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HOME REFERRAL GP ASSESSMENT ULTRASOUND CAUSES OF OSTEOPOROSIS
GUIDELINES FOR PREVENTION & TREATMENT BACKGROUND RESEARCH
Here I will place important scientific abstracts that help understand ultrasound measurement of bone.
What is the evidence that ultrasound measurements of the heel predict fracture?
Are the same T scores used for managing osteoporosis the same for ultrasound as for DXA?
Is ultrasound helpful in the management of cortico-steroid induced osteoporosis?
What effect does temperature have on ultrasound measurements?
Are low ultrasound scores associated with increased mortality?
Is ultrasound helpful in the management of patients with anorexia nervosa?
Q: What is the evidence that ultrasound measurements of the heel predict fracture?
A: These 11 Studies are the main ones.
Ultrasonographic heel measurements to predict hip fracture
in elderly women: the EPIDOS prospective study.
Lancet 1996 Aug 24;348(9026):511-4
Hans D, Dargent-Molina P, Schott AM, Sebert JL, Cormier C, Kotzki PO, Delmas
PD, Pouilles JM, Breart G, Meunier PJ.
INSERM Unite 403, Lyon, France.
BACKGROUND: The ability of ultrasonographic measurements to discriminate between
patients with hip fracture and age-matched controls has until now been tested
mainly through cross-sectional studies. We report the results of a prospective
study to assess the value of measurements with ultrasound in predicting the risk
of hip fracture. METHODS: 5662 elderly women (mean age 80.4 years) had both
baseline calcaneal ultrasonography measurements and femoral radiography
(dual-photon X-ray absorptiometry, DPXA) to assess their bone quality. Follow-up
every 4 months enabled us to identify incident fractures. 115 hip fractures were
recorded during a mean follow-up duration of 2 years. FINDINGS: Low calcaneal
ultrasonographic variables (obtained from measurements of broadband ultrasound
attenuation by, and speed of sound through the bone) were able to predict an
increased risk of hip fracture, with similar accuracy to low femoral bone
mineral density (BMD) obtained by DPXA. The relative risk of hip fracture for 1
SD reduction was 2.0 (95% CI 1.6-2.4) for ultrasound attenuation and 1.7
(1.4-2.1) for speed of sound, compared with 1.9 (1.6-2.4) for BMD. After control
for the femoral neck BMD, ultrasonographic variables remained predictive of hip
fracture. The incidence of hip fracture among women with values above the median
for both calcaneal ultrasound attenuation and femoral neck BMD was 2.7 per 1000
woman-years, compared with 19.6 per 1000 woman-years for those with values below
the median for both measures. INTERPRETATION: Ultrasonographic measurements of
the os calcis predict the risk of hip fracture in elderly women living at home
as well as DPXA of the hip does, and the combination of both methods makes
possible the identification of women at very high or very low risk of fracture.
Broadband ultrasound attenuation predicts fractures strongly
and independently of densitometry in older women. A prospective study. Study of
Osteoporotic Fractures Research Group.
Arch Intern Med 1997 Mar 24;157(6):629-34
Bauer DC, Gluer CC, Cauley JA, Vogt TM, Ensrud KE, Genant HK, Black DM.
Division of General Internal Medicine, University of California, San Francisco,
USA.
BACKGROUND: Quantitative ultrasound of bone is a new radiation-free technique
that measures bone mass and may assess bone quality. Retrospective studies have
suggested that low-bone ultrasound of the calcaneus is associated with an
increased risk for hip and other fractures in older women. OBJECTIVES: To
establish the utility of calcaneal quantitative ultrasound of bone for the
prediction of fractures and to compare quantitative ultrasound of bone with bone
mineral densitometry by performing a prospective cohort study within the Study
of Osteoporotic Fractures. SUBJECTS AND METHODS: We studied 6189 postmenopausal
women older than 65 years of 4 US clinical centers. Broadband ultrasound
attenuation (BUA), a measurement of the differential attenuation of sound waves
transmitted through the calcaneus, and bone mineral density of the calcaneus and
hip were measured. Subsequent hip and other nonspine fractures were documented
during a mean follow-up of 2.0 years. RESULTS: In age- and clinic-adjusted
analyses, each SD reduction in calcaneal BUA was associated with a doubling of
the risk for hip fractures (relative risk [RR], 2.0; 95% confidence interval
[CI], 1.5-2.7); a similar relationship was observed with bone mineral density of
the calcaneus (RR, 2.2; 95% CI, 1.9-3.0) and femoral neck (RR, 2.6; 95% CI,
1.9-3.8). After adjustment for bone mineral density of the femoral neck, BUA was
still associated with an increased risk for hip fracture (RR, 1.5; 95% CI,
1.0-2.1). Intertrochanteric fractures in particular were strongly associated
with a low BUA measurement (RR, 3.3; 95% CI, 2.0-5.5). CONCLUSIONS: Broadband
ultrasound attenuation predicts the occurrence of fractures in older women and
is a useful diagnostic test for osteoporosis. The strength of the association
between BUA and fracture is similar to that observed with bone mineral density.
Ultrasound measurements for the prediction of osteoporotic fractures in elderly people.
Osteoporos Int. 1999;9(6):550-6.
Pluijm SM, Graafmans WC, Bouter LM, Lips P.
Institute of Research in Extramural Medicine (EMGO Institute), Vrije Universiteit, Amsterdam, The Netherlands.
In this prospective study we investigated the predictive value of quantitative ultrasound (QUS) measurements and other potential predictors of osteoporotic fractures in the elderly. During a 1-year period, 710 participants (132 men and 578 women), aged 70 years and older (mean age +/- SD: 82.8 +/- 5.9), were recruited from seven homes and apartment houses for the elderly. QUS measurements (broadband ultrasound attenuation (BUA) and speed of sound (SOS)) were assessed with a clinical bone densitometer. A structured questionnaire was used to collect information on other potential predictors. Follow-up of fractures was done each half year by telephone interviews. During the study period (median follow-up 2.8 years, maximum 3.7 years), 30 participants had a first hip fracture and 54 suffered from a first other nonspinal fracture. Cox regression analyses, adjusted for age and sex, showed that the relative risk (RR) of hip fracture for each standard deviation reduction was 2.3 (95% CI, 1.4-3.7) for BUA and 1.6 (95% CI, 1.1-2.3) for SOS. Slightly weaker relationships were found for any fracture (BUA: RR, 1.6; 95% CI, 1.2-2.1; SOS: RR, 1.3; 95% CI, 1.0-1.6). Multivariable analyses identified low BUA values and immobility as the strongest predictors for hip fractures and any fracture. Female gender proved to be the strongest predictor for other nonspinal fractures. It can be concluded that QUS measurements can predict the risk for hip fracture and any fracture in elderly people.
Assessment of a new quantitative ultrasound calcaneus measurement: precision and discrimination of hip fractures in elderly women compared with dual X-ray absorptiometry.
Osteoporos Int. 2000;11(4):354-60.
He YQ, Fan B, Hans D, Li J, Wu CY, Njeh CF, Zhao S, Lu Y, Tsuda-Futami E, Fuerst T, Genant HK.
Department of Radiology, University of California, San Francisco 94143-1349, USA.
The incidence of osteoporotic hip fracture increases in postmenopausal women with low hip bone mineral density (BMD). Dual X-ray absorptiometry (DXA) is the most commonly used technique for the assessment of bone status and provides good measurement precision. However, DXA affords little information about bone architecture. Quantitative ultrasound (QUS) systems have been developed to evaluate bone status for assessment of fracture risk. Our study was designed to assess a new QUS system from Hologic, the Sahara; to compare it with a previous model, the Walker-Sonix UBA 575+; and to investigate whether it is able to discriminate between women with and without fracture. Using both ultrasound devices, the measurements were performed at the heels of 33 postmenopausal women who had recently sustained hip fracture. A control group of 35 age-matched postmenopausal women was recruited for comparison. The total, neck and trochanter femoral BMD values were assessed using DXA for both groups. QUS and DXA measurements were significantly lower in fractured patients (p < 0.005) than in the control group. The short-term, mid-term and standardized short-term precisions were used to evaluate the reproducibility of the two QUS systems. The Sahara showed a better standardized coefficient of variation for broadband ultrasound attenuation (BUA) than did the UBA 575+ (p < 0.001). The correlation of BUA and speed of sound (SOS) between the two QUS devices was highly significant, with an r value of 0.92 for BUA and 0.91 for SOS. However, the correlation between DXA and ultrasound parameters ranged from 0.28 to 0.44. We found that ultrasound measurements at the heel were significant discriminators of hip fractures with odds ratios (OR) ranging from 2.7 to 3.2. Even after adjusting the logistic regressions for total, neck or trochanter femoral BMD, QUS variables were still significant independent discriminators of hip fracture. The areas under the ROC curves of each ultrasound parameter ranged from 0.75 to 0.78, and compared very well with femoral neck BMD (p > 0.05). In conclusion, our study indicated that the calcaneal QUS variables, as measured by the Sahara system can discriminate hip fracture patients equally as well as hip DXA.
