2016 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Hypovitaminosis D and Low Bone Mineral Density in Inflammatory Bowel Disease Patients

Background: Increasing evidences suggest that hypovitaminosis D can play an important role in immuno-mediated diseases, such as Inflammatory Bowel Diseases (IBD). The hypovitaminosis D is an established risk factor for the development of osteopenia, osteoporosis and pathological fractures. Studies have reported a correlation between hypovitaminosis D, disease history and clinical features in Crohn's Disease (CD) and Ulcerative Colitis (UC). The aim of this study is to evaluate the vitamin D serum levels and the prevalence of bone mineral density (BMD) alterations in a population of Italian IBD patients and to correlate the prevalence of hypovitaminosis D with disease history and clinical features. Method: Between October 2013 and November 2014 we enrolled patients from our center that were affected by UC or CD. Exclusion criteria were age below 18 and over 60, concomitant vitamin D replacement therapy and concomitant gastrointestinal or endocrinological diseases which may alter vitamin D metabolism. All patients underwent 25-OH-vitamin D, ESR, C-reactive protein (CRP), PTH, serum calcium and phosphorus, β-CTX, alkaline phosphatase (bone isoenzyme) plasma assay and bone mass density (BMD) evaluation by lumbar and femoral dual-energy X-ray absorptiometry (DXA) scan. Both measurements were made at the same time, during the autumn and winter months. Following 2012 Osteoporosis Italian Society Guidelines, we defined as hypovitaminosis D plasmatic values <30 ng/mL, vitamin D levels were considered as insufficient if between 20 and 30 ng/ mL and deficient if <20 ng/mL. We collected data regarding patients’ life habits and clinical history, disease course and disease clinical activity at enrollment. For BMD evaluation T-score and/or Z-score were calculated for each patient at lumbar (L1-L4) and femoral neck level, and the diagnosis of osteopenia or osteoporosis was made according to international guidelines. Results: We enrolled 88 patients (62 CD, 26 UC); median age at enrollment was 42 years for CD and 43 years for UC. Mean Body Mass Index (BMI) was 22.6 in CD and 23.7 in UC patients. Age at diagnosis was 29.8 years for CD and 33.5 years for UC, with mean disease duration of 12.8 years for CD and 9.1 years for UC.Hypovitaminosis D was observed in 84.1% of the patients. Of these, 31.8% had insufficient vitamin D levels, whereas 57.3% deficient. Mean vitamin D level was 20.4 ng/mL, but there was no difference with respect to sex or disease type. Indeed, there was no correlation between hypovitaminosis D and disease duration or patients age at diagnosis. A statistically significant correlation was found between hypovitaminosis D and history of steroid-dependancy (p=0.03), need of therapy with anti- TNF-α drugs (p=0.01) and cigarette smoke habit in CD patients (p=0.01). In CD patients we also found a correlation, at the limit of statistical significance (p=0.05), between hypovitaminosis D, high CRP values and HarveyBradshaw Index (HBI) at enrollment.70 patients underwent the lumbar DXA analysis, 67 the femoral DXA. Lumbar BMD was found to be below the normal range in 37.1% of the patients, suggesting that 24.2% and 12.9% were affected by osteopenia or osteoporosis, irrespective of sex and disease type (CD or UC). Similarly, femoral BMD was below the normal range for age in 43.3% of the patients. This figure is consistent with osteopenia or osteoporosis in 34.3% and 9%, irrespective of sex and disease type and femoral Z-score that was found significantly lower in CD than UC patients (p=0.03). Reduced BMD correlated with lower BMI and hypovitaminosis D. Conclusion: In our study we found a high prevalence of hypovitaminosis D in an IBD population irrespective of patients' sex, type and duration of disease. Our data show a strong correlation between hypovitaminosis D and a more aggressive disease course in terms of history of steroiddependancy, need of therapy with anti TNF-α drugs and smoke habit in CD patients. Hypovitaminosis D may play a crucial role in causing a more severe clinical behavior of IBD. Alteration of bone metabolism is a concern in IBD patients. We observed a high prevalence of BMD alterations in both men and women affected by UC and CD, even if of young age and with a short disease duration, irrespective of the type of IBD. Such patients may be prescribed lumbar and femoral, especially in cases of hypovitaminosis D and low BMI. This would allow an early diagnosis of BMD alterations, to start specific therapy and to prevent further complications.