Journal of Clinical Densitometry

Proceedings of the 2011 Santa Fe Bone Symposium

2012-01-01

Abstract: The 11th Santa Fe Bone Symposium was held in Santa Fe, NM, USA, on August 6–7, 2010. This annual event addresses the clinical relevance of recent scientific advances in the fields of osteoporosis and metabolic bone disease. The symposium format included plenary presentations, oral abstracts, and interactive panel discussions, with participation of clinicians, researchers, and bone densitometry technologists. Among the many topics included in the symposium were new developments in nutritional therapy for osteoporosis, parathyroid hormone for the assessment and treatment of skeletal disease, osteoporosis in men, new and emerging concepts in osteoporosis therapy, report on the 2010 International Society for Clinical Densitometry (ISCD)—International Osteoporosis Foundation FRAX Initiative and the ISCD Position Development Conference, balancing benefits and risks of bisphosphonate therapy, and an advanced bone densitometry workshop for clinicians and technologists.

BMD Measurement and Precision: A Comparison of GE Lunar Prodigy and iDXA Densitometers

Diane Krueger, Nellie Vallarta-Ast, Mary Checovich, Dessa Gemar, Neil Binkley — 2011-11-10

Abstract: This study assessed bone mineral density (BMD) comparability and precision using Lunar Prodigy and iDXA densitometers (GE Healthcare, Madison, WI) in adults. Additionally, the utility of supine forearm measurement with iDXA was investigated.Lumbar spine and bilateral proximal femur measurements were obtained in routine clinical manner in 345 volunteers, 202 women and 143 men of mean age 52.5 (range: 20.1–91.6)yr. Seated and supine distal forearm scans were obtained in a subset (n=50). Lumbar spine and proximal femur precision assessments were performed on each instrument following International Society for Clinical Densitometry recommendations in 30 postmenopausal women.BMD at the L1–L4 spine, total proximal femur, and femoral neck was very highly correlated (r2≥0.98) between densitometers, as was the one-third radius site (r2=0.96). Bland-Altman analyses demonstrated no clinically significant bias at all evaluated sites. BMD precision was similar between instruments at the L1–L4 spine, mean total proximal femur, and femoral neck. Finally, one-third radius BMD measurements in the supine vs seated position on the iDXA were highly correlated (r2=0.96). In conclusion, there is excellent BMD correlation between iDXA and Prodigy densitometers. Similarly, BMD precision is comparable with these two instruments.

Which to Use to Evaluate Change in BMD at Follow-Up: RMS-SD or RMS-%CV?

Gary M. Kiebzak, Sarah L. Morgan, Frederick Peace — 2011-12-12

Abstract: There is bias toward the use of root-mean-square standard deviation (RMS-SD) over root-mean-square coefficient of variation (RMS-%CV) to calculate a least significant change (LSC) value that is used to determine if change in bone mineral density (BMD) at follow-up is statistically significant. In part, this bias is based on the assumption that SD is relatively constant over a wide range of BMD as opposed to %CV, which is assumed to increase as BMD decreases. However, evidence to support these assumptions is scant. The purpose of this project was to determine the frequency of discrepancies in interpretation of follow-up data using an LSC based on RMS-SD (LSC-SD) vs RMS-%CV (LSC-%CV). A convenience sample of 100 patients returning for follow-up dual-energy X-ray absorptiometry scans was used to compare the frequency of change in BMD exceeding LSC-SD vs LSC-%CV. Results showed that agreement in exceeding (or not) both LSC-SD and LSC-%CV was 94% for L1–L4 (lumbar spine), femoral neck, and total hip. Disagreements were characterized by BMD changes that usually marginally exceeded either LSC-SD or LSC-%CV but not the other, and they occurred at both high and low absolute BMD. We conclude that significant change in BMD typically exceeds both LSC-SD and LSC-%CV. Thus, there seems to be no basis for the bias in favor of using LSC-SD as long as RMS-SD and RMS-%CV are calculated in the same manner. Furthermore, a criterion that both LSC-SD and LSC-%CV must be exceeded may help avoid overcalling marginal change as being significant, especially at high and low BMD.