Quantitative ultrasound of the os calcis in postmenopausal women with spine and hip fracture.
J Clin Densitom. 2000 Fall;3(3):233-9.
Hadji P, Hars O, Gorke K, Emons G, Schulz KD.
Department of Human Biology, University of Hamburg, Germany. peyman.hadji@t-online.de
Quantitative ultrasonometry (QUS) of the os calcis has been shown to predict hip fracture in late postmenopausal women, and vertebral and forearm fracture in early postmenopausal women. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index (SI) of the os calcis were measured using the Achilles ultrasonometer (Lunar, Madison, WI). Osteoporosis risk factors were assessed by a detailed questionnaire. We examined 1314 normal women from age 48 to 79 yr, with a mean age 60 +/- 7.5 yr. In addition, we examined women of similar age, of whom 80 had suffered a hip fracture and 40 a spine fracture. The short-term precision in vivo expressed as the coefficient of variation was 1.2% for BUA, 0.2% for SOS, and 1.3% for SI. A total of 813 women were measured at both the right and left heel. There was high correlation between the two sides (r = 0.80-0.93) (p < 0.001), with no systematic offset. The ultrasound variables decreased significantly (p < 0.001) with age in healthy women; the annual decrease was -0.4% for BUA, -0.07% for SOS, and -0.7% for SI. BUA, SOS and SI discriminated (p < 0.001) between fracture and non-fracture subjects, but the fracture groups were 2 to 4 yr older. The T-score in the controls averaged -2.1 while that in the fracture patients averaged about -3.0. After control for age, years since menopause, and body size, BUA, SOS as well as the SI remained significantly lower (11 to 12% for SI) in women with fracture. The Z-score was -0.8 (p < 0.01) in spine fracture cases, and -0.9 (p < 0.001) in hip fracture patients. QUS provides a gradient of fracture risk comparable to X-ray densitometry of the axial skeleton, and gives comparable Z- and T-scores in younger postmenopausal women. It provides a precise, radiation-free, low-cost, and rapid method for fracture risk assessment in clinical practice.
Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment.
JAMA. 2001 Dec 12;286(22):2815-22.
Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood LM.
Toni Stabile Osteoporosis Center, Columbia Presbyterian Medical Center, 180 Fort Washington Ave, New York, NY 10032-3784, USA. es27@columbia.edu
CONTEXT: Large segments of the population at risk for osteoporosis and fracture have not been evaluated, and the usefulness of peripheral measurements for short-term prediction of fracture risk is uncertain. OBJECTIVES: To describe the occurrence of low bone mineral density (BMD) in postmenopausal women, its risk factors, and fracture incidence during short-term follow-up. DESIGN: The National Osteoporosis Risk Assessment, a longitudinal observational study initiated September 1997 to March 1999, with approximately 12 months of subsequent follow-up. SETTING AND PARTICIPANTS: A total of 200 160 ambulatory postmenopausal women aged 50 years or older with no previous osteoporosis diagnosis, derived from 4236 primary care practices in 34 states. MAIN OUTCOME MEASURES: Baseline BMD T scores, obtained from peripheral bone densitometry performed at the heel, finger, or forearm; risk factors for low BMD, derived from questionnaire responses; and clinical fracture rates at 12-month follow-up. RESULTS: Using World Health Organization criteria, 39.6% had osteopenia (T score of -1 to -2.49) and 7.2% had osteoporosis (T score </=-2.5). Age, personal or family history of fracture, Asian or Hispanic heritage, smoking, and cortisone use were associated with significantly increased likelihood of osteoporosis; higher body mass index, African American heritage, estrogen or diuretic use, exercise, and alcohol consumption significantly decreased the likelihood. Among the 163 979 participants with follow-up information, osteoporosis was associated with a fracture rate approximately 4 times that of normal BMD (rate ratio, 4.03; 95% confidence interval [CI], 3.59-4.53) and osteopenia was associated with a 1.8-fold higher rate (95% CI, 1.49-2.18). CONCLUSIONS: Almost half of this population had previously undetected low BMD, including 7% with osteoporosis. Peripheral BMD results were highly predictive of fracture risk. Given the economic and social costs of osteoporotic fractures, strategies to identify and manage osteoporosis in the primary care setting need to be established and implemented.
Prediction of fracture risk in postmenopausal white women with peripheral bone densitometry: evidence from the National Osteoporosis Risk Assessment.
J Bone Miner Res. 2002 Dec;17(12):2222-30.
Miller PD, Siris ES, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Chen YT, Berger ML, Santora AC, Sherwood LM.
Colorado Center for Bone Research, Lakewood, Colorado 80227, USA.
Low bone mineral density (BMD) is a risk factor for fracture. Although the current "gold standard" test is DXA of the hip and spine, this method is not universally available. No large studies have evaluated the ability of new, less expensive peripheral technologies to predict fracture. We studied the association between BMD measurements at peripheral sites and subsequent fracture risk at the hip, wrist/forearm, spine, and rib in 149,524 postmenopausal white women, without prior diagnosis of osteoporosis. At enrollment, each participant completed a risk assessment questionnaire and had BMD testing at the heel, forearm, or finger. Main outcomes were new fractures of the hip, wrist/forearm, spine, or rib within the first 12 months after testing. After 1 year, 2259 women reported 2340 new fractures. Based on manufacturers' normative data and multivariable adjusted analyses, women who had T scores < or = -2.5 SD were 2.15 (finger) to 3.94 (heel ultrasound [US]) times more likely to fracture than women with normal BMD. All measurement sites/devices predicted fracture equally well, and risk prediction was similar whether calculated from the manufacturers' young normal values (T scores) or using SDs from the mean age of the National Osteoporosis Risk Assessment (NORA) population. The areas under receiver operating characteristic (ROC) curves for hip fracture were comparable with those published using measurements at hip sites. We conclude that low BMD found by peripheral technologies, regardless of the site measured, is associated with at least a twofold increased risk of fracture within 1 year, even at skeletal sites other than the one measured.
Risk factors for fractures of the proximal humerus: results from the EPIDOS prospective study.
J Bone Miner Res. 2002 May;17(5):817-25.
Lee SH, Dargent-Molina P, Breart G; EPIDOS Group. Epidemiologie de l'Osteoporose Study.
INSERM, Unite 149, Villejuif, France.
Fracture of the proximal humerus is one of the most frequent fractures attributable to osteoporosis; yet, it has seldom been studied. Two types of factors (related to bone fragility and falls) were evaluated to identify risk factors for proximal humerus fractures as well as to examine possible interactions between them. Subjects were 6901 white women aged > or =75 years and all participated in the EPIDOS study of risk factors for osteoporotic fractures (France, 1992-1998). The baseline examination included measurements of femoral neck bone mineral density (BMD) and calcaneal ultrasound parameters (speed of sound [SOS] and broadband ultrasound attenuation [BUA]), a functional clinical examination, and completing a questionnaire on health status and lifestyle. During a mean of 3.6 (0.8) years of follow-up, 165 women had a humeral fracture. Using multivariate Cox regression models, we identified three predictors related to bone fragility-low BMD (relative risk [RR] = 1.4; 95% CI, 1.1-1.7), low SOS (RR = 1.3; 95% CI, 1.0-1.6), and maternal history of hip fracture (RR = 1.8; 95% CI, 1.0-3.0)-and four fall-related predictors-a previous fall (RR = 3.0; 95% CI, 1.5-6.1), a low level of physical activity (RR = 2.2; 95% CI, 1.1-4.4), impaired balance (RR = 1.8; 95% CI, 1.1-2.9), and pain in lower limb extremity (RR = 1.4; 95% CI, 1.0-2.1). The effect of these fall-related predictors varied according to the BMD level; they were significantly associated with proximal humerus fractures in women with osteoporosis (BMD T score < -2.5) but not in nonosteoporotic women. The incidence of proximal humerus fracture in women with osteoporosis and a low fall risk score (5.1 per 1000 woman-years) was only slightly higher than in nonosteoporotic women (4.6 per 1000 woman-years) and similar to the incidence in women without osteoporosis but a high fall risk score (5.3 per 1000 woman-years). On the other hand, the incidence in women who had both types of risk factors was more than two times higher (12.1 per 1000 woman-years) than in women with only one of the two risk factors. These results suggest that women who have both types of risk factors should receive the highest priority for prevention.
The ability of quantitative ultrasound at the calcaneus to identify postmenopausal women with different types of nontraumatic fractures.
Ultrasound Med Biol. 2002 Nov-Dec;28(11-12):1491-7.
Drozdzowska B, Pluskiewicz W.
Department of Pathomorphology, Silesian School of Medicine, Zabrze, Poland. bognadr@poczta.onet.pl
The aim of the cross-sectional study was to determine if ultrasound (US) measurements of the calcaneus have the ability to predict the risk for fractures and to discriminate between postmenopausal women with and without different types of nontraumatic fractures. All women (n = 1,129, age range 40 to 87 years) were divided into group 1, created by 656 women with 956 nontraumatic past fractures, and group 2, consisting of 473 women without fractures. Group 1 was divided into subgroups: with hip fractures, with vertebral (nonhip) fractures, with wrist (nonhip and nonspine) fractures and with other (nonhip, nonspine and nonwrist) fractures. The speed of sound (SOS; m/s) and broadband ultrasound attenuation (BUA; dB/MHz) were measured with the Achilles system (Lunar), which also calculates stiffness index (SI; %). US values were significantly lower in group 1 (1,481.4 +/- 20.2 m/s, 98.7 +/- 9.4 dB/MHz, 61.1 +/- 11.0%; p < 0.000001) and in subgroups (p < 0.000001), and these women had a higher mean age and longer postmenopausal period than women without fractures (1508.2 +/- 26.5 m/s, 107.7 +/- 9.9 dB/MHz, 74.2 +/- 13.0%). Women with hip fractures had the lowest US values (1464.6 +/- 18.6 m/s, 89.9 +/- 8.7 dB/MHz, 50.6 +/- 10.5%), women with vertebral fractures had intermediate values (1473.6 +/- 17.4 m/s, 94.8 +/- 8.9 dB/MHz, 56.4 +/- 10.0%), and women with wrist (1,484.3 +/- 19.8 m/s, 99.9 +/- 9.3 dB/MHz, 62.7 +/- 10.7%) and other fractures (1,483.3 +/- 21.0 m/s, 100.4 +/- 8.6 dB/MHz, 62.7 +/- 10.6%) had the highest values. The US values differed significantly between subgroups with fractures (p < 0.05), with no significant differences between women with wrist and other fractures. ROC analysis showed SOS to have the best sensitivity and specificity in detecting fracture cases. All US parameters revealed the greatest areas under the ROC curve (AUCs) for hip fracture (0.92 to 0.93) in comparison to smaller AUCs for vertebral fractures (ranging from 0.84 to 0.87), and the smallest AUCs for wrist and other fractures (ranging from 0.72 to 0.77 and 0.72 to 0.78, respectively). Generally, the SOS measurement presented greater odds ratio (OR) than BUA and SI: 4.1 (3.09 to 5.43) for any fracture, 11.66 (3.09 to 43.96) for hip fracture, 6.51 (3.61 to 11.73) for vertebral fracture, 3.32 (2.41 to 4.58) for wrist fracture and 4.2 (2.7 to 6.54) for other fracture. The present study demonstrates the ability of calcaneal QUS to discriminate between healthy individuals and subjects with different types of nontraumatic fractures. Calcaneal US parameters show the best sensitivity and specificity in discriminating the hip fracture patients from the controls. Generally, the SOS parameter is a better discriminator than SI and BUA and estimates the highest OR for fractures.
A comparison of fracture discrimination using calcaneal quantitative ultrasound and dual X-ray absorptiometry in women with a history of fracture at sites other than the spine and hip.
Calcif Tissue Int. 2002 Sep;71(3):207-11.
Frost ML, Blake GM, Fogelman I.
Osteoporosis Screening & Research Unit, Guy's, King's and St Thomas' School of Medicine, London, UK. michelle.frost@kcl.ac.uk
The aim of this study was to determine whether calcaneal quantitative ultrasound can discriminate between women with and those without fragility fracture at (1) the wrist or (2) at sites other than the spine, hip, or forearm, as well as axial DXA measurements of BMD can. The study population consisted of 342 postmenopausal Caucasian women who were placed into one of three groups: (1) healthy women with no clinical risk factors for osteoporosis (n = 240); (2) women with a history of atraumatic fracture at the wrist (n = 50); (3) women with a history of atraumatic fracture at a skeletal site other than the spine, hip, or wrist (n = 52). Subjects had DXA measurements of the lumbar spine (LS), femoral neck (FN), and total hip (THIP), and calcaneal broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements on the Hologic Sahara (s) and Osteometer DTUone (d). Z-scores were calculated using the mean and SD obtained from the healthy postmenopausal group. All the BMD and QUS variables were significantly reduced in women reporting a fracture of the wrist or at a site other than the spine, hip, or forearm. When the group of women with a history of wrist fracture were compared with the postmenopausal controls, age-adjusted logistic regression yielded odds ratios associated with a 1 SD decrease, that were significant for both BMD and QUS, averaging 2.2. The AUC values ranged from 0.65 for FN BMD to 0.75 for BUAd. BMD and QUS measurements were also significantly reduced in women reporting a skeletal fracture at a site other than the spine, hip, or wrist, and odds ratios for BMD and QUS were significant, averaging 1.7. BMD and QUS showed similar fracture discriminatory abilities that were not significantly different from one another. In conclusion, calcaneal QUS can discriminate between women with and those without fracture at the wrist or at sites other than the spine, hip, or forearm as well as axial DXA measurements of BMD can.
Discriminatory ability of quantitative ultrasound parameters and bone mineral density in a population-based sample of postmenopausal women with vertebral fractures: results of the Basel Osteoporosis Study.
J Bone Miner Res. 2002 Feb;17(2):321-30.
Hartl F, Tyndall A, Kraenzlin M, Bachmeier C, Guckel C, Senn U, Hans D, Theiler R.
Department of Rheumatology, Felix Platter-Hospital, University of Basel, Switzerland.
The discriminatory potential to classify subjects with or without vertebral fractures was tested cross-sectionally with different methods for the measurement of bone status in a population-based sample of postmenopausal women. Quantitative ultrasound (QUS) measurement at the calcaneus (Lunar Achilles, Hologic Sahara), the proximal phalanges (Igea Bone Profiler), and measurement of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA; Lunar Expert) at several anatomic sites was performed in 500 postmenopausal women (aged 65-75 years) randomly selected from the population. In addition, 50 young female subjects (20-40 years old) had QUS measurements and served as controls to express QUS results as T-score values. Radiographs of the lumbar and thoracic spine were performed in the elderly women. Two independent radiologists reviewed the X-rays for the presence of vertebral fractures. Of 486 eligible study participants, no fracture was seen in 396 participants. Single vertebral fractures were observed in 71 subjects; 19 individuals presented multiple fractures. The overall prevalence of vertebral fractures was 18.5%. Participants without vertebral fractures were compared with subjects with vertebral fractures. Normal statistical distributions were found for all bone measurement results. Risk of vertebral fracture in subjects with no and multiple vertebral fracture was estimated using age adjusted odds ratios (ORs) for QUS and dual-energy X-ray absorptiometry (DXA) values. Each SD decrease in bone measurement increased the risk of multiple vertebral fracture by 3.0 (95% CI, 1.6-5.6) for the Achilles stiffness, by 3.8 (95% CI, 1.8-8.2) for the Sahara QUI, 2.1 (95% CI, 1.3-3.4) for the Bone Profiler amplitude-dependent speed of sound (AD-SOS), and 2.1 (95% CI, 1.2-3.9) and 2.4 (95% CI, 1.3-4.3) for DXA lumbar spine and for DXA total hip, respectively. Results of a discriminant analysis showed sensitivities between 84% and 58% and specificities between 72% and 58% for the respective DXA and QUS parameters. Optimum fracture thresholds for QUS measurements derived from this analysis were calculated also. Optimum T-score threshold values for QUS measurements tended to be higher than those for DXA measurements. However, the performance of QUS measurements is at least comparable with DXA measurements in identifying subjects with multiple vertebral fractures randomly selected from the population.