Impact of a New Sarco-Osteopenia Definition on Health-related Quality of Life in a Population-Based Cohort in Northern Europe

Mart Kull, Riina Kallikorm, Margus Lember — 2011-11-10

Abstract: Sarcopenia has been shown to be a marker of falling; therefore, combining osteopenia and sarcopenia could identify a frailer, higher-fracture-risk population. We aimed to define sarco-osteopenia (SOP) in a population-based healthy young sample using both muscle functional and quantitative parameters and assessing the impact of this definition on health-related quality of life. A population sample of 304 patients aged 25–70 yr was analyzed with a Lunar DPX-IQ dual-energy X-ray absorptiometry machine (GE Healthcare, Pollards Wood, UK), and their health-related quality of life was assessed with the Short-Form-36 (SF-36) questionnaire. SOP was defined as bone mineral density (BMD) −1 standard deviation (SD) and height-adjusted appendicular muscle mass −2 SD and/or grip strength −2 SD less than the mean values of 77 young individuals in the population sample (age: 25–39yr). Our proposed SOP definition identifies 3–9% of the population older than 40yr as sarco-osteopenic. These individuals also show markedly lower scores in the role-physical (p=0.01), vitality (p=0.03), and role-emotional (p=0.02) subscales of the SF-36 questionnaire. No difference in the quality of life was observed between osteopenic individuals and those with normal BMD. The new definition identifies a population with significant decrements in health-related quality of life.

Rheumatoid Arthritis is Associated With Less Optimal Hip Structural Geometry

2011-08-18

Abstract: The overall goal of this study was to assess the longitudinal changes in bone strength in women reporting rheumatoid arthritis (RA; n=78) compared with nonarthritic control participants (n=4779) of the Women's Health Initiative bone mineral density (WHI-BMD) subcohort. Hip structural analysis program was applied to archived dual-energy X-ray absorptiometry scans (baseline, years 3, 6, and 9) to estimate bone mineral density (BMD) and hip structural geometry parameters in 3 femoral regions: narrow neck (NN), intertrochanteric (IT), and shaft (S). The association between RA and hip structural geometry was tested using linear regression and random coefficient models. Compared with the nonarthritic control, the RA group had a lower BMD (p=0.061) and significantly lower outer diameter (p=0.017), cross-sectional area (p=0.004), and section modulus (p=0.035) at the NN region in the longitudinal models. No significant associations were seen at the IT regions or S regions, and the association was not modified by age, ethnicity, glucocorticoid use, or time. Within the WHI-BMD, women with RA group had reduced BMD and structural geometry at baseline, and this reduction was seen at a fixed rate throughout the 9yr of study.

The Importance of Physicians’ Risk Perception in Osteoporosis Treatment Decision Making

Joan M. Neuner, Marilyn M. Schapira — 2011-11-10

Abstract: Recent physicians’ guidelines for postmenopausal osteoporosis emphasize the use of fracture-risk scores. To determine whether adherence to the guidelines has potential to improve targeting of care, we examined survey results from a random sample of US primary care physicians prior to the new guidelines. Survey measures included physicians’ knowledge, attitudes, and perceived barriers to care. Physicians’ estimates of 5-yr and lifetime absolute hip fracture risks and their treatment decisions were examined for patient vignettes depicting postmenopausal women of varying ages, weights, and bone mineral density (BMD) results. The 360 US physician respondents were accurate in their estimates of lifetime fracture risk for all 4 vignettes, but overestimated 5-yr hip fracture risk by a factor of 10 or more; 36–45% of the physicians recommended treatment for patients whose history and BMD placed them below guideline-recommended treatment thresholds, and 5-yr risk estimates were strongly associated with prescription treatment decisions for 2 of 3 such vignettes (both p<0.01). Other potential barriers to care include medication costs and adverse effects. Our findings suggest efforts to improve targeting of osteoporosis care are appropriately addressing physicians’ risk estimation. Evidence from other conditions suggests these efforts must be intensive and available at the point of care.