Q: Do ultrasound parameters change in response to treatment?
Heel ultrasonography in monitoring alendronate therapy: a four-year longitudinal study.
Osteoporos Int. 2002 May;13(5):415-21.
Gonnelli S, Cepollaro C, Montagnani A, Martini S, Gennari L, Mangeri M, Gennari C.
Institute of Internal Medicine, University of Siena, Italy. gonnelli@unisi.it
The possibility of using quantitative ultrasound (QUS) in monitoring the response to antiresorptive drugs has yet to be defined. The aim of the present study was to evaluate whether heel ultrasonography, considering its characteristics of long-term precision, is able to monitor osteoporotic patients treated with alendronate. We studied 150 postmenopausal osteoporotic women (age 59.6 +/- 5.3 years) treated with alendronate and calcium (n = 74) or with calcium alone (n = 76) for 4 years. At baseline and after 12, 24, 36 and 48 months, we measured bone mineral density (BMD) at the lumbar spine by dual-energy X-ray absorptiometry (DXA, Hologic 4500), and speed of sound (SOS), broadband ultrasound attenuation (BUA) and Stiffness at the calcaneus by Achilles plus. Moreover, the longitudinal precision of QUS parameters was assessed by measuring 10 subjects once a month for 1 year and, on the basis of the coefficients of variation we obtained, we calculated the Least Significant Change between two measurements. In the alendronate-treated patients, at year 1, BMD increased by 4.2%, SOS by 0.4%, BUA by 1.1% and Stiffness by 3.2%; at year 2, BMD increased by 5.0%, SOS by 0.7%, BUA by 1.4% and Stiffness by 5.7%. At year 3, BMD increased by 6.2%, SOS by 0.9%, BUA by 1.8% and Stiffness by 7.6%. At the end of the study period, BMD increased by 7.6%, SOS by 1.2%, BUA by 1.9% and Stiffness by 9.0%. The minimal significant difference between two measurements was 0.8% for SOS, 5.6% for BUA and 5.0% for Stiffness. Among the QUS parameters, Stiffness showed the greatest total treatment effect and a longitudinal sensitivity which was only slightly lower than BMD. The MTI, which represents the period between scans required to show that a 'true' change has occurred, was 1.8, 2.7, 11.9 and 2.2 years for BMD, SOS, BUA and Stiffness respectively. Therefore, although the spinal BMD remains the optimal method, QUS at the heel, and in particular Stiffness, seems to be a sensitive tool for monitoring the response to alendronate.
Alendronate Treatment in Men With Primary Osteoporosis: A Three-Year Longitudinal Study.
Calcif Tissue Int. 2003 May 21 [Epub ahead of print].
Gonnelli S, Cepollaro C, Montagnani A, Bruni D, Caffarelli C, Breschi M, Gennari L, Gennari C, Nuti R.
Department of Internal Medicine, Endocrine-Metabolic Science and Biochemistry, University of Siena, Italy.
Bisphosphonates have been widely used in the treatment of osteoporosis in women, whereas until now there have been few data on their use in men. The aim of this study was to evaluate the effect of a 3-year alendronate treatment on bone mineral density (BMD) and quantitative ultrasound (QUS) in men with primary osteoporosis. We studied 77 osteoporotic men (aged 57.1 +/- 10.8 yrs) who completed a 3-year treatment with alendronate (10 mg/day) plus calcium (1000 mg/day) (n = 39), or calcium alone (n = 38). At baseline and at a 12-month interval, we measured BMD at the lumbar spine and femur (femoral neck and total hip) by DXA (Hologic) and speed of sound (SOS), broadband ultrasound attenuation (BUA) and Stiffness (S) at the os calcis by Achilles plus (Lunar). Alendronate treatment had significantly increased lumbar spine BMD by 4.2% at year 1, by 6.3% at year 2, and 8.8% at year 3. BMD at the femoral neck and total hip had increased by 2.1% and 1.6% at year 1, by 3.2% and 2.9% at year 2, and by 4.2% and 3.9% at year 3, respectively. BUA and Stiffness showed a significant increase in the alendronate-treated group at year 2 (3.2% and 4.9%, respectively) and at year 3 (3.8% and 6%, respectively). BMD at the lumbar spine showed the best longitudinal sensitivity whereas longitudinal sensitivity of both QUS at the heel and femur BMD were similar. In conclusion, this study confirms that alendronate represents an important therapeutic advance in the management of male osteoporosis. BMD at the lumbar spine appears to be the best method for monitoring the effect of alendronate on bone mass in osteoporotic men.
Q:-Are
the clinical risk factors that are associated with low bone density by DXA,
associated with low ultrasound scores?
The effect of age, weight, and lifestyle factors on calcaneal quantitative ultrasound: the ESOPO study.
Osteoporos Int. 2003 Mar;14(3):198-207. Epub 2003 Apr 11.
Adami S, Giannini S, Giorgino R, Isaia G, Maggi S, Sinigaglia L, Filipponi P, Crepaldi G, Di Munno O.
Riabilitazione Reumatologica, University of Verona, Ospedale Valeggio, 37067, Verona, Italy, silvano.adami@univr.it
Quantitative ultrasound (QUS) techniques have been shown to be as good as bone mineral density (BMD) assessed by dual-energy X-ray absorptiometry (DXA), in predicting fracture risk: QUS technique could increase substantially the accessibility to a reliable bone osteoporosis risk evaluation, but little is know regarding the relationship of QUS to risk factors that have been found to predict DXA-BMD values and this is even more true in men. We studied 6,811 postmenopausal women 40 to 80 years of age and 4,981 men 60-80 years of age representative of the general population of all regions of Italy. All participants were questioned on lifestyle habits and on their medical history. After a physical examination "bone stiffness" (called here for simplicity, stiffness), which is derived from the values of broadband ultrasound attenuation (BUA) and speed of sounds (SoS) was measured by a heel QUS device (Achilles apparatus, Lunar, Madison, USA). The most common recognized determinants of bone mass (either categorical or continuous variables) were modeled with stiffness by multiple regression analysis or ANOVA. Stiffness was strongly related to age and weight. After adjusting for these variables, the women who had taken hormone replacement therapy for more than a year had significantly higher stiffness values. The difference versus nonusers remained significant for up to 20 years-since-menopause (YSM). This effect was so strong that for further analysis these women were excluded. By multivariate analysis, stiffness was then found to be significantly related to recalled body weight at 25 years of age, actual and past cigarettes smoked per day, and dairy calcium intake. Stiffness was also associated with a number of categorial factors adjusted for age, weight, and YSM: prior ovariectomy, history of more than 2 months confined to bed, outdoor physical activity, smoking, chronic use of any drug, and past corticosteroid use. All these categorial and continuous variables predicted stiffness equally in men and women. In conclusion, QUS bone measurements discriminate postmenopausal women according to past use of hormone replacement therapy. Risk factors usually associated to BMD as measured by DXA are also associated to calcaneal bone stiffness as measured by QUS, and most risk factors for osteoporosis usually observed in women are equally applicable to men.
Factors affecting broadband ultrasound attenuation results of the calcaneus using a gel-coupled quantitative ultrasound scanning system.
Osteoporos Int. 1999;10(6):495-504.
Cheng S, Fan B, Wang L, Fuerst T, Lian M, Njeh C, He Y, Kern M, Lappin M,
Tylavsky F, Casal D, Harris S, Genant HK.
Osteoporosis and Arthritis Research Group, University of California, San Francisco, California, USA. cheng@maila.jyu.fi
This study aimed to assess the factors that may influence the distribution and description of broadband ultrasound attenuation (BUA) and to identify specific criteria for diagnostic consideration when collecting BUA reference data. Two hundred Caucasian women (aged 20-79 years) without a history of atraumatic fractures or medicines known to affect bone metabolism were selected for this study. Medical and menstrual history, medication usage, family history of osteoporosis (FHO), physical activity, activities of daily living (ADL), dietary calcium intake, as well as smoking and alcohol consumption were obtained. Broadband ultrasound attenuation (BUA, dB/MHz) was determined in the right foot using a new gel-coupled ultrasound system. BUA was significantly associated with age (p<0.001), body weight (p<0.001), level of physical activity (p = 0.024) and dietary calcium intake (p = 0.023). Smoking, alcohol and coffee consumption and ADL were not associated with BUA (p>0.05). There were no differences in BUA (p>0.05) between those women who reported taking medications or had diseases (known to not affect bone metabolism), were using contraceptives, taking vitamin/mineral supplements and/or had traumatic fractures and their counterparts who did not report these characteristics. Premenopausal women with a FHO had significantly lower BUA values compared with those without a FHO (p = 0.013). When those participants with a FHO were removed from the sample, the peak BUA value was 1.1-4.4% higher and the variability (SD) was reduced by about 3.3-9.3% depending on which age range was used to define the peak BUA value. Consequently, an additional 4.5% of the population were classified as having a T-score <-2. Our results suggest that the impact on BUA of risk factors such as a FHO, body weight, physical activity and dietary calcium intake is similar to that on bone mineral density obtained by dual-energy X-ray absorptiometry (DXA), and thus provides further information on the comparability of quantitative ultrasound and DXA for assessment of risk of fracture. The criteria for calculating the T-score need further study to determine whether young adults with FHO should be included and what cutoff age range should be used in collecting peak values of quantitative ultrasound parameters.
Quantitative ultrasound and bone mineral density are equally strongly associated with risk factors for osteoporosis.
J Bone Miner Res. 2001 Feb;16(2):406-16.
Frost ML, Blake GM, Fogelman I.
Osteoporosis Screening and Research Unit, Guy's Hospital, London, United Kingdom.
Because resources do not allow all women to be screened for osteoporosis, clinical risk factors are often used to identify those individuals at increased risk of fracture who are then assessed by bone densitometry. The aim of this study was to compare calcaneal quantitative ultrasound (QUS) and axial bone mineral density (BMD) T and Z scores in a large group of women, some with no clinical risk factors and others with one or more risk factors for osteoporosis. The study population consisted of 1115 pre- and postmenopausal women. A subgroup of 530 women was used to construct reference data for calculating T and Z scores. A total of 786 women was found to have one or more of the following risk factors: (i) atraumatic fracture since the age of 25 years, (ii) report of X-ray osteopenia, (iii) predisposing medical condition or use of therapy known to affect bone metabolism, (iv) premature menopause before the age of 45 years or a history of amenorrhea of longer than 6 months duration, (v) family history of osteoporosis, (vi) body mass index (BMI) <20 kg/m2, and (vii) current smoking habit. Calcaneal broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements were performed on a Hologic Sahara and a DTUone and BMD was measured at the spine and hip using dual-energy X-ray absorptiometry (DXA). The Z score decrements associated with the seven risk factors calculated using multivariate regression analysis were similar for QUS and BMD measurements. Z score decrements (mean of BMD and QUS measurements combined) associated with a history of atraumatic fracture (-0.67), X-ray osteopenia (-0.36), a family history of osteoporosis (-0.23), and a low BMI (-0.53) were all statistically significant compared with women with no risk factors. Z score decrements associated with a medical condition or use of therapy known to affect bone metabolism, a premature menopause or prolonged amenorrhea, or those who were current smokers were not significantly different from zero. As the number of risk factors present in each individual increased, the mean Z score decrements became more negative, increasing from -0.28 for women with one risk factor to -1.19 for those with four or more risk factors. QUS and BMD measurements yielded similar mean Z scores for women with one, two, three, or more than four risk factors. Using the World Health Organization (WHO) criteria to diagnose osteoporosis for BMD measurements and revised diagnostic criteria for QUS, approximately one-third of postmenopausal women aged 50+ years with clinical risk factors were classified as osteoporotic compared with only 12% of women without clinical risk factors. Over two-thirds of postmenopausal women with risk factors were classified as osteopenic or osteoporotic and approximately 28% were classified as normal. The proportion of women classified into each diagnostic category was similar for BMD and QUS. In conclusion, clinical risk factors for osteoporosis affected calcaneal BUA and SOS Z score measurements to the same extent as axial BMD Z score measurements. Provided revised diagnostic criteria are adopted for QUS, similar proportions of postmenopausal women are identified as osteopenic or osteoporotic as with BMD.
Q: Are the same T scores used for managing osteoporosis the same for ultrasound as for DXA?
Quantitative US of the calcaneus: cutoff levels for the distinction of healthy and osteoporotic individuals.
Radiology. 2001 Aug;220(2):400-5.
Grampp S, Henk C, Lu Y, Krestan C, Resch H, Kainberger F, Youssefzadeh S, Vorbeck F, Imhof H.
Department of Osteology, Universitatsklinik fur Radiodiagnostik, Wahringer Gurtel 18-20, 1090 Vienna, Austria. stephan.grampp@univie.ac.at
PURPOSE: To calculate cutoff levels for quantitative ultrasonography (US) performed to distinguish healthy individuals and those with osteoporosis identified with dual x-ray absorptiometry. MATERIALS AND METHODS: In 1,357 patients (856 females, aged 55.1 years +/- 15.4 [mean +/- SD]; 501 males, aged 50.4 years +/- 15), bone mineral density measurements of the lumbar spine (posteroanterior, L1 through L4) and femoral neck were obtained, and quantitative US was performed to determine the stiffness of the calcaneus. Individuals with a T score less than -2.5 (osteoporotic) at the spine and femur were identified, and upper T-score cutoff values (3 SDs from the mean) in the groups of male and female patients with osteoporosis were identified. RESULTS: Females with dual x-ray absorptiometric values that were indicative of osteoporosis of the spine had an upper T-score cutoff value of -1.0 (males, -0.2). Females who had femoral osteoporosis showed an upper quantitative US T-score cutoff value of -0.6 (males, 0). CONCLUSION: Cutoff values may permit the use of quantitative US to screen for the presence of osteoporosis in the spine and femur. Quantitative US will help to prevent unnecessary dual x-ray absorptiometric and conventional radiographic examinations.
Discordance in patient classification using T-scores.
J Clin Densitom. 1999 Fall;2(3):343-50.
Faulkner KG, von Stetten E, Miller P.
Synarc Portland, Portland, OR 97220, USA. ken.faulkner@synarc.com
In their original study report, "Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis," the World Health Organization (WHO) explicitly stated that any T-score criterion for osteoporosis is sensitive to bone mineral density (BMD) measurement site and technique, as well as the young adult reference population. Yet, the T = -2.5 criterion introduced by WHO is used for many different BMD techniques, despite the fact that it was based primarily on the relationship between forearm measurements and prevalent hip fracture in postmenopausal Caucasian females. It is reasonable to expect that a T-score threshold of -2.5 may be inappropriate for different skeletal sites and measurement techniques. This may explain the large variation in osteoporosis prevalence observed when different skeletal sites are measured. In this study, we compared the prevalence of osteoporosis (based on the T = -2.5 criterion) at different skeletal sites using the manufacturer's normative data. We determined the expected mean T-score for a 60-yr-old Caucasian female at the heel (ultrasound), hip (dual X-ray absorptiometry [DXA]), spine (PA DXA, lateral DXA, and quantitative computed tomography [QCT]), and forearm (DXA). Assuming a normal distribution of T-scores at a fixed age, we computed the expected percentage of 60-yr-old Caucasian women that would be classified as osteoporotic using the -2.5 standard deviation criterion for each technique. At age 60 yr, the expected mean T-score ranged from -2.5 (spine QCT) to -0.7 (heel). Prevalence estimates ranged from 3% at the heel to 50% for spinal QCT. It was also noted that the sites with the strongest relationship to hip fracture risk (the hip and heel) showed the least age-related T-score decline and lowest estimated prevalence. We conclude that a single T-score criterion cannot be universally applied to all BMD measurements. The discrepancies in the prevalence of osteoporosis are the result of several factors, including differences in age-related bone loss at different skeletal sites, differences in the young adult reference populations used by the various bone densitometry devices, and technology-related differences. Using estimated BMD by heel ultrasound, few patients will have T-scores below -2.5, whereas most postmenopausal women will fall below this level for spine bone density measurements performed by lateral DXA or QCT. Based on these data, it may be necessary to provide a T-score criterion specific to the type of densitometric evaluation performed.