Association Between Vascular Calcification and Osteoporosis in Men With Type 2 Diabetes

Elba Bandeira, Ana Paula Neves, Christiane Costa, Francisco Bandeira — 2011-11-10

Abstract: Atherosclerotic vascular disease is common in diabetes, and some data support a link with bone loss. This study evaluates the association between osteoporosis and clinical and metabolic factors and chronic complications of diabetes. We studied 59 diabetic men aged 50–80yr who were assessed with bone densitometry (dual-energy X-ray absorptiometry). Of them, 10.2% of the patients were found to have osteoporosis in the lumbar spine and 45.8% osteopenia, whereas in the femoral neck, 11.8% had osteoporosis and 49% had osteopenia. There was a significant association of osteoporosis in the lumbar spine L1–L4 (p=0.004) and in the femoral neck (p=0.036) with iliac artery calcification. In addition, there was no association with any other metabolic factors, clinical factors, or chronic complications of diabetes evaluated, except for an association between a previous personal history of fractures (p=0.016) and low bone mineral density in the femoral neck. In conclusion, we found a positive association between the iliac artery calcification and osteoporosis in type 2 diabetic male patients.

Predictors of Bone Mineral Density Testing in Patients at High Risk of Osteoporosis: Secondary Analyses From the OSTEOPHARM Randomized Trial

Nesé Yuksel, Ross T. Tsuyuki, Sumit R. Majumdar — 2011-11-10

Abstract: In a randomized trial, we demonstrated that a community pharmacist osteoporosis screening intervention doubled the rates of bone mineral density (BMD) testing in high-risk patients. The purpose of this secondary analysis was to evaluate the potentially modifiable factors associated with BMD testing. From 2005 to 2007, 15 pharmacies randomized 262 patients to intervention (education, pamphlets, point-of-care quantitative heel ultrasound [QUS]) or usual care. The main outcome was BMD testing within 4mo. Multivariate regression was used to determine independent correlates of BMD testing. The median age of the cohort was 62yr, 65% were women, and 49% (n=129) were randomized to intervention. Compared with patients who were not tested, those with BMD were more likely to be women (p=0.007) and have excellent or very good health (p<0.001). Postrandomization correlates of BMD test were intervention (p=0.017), greater osteoporosis knowledge (p=0.004), and osteoporosis-specific physician visits (p<0.001). In adjusted analyses, only female sex (adjusted odds ratio [aOR]: 3.0; 95% confidence interval [CI]: 1.3–7.4) and osteoporosis-specific visits (aOR: 3.2; 95% CI: 1.4–7.8) were independently associated with BMD testing. In analyses restricted to intervention patients, abnormal QUS (aOR: 3.7, 95% CI: 1.4–9.1) was the only independent predictor of BMD test. Future interventions should incorporate the finding that osteoporosis-specific visits and abnormal QUS results were strongly associated with getting a BMD testing and should give greater attention to men.

Forearm Bone Mineral Density Measurement With Different Scanning Positions: A Study in Right-Handed Chinese Using Dual-Energy X-Ray Absorptiometry

Yin-Juan Chang, Wei Yu, Qiang Lin, Jin-Peng Yao, Xiao-Hong Zhou, Jun-Ping Tian — 2011-12-12

Abstract: The purpose of our study was to determine whether different scanning positions influence forearm bone mineral density (BMD) measurements and to evaluate the association between forearm BMDs in different scanning positions and those of other skeleton sites. The study population consisted of 30 right-handed healthy Chinese volunteers. BMD was measured with GE Lunar Prodigy at the left forearm in both sitting and supine positions, and at lumbar spine and the right femur. All subjects received repeated measurements in the same day (repositioning), and the average of repeated BMD results was used for analysis. The BMD precision errors of the nondominant forearm in the sitting and supine positions varied from 1.13% to 2.46%. There were no statistically significant differences between BMD precision errors for each region of interest (ROI) between sitting and supine positions (all the p values were greater than 0.05). When comparing BMDs on the same side in the sitting position with those in the supine position, there were significant differences at both the 1/3 radius level and in the total radius (p<0.05). The BMD values at these ROIs obtained in the supine position were lower than those in the routine sitting position. The BMDs of the ultradistal radius in the both 2 different scanning positions were significantly associated with lumbar spine and femoral neck BMD, respectively. The total radius BMD in the different positions was associated with the BMD of the femoral neck. A change in body scanning position from sitting to supine will significantly influence forearm BMD results.