Contact quantitative ultrasound: an evaluation of precision, fracture discrimination, age-related bone loss and applicability of the WHO criteria.
Osteoporos Int. 1999;10(6):441-9.
Frost ML, Blake GM, Fogelman I.
Osteoporosis Unit, Guy's Hospital, London, UK. michelle.frost@kcl.ac.uk
The aim of this study was to assess a dry calcaneal quantitative ultrasound (QUS) device by examining: (i) short- and long-term precision; (ii) the ability of the ultrasound parameters to identify women with vertebral fractures; (iii) age- and menopause-related bone loss; (iv) applicability of the WHO criteria in scan interpretation. The study group consisted of 422 healthy women with no risk factors associated with osteoporosis (227 premenopausal and 195 postmenopausal) and 93 women with one or more vertebral fractures. All women had calcaneal QUS and bone mineral density (BMD) measurements of the lumbar spine and hip performed. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements in the heel were combined and expressed as estimated heel BMD. Short-term precision studies yielded coefficient of variations of 0. 3% for SOS, 4% for BUA and 3.3% for estimated heel BMD. Standardized short-term precision values were approximately 0.2 SD. Long-term standardized precision errors ranged from 0.17 to 0.38 SD. All the QUS and BMD measurement parameters showed significant negative relationships with age in the postmenopausal group. Annual losses were 0.35 dB/MHz per year for BUA, 0.56 m/s per year for SOS and 0. 002 g/cm(2) per year for estimated heel BMD. All the QUS and BMD parameters were able to discriminate between healthy postmenopausal women and women with vertebral fracture. Age-adjusted odds ratios for each SD decline in QUS measurements were 3.63, 5.25 and 4.79 for BUA, SOS and estimated heel BMD respectively. Corresponding odds ratios for BMD at the lumbar spine, femoral neck and total hip were 2.39, 2.51 and 2.95 respectively. When the QUS and BMD parameters were expressed as T-scores, estimated heel BMD showed the least age-related decline, while femoral neck BMD displayed the greatest decrease with age. The mean T-score and prevalence of osteoporosis (T<-2.5) for a Caucasian woman aged 60-65 years were -1.35 and 21% respectively for the lumbar spine compared with -0.59 and 2% for estimated heel BMD. In conclusion, this study revealed that contact ultrasound can detect age- and menopause-related influences on bone status and was able to discriminate between healthy individuals and women with vertebral fracture. However, the widely accepted threshold of a T-score of less than -2.5 for the definition of osteoporosis may need modifying for the interpretation of QUS scans.
Device-specific weighted T-score for two quantitative ultrasounds: operational propositions for the management of osteoporosis for 65 years and older women in Switzerland.
Osteoporos Int. 2003 Mar;14(3):251-8. Epub 2003 Apr 01.
Hans D, Hartl F, Krieg MA.
Division of Nuclear Medicine, Geneva University Hospital, 1211, Geneva, Switzerland, dhans@iprolink.ch
The World Health Organization (WHO) criteria for the diagnosis of osteoporosis are mainly applicable for dual X-ray absorptiometry (DXA) measurements at the spine and hip levels. There is a growing demand for cheaper devices, free of ionizing radiation such as promising quantitative ultrasound (QUS). In common with many other countries, QUS measurements are increasingly used in Switzerland without adequate clinical guidelines. The T-score approach developed for DXA cannot be applied to QUS, although well-conducted prospective studies have shown that ultrasound could be a valuable predictor of fracture risk. As a consequence, an expert committee named the Swiss Quality Assurance Project (SQAP, for which the main mission is the establishment of quality assurance procedures for DXA and QUS in Switzerland) was mandated by the Swiss Association Against Osteoporosis (ASCO) in 2000 to propose operational clinical recommendations for the use of QUS in the management of osteoporosis for two QUS devices sold in Switzerland. Device-specific weighted "T-score" based on the risk of osteoporotic hip fractures as well as on the prediction of DXA osteoporosis at the hip, according to the WHO definition of osteoporosis, were calculated for the Achilles (Lunar, General Electric, Madison, Wis.) and Sahara (Hologic, Waltham, Mass.) ultrasound devices. Several studies (totaling a few thousand subjects) were used to calculate age-adjusted odd ratios (OR) and area under the receiver operating curve (AUC) for the prediction of osteoporotic fracture (taking into account a weighting score depending on the design of the study involved in the calculation). The ORs were 2.4 (1.9-3.2) and AUC 0.72 (0.66-0.77), respectively, for the Achilles, and 2.3 (1.7-3.1) and 0.75 (0.68-0.82), respectively, for the Sahara device. To translate risk estimates into thresholds for clinical application, 90% sensitivity was used to define low fracture and low osteoporosis risk, and a specificity of 80% was used to define subjects as being at high risk of fracture or having osteoporosis at the hip. From the combination of the fracture model with the hip DXA osteoporotic model, we found a T-score threshold of -1.2 and -2.5 for the stiffness (Achilles) determining, respectively, the low- and high-risk subjects. Similarly, we found a T-score at -1.0 and -2.2 for the QUI index (Sahara). Then a screening strategy combining QUS, DXA, and clinical factors for the identification of women needing treatment was proposed. The application of this approach will help to minimize the inappropriate use of QUS from which the whole field currently suffers.
Can the WHO criteria for diagnosing osteoporosis be applied to calcaneal quantitative ultrasound?
Osteoporos Int. 2000;11(4):321-30.
Frost ML, Blake GM, Fogelman I.
Osteoporosis Unit, Guy's Hospital, London, UK. michelle.frost@kcl.ac.uk
With the increasing number of quantitative ultrasound (QUS) devices in use worldwide it is important to develop strategies for the clinical use of QUS. The aims of this study were to examine the age-dependence of T-scores and the prevalence of osteoporosis using the World Health Organization Study Group criteria for diagnosing osteoporosis and to examine the T-score threshold that would be appropriate to identify women at risk of osteoporosis using QUS. Two groups of women were studied: (i) 420 healthy women aged 20-79 years with no known risk factors associated with osteoporosis; (ii) 97 postmenopausal women with vertebral fractures. All subjects had dual-energy X-ray absorptiometry (DXA) measurements of the spine and hip and QUS measurements on three calcaneal ultrasound devices (Hologic Sahara, Hologic UBA575+, Osteometer DTUone). A subgroup of 102 (76 on the DTUone) healthy women aged 20-40 years was used to estimate the young adult mean and SD for each QUS and DXA measurement parameter to calculate T-scores. The age-related decline in T-scores for QUS measurement parameters was half the rate observed for the bone mineral density (BMD) measurements. The average T-score for a woman aged 65 years was -1.2 for QUS measurements and -1.75 for the BMD measurements. When osteoporosis was defined by a T-score < or = -2.5 the prevalence of osteoporosis in healthy postmenopausal women was 17%, 16% and 12% for lumbar spine, femoral neck and total hip BMD respectively. When the same definition was used for QUS measurements the prevalence of osteoporosis ranged from 2% to 8% depending on which ultrasound device and measurement parameter was used. Four different approaches, based on DXA-equivalent prevalence rates of osteoporosis, were utilized to examine which T-score threshold would be appropriate for identifying postmenopausal women at risk of osteoporosis using QUS measurements. These ranged from -1.05 to -2.12 depending upon the approach used to estimate the threshold and on which QUS device the measurements were performed, but all were significantly lower than the threshold of -2.5 used for BMD measurements. In conclusion, the WHO threshold of T = -2.5 for diagnosing osteoporosis requires modification when using QUS to assess skeletal status. For the three QUS devices used in this study, a T-score threshold of -1.80 would result in the same percentage of postmenopausal women classified as osteoporotic as the WHO threshold for BMD measurements. Corresponding T-score thresholds for individual measurement parameters on the two commercially available devices were -1.61, -1.94 and -1.90 for Sahara BUA, SOS and estimated heel BMD respectively and -1.45 and -2.10 for DTU BUA and SOS respectively Additional studies are needed to determine suitable T-score thresholds for other commercial QUS devices.
Q:-Is ultrasound helpful in the management of cortico-steroid induced osteoporosis?
Osteoporosis with low dose corticosteroids: contribution of underlying disease effects and discriminatory ability of ultrasound versus bone densitometry.
J Rheumatol. 2001 May;28(5):1063-7.
Sambrook P, Raj A, Hunter D, Naganathan V, Mason R, Robinson B.
Department of Rheumatology, Kolling Institute for Medical Research, University of Sydney, Royal North Shore Hospital, Australia.
OBJECTIVE: Corticosteroid use is associated with rapid bone loss, but the effect of low dose corticosteroids (CS) remains controversial and the extent to which increased fracture risk relates to quantitative effects, as reflected by change in bone mineral density (BMD), or to qualitative effects due to altered microarchitecture is unclear. Moreover the contribution of the underlying disease, for which CS are used, confounds the assessment of CS effects on bone. Our aim was to examine these effects of CS on bone. METHODS: We measured BMD, quantitative ultrasound (US), and clinical and radiological disease indices in 76 patients with rheumatoid arthritis (RA) treated with or without low dose CS. Disease effects were quantitated using the Health Assessment Questionnaire and radiological scores. RESULTS: BMD and US measures were significantly reduced in RA patients compared to age matched controls. Low dose CS use was associated with a further small but nonsignificant reduction in BMD, and US measures did not further discriminate CS effects on bone. Radiological score was an independent predictor of US measures, suggesting that in RA, calcaneal bone may reflect both systemic and local disease effects. CONCLUSION: US did not appear to discriminate effects of low dose CS on bone better than BMD. However, underlying RA disease effects on bone are detectable by US. Quantitative US should be investigated for its utility in assessing disease activity or progress in RA.
The usefulness of the quantitative ultrasound to diagnose glucocorticoids induced
osteoporosis
Minerva Med. 2002 Dec;93(6):485-90.
[Article in Italian]
Ponteggia M, Ponteggia F, Di Cato L, Puxeddu A, Coaccioli S.
Clinica Medica e Scuola di Specializzazione in Reumatologia, Universita degli Studi di Perugia, Perugia, Italy.
BACKGROUND: The aim of this study was to evaluate the utilization of heel ultrasonometry in the diagnosis of glucocorticoid induced osteoporosis. METHODS: The study group included 108 caucasian women, ranging in age from 30 to 81 years. They were all affected by inflammatory disorders (rheumatoid arthritis and other connective tissue diseases) and had been in chronic glucocorticoid therapy for at least 8 months, at an average daily dosage of not less than 7.5 mg of prednisolone. The control group was composed of 112 women. Every subject was evaluated by a heel ultrasonography (Hologic Sahara). RESULTS: The ultrasonometry data average values noted were: QUI (Quantitative Ultrasound Index) 71* (86); SOS (Speed of Sound) 1324 m/sec* (1541); BUA (Broadband Ultrasound Attenuation) 61 dB/MHz (62). The asterisk shows a statistically significant difference in comparison to the value in brackets. QUI/Stiffness and SOS had reached a significant statistic value in all the age groups, with regard to average values of patients not on glucocorticoid therapy. The BUA values did not demonstrate a significant difference, even if they always appeared inferior to the average observed (except in the range 60-70 years age group). CONCLUSIONS: The concept that osteoporosis is a disease characterized exclusively to a reduction in bone density, now leaves room for consideration that corresponds with the concepts of quantitative and quality elements. Chronic glucocorticoid therapy is one of the major causes of osteoporosis. The use of glucocorticoids increases the risk of fractures, independently from the bone uineral BMD in the various ages, which therefore cannot be explained solely by the reduced BMD. Ultrasound may provide information on the bone structure, and so its eventual modification, after chronic glucocorticoid therapy. Our results show that bone ultrasonometry is able to detect a population in chronic glucocorticoid therapy in comparison with those not treated. BUA and SOS are reduced in all the patients. Our experience derives that in the chronic glucocorticoid therapy patients, a major prevalence is noted of SOS which may provide information on the modification of the bone structure.
Q:- Does smoking predispose to osteoporosis?
Effects of cigarette-smoking on bone mass as assessed by dual-energy X-ray absorptiometry and ultrasound.
Osteoporos Int. 2002 Dec;13(12):932-6.
Gerdhem P, Obrant KJ.
Department of Orthopaedics, Malmo University Hospital, Malmo, Sweden.
In order to elucidate the influence of nicotine smoking on bone mass in elderly women, bone mass was cross-sectionally assessed by dual energy X-ray absorptiometry (DXA) in total body, hip and lumbar spine, as well as with ultrasound of calcaneus and phalanges of the hand. Subjects were 1,042, 75-year old women, recruited on a population basis (Osteoporosis Prospective Risk Assessment (OPRA) study). We found bone mineral density (BMD) to be lower in hip (0.71 vs. 0.76 g/cm2, p<0.0001 for femoral neck) and total body (0.96 vs. 1.02 g/cm2, p<0.0001) in current smokers compared to never-smokers. There was no difference in BMD of the lumbar spine between current smokers and never-smokers. Bone mass as assessed by ultrasound of the calcaneus was lower for speed of sound ( p<0.01), broadband ultrasound attenuation ( p<0.0001) and stiffness ( p<0.0001) in current smokers than in never-smokers. No differences were found for ultrasound measurements of the phalanges between smokers and never-smokers. Also, weight and current physical activity as assessed by a questionnaire differed significantly between current smokers and never-smokers.
There was no evident difference between former smokers and never-smokers in any of the skeletal regions assessed by DXA or
ultrasound. After correcting for differences in weight and physical activity, current smokers had lower BMD in all hip sites ( p<0.05) and total body ( p<0.01) compared to never-smokers. Ultrasound and BMD spine did not differ between these two groups after correction for weight and physical
activity. We conclude that nicotine smoking has a negative influence on bone mass independent of differences in weight and physical activity. This difference is detected by DXA but not by ultrasound measurements of the calcaneus or the phalanges. The present data are encouraging since no bone mass differences were found between former and never-smokers.
Q:-Does pregnancy or lactation predispose to osteoporosis?
Influence of pregnancy and breast-feeding on quantitative ultrasonometry of bone in postmenopausal women.
Climacteric. 2002 Sep;5(3):277-85.
Hadji P, Ziller V, Kalder M, Gottschalk M, Hellmeyer L, Hars O, Schmidt S, Schulz KD.
Department of Gynecology, Gynecological Oncology and Endocrinology, Philipps University Marburg, Marburg, Germany.
OBJECTIVE: Reproductive factors such as parity and breast-feeding may be associated with low bone mass and osteoporotic fractures in later years. In this study, os calcis quantitative ultrasonometry was used to elucidate the relationship between parity, lactation and bone mass in postmenopausal women. DESIGN: This was a comparison study using subsequent matched pairs analysis as well as multiple linear regression analysis. The study was carried out at five centers in Germany. The study included 2,080 postmenopausal women (age (mean +/- SD) 58.8 +/- 8.2 years), who were attending for routine check-up and in whom diseases and drug treatments known to affect bone metabolism had been excluded. Methods and outcome measures: Women underwent quantitative ultrasonometry (QUS) measurement at the heel. Values of the ultrasonometry variables -speed of sound, broadband ultrasound attenuation and stiffness index -were calculated and compared for nulliparous and parous women and for women who had and had not breast-fed. Because of some significant intergroup differences, and to determine any effect of the number of live births and the duration of breast-feeding on ultrasonometry results, second analyses were undertaken using equally sized samples, matched for possible confounding variables such as age and body mass index (matched pairs). In these analyses, nulliparous women were compared with parous women, grouped according to number of live births, and women who had never breast-fed were compared with women who had breast-fed, grouped according to duration of breast-feeding. Furthermore, a multiple linear regression analysis was performed to examine the combined effects of reproductive factors on QUS variables. RESULTS: No statistically significant associations were found between ultrasonometry variables and parity or breast-feeding, even after controlling for confounding variables in matched-pairs analysis or in a multiple linear regression analysis.