Influence of Different DXA Acquisition Modes on Monitoring the Changes in Bone Mineral Density After Hip Resurfacing Arthroplasty

2011-11-10

Abstract: Dual-energy X-ray absorptiometry (DXA) is a technique enabling the measurement of bone mineral density (BMD) around prostheses after hip resurfacing arthroplasty (HRA). In this study, we evaluated the consistency of different DXA acquisition modes with 33 patients who had undergone HRA. Patients were scanned with DXA immediately after surgery and at 3-, 6-, and 12-mo time points. All the patients were scanned with dual femur and orthopedic hip acquisition modes and analyzed using 10-region ROI model. With both acquisition modes, a statistically significant decrease (p<0.05, Wilcoxon’s test) in BMD at 3mo was revealed in 3 ROIs, located to upper and lateral upper femur. Both acquisition modes detected similarly (p<0.01) preservation of the femoral bone stock within 12mo in all but 1 ROI. The applied acquisition protocols involved the use of different footplates for hip fixation. Because the differences between acquisition modes ranged between +1.6% and −7.1% and the reproducibility of BMD values can vary by as much as 28% due to hip rotation, it is proposed that both dual femur and orthopedic hip acquisition modes can be used to monitor the changes in BMD after HRA. However, the same hip rotation is recommended for all DXA measurements.

Hip Strength in Adults With Type 1 Diabetes is Associated With Age at Onset of Diabetes

2011-11-10

Abstract: We investigated the association of age at onset of type 1 diabetes with areal bone mineral density (aBMD), estimates of bone strength, and outer diameter. Using dual-energy X-ray absorptiometry (DXA), aBMD, axial strength (cross-sectional area [CSA]), bending strength (section modulus [SM]), and outer diameter at the narrow neck, intertrochanter, and shaft of the proximal femur were determined for 60 adults. Analysis of covariance (ANCOVA) was used to determine if the DXA-based measures of bone were related to age at onset and if this relationship differed by gender. Age at onset, gender, and the interaction of age at onset by gender were included in the ANCOVA models along with current age, duration, height, lean soft tissue mass, and hemoglobin A1c as covariates. In the adjusted models with CSA, SM, or outer diameter as the dependent variable, age at onset (p<0.01) and gender (p<0.0001) were significant with no interaction. For shaft aBMD, there was a significant age at onset by gender interaction (p=0.0285), where an earlier onset was associated with lower aBMD in the femoral shaft of females but not males. The findings suggest that an earlier onset of type 1 diabetes is associated with lower measures of bone strength and outer diameter.

Calcaneal Quantitative Ultrasound Value for Middle-Aged and Elderly Malaysian Chinese Men and Its Association With Age and Body Anthropometry

2011-12-12

Abstract: Quantitative ultrasound (QUS) is a relatively easy, reliable, and safe method for bone status assessment, but reference data for Asian males remain scarce. Our study aimed to determine the values for one QUS parameter, the speed of sound (SOS) at the calcaneus, in Malaysian Chinese men and to determine the association between the SOS and several demographic characteristics, such as age, weight, height, and body mass index. Three hundred forty-eight Malaysian Chinese men aged 40yr and older were recruited, and their calcaneal QUS value was determined using the CM-200 densitometer (Furuno Electric, Nishinomiya City, Japan). The results indicated a significant correlation between SOS and age, and multiple stepwise regression analysis indicated that age and height were important predictors of SOS. A significant reduction in SOS value was observed when men 60yr and older were compared with men aged 40–49yr. Compared with the reference data for Japanese males, Chinese men in Malaysia showed higher SOS values across all the age groups studied. In conclusion, there is an age-related decrease in SOS values in Malaysian Chinese men, and the SOS values established in this study can be used as a reference for future studies.

Validation of Diagnostic Codes for Subtrochanteric, Diaphyseal, and Atypical Femoral Fractures Using Administrative Claims Data

2011-11-10

Abstract: Administrative claims databases have large samples and high generalizability. They have been used to evaluate associations of atypical femoral fractures with bisphosphonates. We developed and assessed accuracy of claims-based algorithms with hospital and physician diagnosis codes for these fractures. Medical records and radiology reports of all adults admitted at University of Alabama at Birmingham Health System from 2004 to 2008 with International Classification of Diseases, Ninth Revision hospital discharges and surgeons’ fracture repair codes for subtrochanteric femoral fractures and random sample of other femoral fractures were reviewed. We identified 137 persons with suspected subtrochanteric femoral fractures and randomly selected 50 persons with either suspected diaphyseal femoral fractures or hip fractures other than subtrochanteric and diaphyseal femoral fractures (typical hip fractures). Eleven patients had radiographic features indicative of atypical femoral fractures. The positive predictive value (PPV) of claims-based algorithms varied with primary or secondary positions on discharge diagnoses and the sources of diagnosis codes. The PPV for fractures ranged 69–89% for subtrochanteric femoral, 89–98% for diaphyseal femoral, and 85–98% for typical hip fractures. The PPV of administrative codes for defining a femoral fracture as atypical was low and imprecise. Claims-based algorithms combining hospital discharges with surgeon’s diagnosis codes had high PPV to identify the site of subtrochanteric or diaphyseal femoral fractures vs typical hip fractures. However, claims-based data were not accurate in identifying atypical femoral fractures. These claims algorithms will be useful in future population-based observational studies to evaluate associations between osteoporosis medications and subtrochanteric and diaphyseal femoral fractures.

Evaluation of the Bone Status in High-Level Cyclists

Gérard Guillaume, Daniel Chappard, Maurice Audran — 2011-11-10

Abstract: The purpose of this study was to evaluate the bone status in highly trained professional cyclists subjected to regular training and tough competitions. Bone mineral density (BMD) was measured at different regions of interest by dual-energy X-ray absorptiometry, and main biological parameters related to bone metabolism were obtained in 29 cyclists. Lumbar BMD was 0.94±0.01g/cm2 (Z-score=−1.28±0.07), and 1 cyclist out of 4 had an abnormally low value (Z-score <−2). The mean Z-score at the total femoral site was −1.22±0.21, and 45% of athletes had an Z-score of <−2. All femoral neck BMD values were within normal boundaries. The lowest BMD Z-score was measured at the midradius or 1/3 proximal site with a mean Z-score of −1.77±0.78, but only 3 cyclists (15%) had Z-scores <−2. Biochemical parameters of bone formation (serum osteocalcin and alkaline phosphatase) were normal. Three cyclists had low 25-hydroxyvitamin D levels. Blood testosterone and thyroid stimulating hormone were in the normal range. Insulin-like growth factor 1 levels were in the normal range; however, a significant inverse correlation was found with lumbar BMD (r=0.495; p=0.003). We confirm that cycling has no positive effect on BMD, BMD being often lower than in normal controls at the lumbar site; femoral BMD is less concerned. The absence of beneficial changes at the spine can be explained by biomechanical conditions related to the cyclists’ position, reducing loading strains. It is necessary to pay greater attention to the bone status of high-level athletes to prevent an increased risk of fractures.

Little Evidence of Low Bone Mass in Acute Lymphoblastic Leukemia Survivors

2011-09-01

Abstract: Childhood acute lymphoblastic leukemia (ALL) survivors represent a specific group at risk for many health problems, including skeletal complications and osteoporosis. The objective of this study was to assess the risk of osteoporosis associated with the prevalence of low bone mass (according to the guidelines of the Pediatric Official Positions of the International Society for Clinical Densitometry 2007) in survivors of childhood ALL. The cross-sectional study was conducted in a cohort of 69 Caucasian children and adolescents (46 boys and 23 girls) aged 12.15±0.5yr diagnosed with ALL and screened up to 5yr after cessation of the treatment. Total body bone mineral content (TB BMC, g), total body bone mineral density (TB BMD, g/cm2), and lumbar spine BMD (LS BMD, g/cm2) were determined using dual-energy X-ray absorptiometry. Time interval from the completion of the treatment to the beginning of this study (subgroup I<2yr or subgroup II>2yr after treatment), methotrexate (MTX) doses (subgroup I—MTX ranging from 0.5 to 1.0g/m2; subgroup II—MTX>2.0g/m2), cranial irradiation (subgroup I—without radiotherapy (RTX) and subgroup II receiving RTX of 12–18Gy), cumulative steroid dose, and impaired endocrine function were considered as potential factors affecting bone metabolism and included in the analysis. No differences were found in bone traits (BMC, TB BMD, LS BMD) in relation to examined risk factors. In multiple regression model that included therapeutical factors, a risk group and central nervous system irradiation were of an important influence on bone mass, and risk group predicted TB BMD in small degree. Risk group and irradiation status lost their significance after the inclusion of anthropometric, age-connected, and time-connected factors. This study suggests that ALL survivors are not at increased risk for low bone mass. However, from the clinical perspective all patients after childhood ALL should be screened for clinical signs, fracture history, and lifestyle risk factors for low bone mass and osteoporosis. They should be referred to bone density evaluation only as often as may be necessary from the clinical evaluation.

Complicated Osteoporosis in Progeroid Syndrome: Treatment With Teriparatide

2011-12-12

Abstract: Human progeroid syndromes (PSs) include a group of genetic “premature aging” diseases that affect a variety of organ systems. Bone diseases are common sequelae of patients diagnosed with PSs.Teriparatide therapy is recommended for elderly men with low bone mineral density (BMD; T-score <−2.5) and at least 1 fragility fracture who are unable to tolerate bisphosphonates. We describe a 20-yr-old patient affected by PS and severe osteoporosis complicated with femoral fracture. The patient experienced a significant improvement in lumbar spine BMD after treatment with teriparatide.

Dramatic Effect of Vitamin D Supplementation and a Gluten-Free Diet on Bone Mineral Density in a Patient With Celiac Disease

Donald R. Duerksen, Massud Ali, William D. Leslie — 2011-09-01

Low bone mineral density (BMD) and osteoporosis are frequent findings in patients with celiac disease (CD), affecting up to 70% of individuals . The pathogenesis is unknown, but 2 potential mechanisms include malabsorption of calcium, vitamin D, and other nutrients, which lead to malnutrition, and release of proinflammatory mediators .

Effect of Silicone Gluteal Implant on Bone Mineral Density Evaluation by DXA Scan

2011-08-18

We present a case report on the potential effects of gluteal implants on bone mineral density (BMD) measurement using dual-energy X-ray absorptiometry (DXA) scan of the hips. A 69-yr-old genotypic male underwent a gender reassignment surgery to become a phenotypic female. The patient, in association with the reassignment, started estrogen 5mg po daily. Baseline DXA of the spine and hips performed on a Lunar Prodigy (GE Healthcare, Waukesha, WI) in 2007 demonstrated low bone density or osteopenia with a T-score of −1.5 in the femurs (). Vitamin D, calcium, and parathyroid hormone levels were found to be within normal limits, and the patient was started on bisphosphonate therapy. The patient then underwent gluteal augmentation surgery with implant of silicon-based prostheses.

2012-01-01

Journal of Clinical Densitometry

Proceedings of the 2011 Santa Fe Bone Symposium

BMD Measurement and Precision: A Comparison of GE Lunar Prodigy and iDXA Densitometers

Which to Use to Evaluate Change in BMD at Follow-Up: RMS-SD or RMS-%CV?

Impact of a New Sarco-Osteopenia Definition on Health-related Quality of Life in a Population-Based Cohort in Northern Europe

Rheumatoid Arthritis is Associated With Less Optimal Hip Structural Geometry

The Importance of Physicians’ Risk Perception in Osteoporosis Treatment Decision Making

Association Between Vascular Calcification and Osteoporosis in Men With Type 2 Diabetes

Predictors of Bone Mineral Density Testing in Patients at High Risk of Osteoporosis: Secondary Analyses From the OSTEOPHARM Randomized Trial

Forearm Bone Mineral Density Measurement With Different Scanning Positions: A Study in Right-Handed Chinese Using Dual-Energy X-Ray Absorptiometry

Influence of Different DXA Acquisition Modes on Monitoring the Changes in Bone Mineral Density After Hip Resurfacing Arthroplasty

Hip Strength in Adults With Type 1 Diabetes is Associated With Age at Onset of Diabetes

Calcaneal Quantitative Ultrasound Value for Middle-Aged and Elderly Malaysian Chinese Men and Its Association With Age and Body Anthropometry

Validation of Diagnostic Codes for Subtrochanteric, Diaphyseal, and Atypical Femoral Fractures Using Administrative Claims Data

Evaluation of the Bone Status in High-Level Cyclists

Little Evidence of Low Bone Mass in Acute Lymphoblastic Leukemia Survivors

Complicated Osteoporosis in Progeroid Syndrome: Treatment With Teriparatide

Dramatic Effect of Vitamin D Supplementation and a Gluten-Free Diet on Bone Mineral Density in a Patient With Celiac Disease

Effect of Silicone Gluteal Implant on Bone Mineral Density Evaluation by DXA Scan

Contents