Q:-What
effect does temperature have on ultrasound measurements?
Effect of temperature on ultrasonic properties of the calcaneus in situ.
Osteoporos Int. 2002 Nov;13(11):888-92.
Nicholson PH, Bouxsein ML.
Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
To assess the dependence of calcaneal quantitative ultrasound (QUS) on foot temperature, a series of acoustic measurements were made in five cadaver feet in situ (all soft tissues retained) over a temperature range of 25 degrees C to 40 degrees C in steps of 5 degrees C. An implanted probe was used to measured temperature directly in the calcaneus itself. Ultrasound velocity decreased linearly with increasing temperature, with a mean thermal coefficient of -2.2 m/s/ degrees C. In contrast, broadband ultrasonic attenuation (BUA) increased with temperature with a mean thermal coefficient of +0.75 dB/MHz/ degrees C. We argue that the temperature trends in velocity are likely to be due to the influence of fat, present in the bone marrow and in the soft tissues, which has a negative thermal coefficient for acoustic velocity. The attenuation trends may arise, in part, from greater scattering losses inside the cancellous bone due to an increased acoustic impedance mismatch between trabeculae and fatty marrow at higher temperatures. These considerations suggest that the greatest temperature effects may be expected in patients with a high proportion of fat within the measured volume and/or low calcaneal bone density. Given the magnitude of the thermal coefficients observed, the clinical impact of temperature-related QUS errors is likely to be modest for diagnostic purposes but of greater significance in follow-up studies.
Q:-Are low ultrasound scores associated with increased mortality?
Quantitative ultrasound and mortality: a prospective study.
Osteoporos Int. 2002 Aug;13(8):606-12.
Bauer DC, Bauer DC, Palermo L, Black D, Cauley JA; Study of Osteoporotic Fractures Research Group: Universities of California (San Francisco), Pittsburgh, Minnesota (Minneapolis), and Kaiser Center for Health Research, Portland.
Division of General Internal Medicine, Department of Epidemiology and Biostatistics, University of California, San Fransico, USA. dbauer@psg.ucsf.edu
Previous studies suggest that low bone mineral density (BMD) is associated with increased mortality, but the relationship between quantitative ultrasound (QUS) and mortality is unknown. We studied 5816 women over age 70 years enrolled in the Study of Osteoporotic Fractures. QUS of the calcaneus, and BMD of the calcaneus and hip, were measured at baseline, and women were contacted every 4 months to determine vital status. All reported deaths were confirmed by review of the death certificate or hospital records, and classified by ICD-9 code. During 5.0 years of follow-up, 677 women died. Women in the lowest quintile of QUS had the highest mortality during follow-up. After adjustment for age, grip strength, weight, height, health status, estrogen use, smoking, physical activity, and history of hypertension, diabetes, cardiovascular disease, cancer and stroke, each 1 SD reduction in broadband ultrasonic attenuation (BUA) was associated with a 16% increase in mortality (RH = 1.16; 95% CI: 1.07, 1.26). Mortality from cardiovascular disease, cancer and other causes were all increased among women with low QUS, but the association with cancer deaths was not statistically significant after multiple adjustments (RH = 1.09; CI: 0.93, 1.27). Low BMD was also associated with an increased risk of total and cause-specific mortality, but we found little evidence that BUA and BMD were independent predictors of mortality. Results were similar among women who did not fracture during follow-up. In this large population-based study of older women, low QUS is associated with both total and cause-specific mortality. This relationship was independent of other factors associated with mortality, such as age and health status, and suggests QUS and BMD may reflect some aspect of aging not captured by these traditional factors.
Q:-Do low ultrasound scores run in families?
Quantitative ultrasound at the calcaneus in premenopausal women and their postmenopausal mothers.
Bone. 2001 Jul;29(1):79-83.
Drozdzowska B, Pluskiewicz W.
Department of Pathomorphology, Silesian School of Medicine, Zabrze, Poland.
The aim of the study was to establish a relationship between mothers' and daughters' bone status. Forty-eight postmenopausal women and their 48 premenopausal daughters were evaluated. The analysis was made for the whole group and for two subgroups: 27 healthy mothers and their 27 daughters; and 21 fractured mothers and their 21 daughters. The subgroups were matched for age and years since menopause (YSM), and height, weight, and body mass index (BMI) did not differ significantly. Bone status was evaluated by ultrasound measurement at the heel using the Achilles system (Lunar, Madison, WI), which measures speed of sound (SOS [m/sec]) and broadband ultrasound attenuation (BUA [dB/MHz]). The Achilles software also calculates a stiffness index (SI [%]). Ultrasound values for BUA, SOS, stiffness index, and Z score were significantly lower both in mothers with previous fractures and in their daughters, compared with respective values in mothers without fractures and their daughters. Future values in daughters were predicted using a stepwise, multiple regression analysis separately in the whole group and in the two subgroups. Future values were predicted in two models taking into consideration mothers' present SOS, BUA, and age or present SOS, BUA, and YSM. In both models, daughters' present SOS, BUA, age, height, and weight were taken into consideration. Predictive values were found to be high for daughters of women having had fractures (r = 0.72-0.87, p = 0.015-0.00007, SEE = 6.0-15.8) and lower for all daughters studied (r = 0.38-0.62, p = 0.03-0.0001, SEE = 8.8-21.5). In daughters of mothers without past fractures, prediction was not possible. Heritability of ultrasound values in daughters of women with past fractures ranged between 52% and 76%, whereas in the whole group the range was 14%-40%. In conclusion, the data indicate that, as a group, the daughters of women with osteoporotic fracture are likely to be at an increased risk for fractures because they have relatively low ultrasound values. Their future ultrasound values can be predicted on the basis of a single ultrasound evaluation with the condition that there is a history of maternal past fracture.
Q:- Is ultrasound helpful in the management of patients with anorexia nervosa?
Ultrasound and X-ray-based bone densitometry in patients with anorexia nervosa.
Calcif Tissue Int. 2000 May;66(5):338-41.
Resch H, Newrkla S, Grampp S, Resch A, Zapf S, Piringer S, Hockl A, Weiss P.
Department of Internal Medicine, Department of Psychosomatic Medicine, KH Barmherzige Schwestern (St. Vincent Hospital), Stumpergasse 13, 1060 Vienna, Austria.
In 20 patients (mean age 23+/-5 years) with anorexia nervosa (AN), bone mass was evaluated by broadband ultrasound attenuation (BUA) of the calcaneus, peripheral quantitative computed tomography (pQCT) of the distal radius, and dual X-ray absorptiometry (DXA) of the lumbar spine and the hip. Compared with 20 age- and sex- matched healthy controls, patients with AN showed marked osteopenia at all measuring sites. Values of BUA (33.0+/-9 dB/MHz vs. 51.0+/-5.7 dB/MHz; P<0.0001) and of BMD of all regions of the hip (e.g., femoral neck: 0.71+/-0.13 g/cm(2) versus 0.89+/-0.07 g/cm(2); P<0.001), lumbar spine (0.82+/-0.15 g/cm(2) versus 1.24+/-0.06 g/cm(2); P<0.003) and total BMD of the peripheral radius (303.2+/-75 g/cm(3) versus 369.4+/-53.2 g/cm(3), P<0.001) were significantly reduced. Calculating a Z-score we found the most prominent differences between AN and controls by BUA of the calcaneus (-3.2+/-1.6), followed by DXA at the lumbar spine (-2.9+/-2.2) and the hip (femoral neck -2.1+/-1.7) and by pQCT at the distal radius (total BMD -1.2+/-2.0). There were highly significant correlations between BUA of the calcaneus and BMD of the femoral neck (r = 0.78, P<0.0001) and lumbar spine (r = 0.75, P<0.0001) as well as between BMD values of the femoral neck and lumbar spine (r = 0.95; P<0.0001). In addition, there were significant correlations (P<0.001) between body mass index (BMI) and the three different measuring sites and between the duration of the disease and BUA (r = 0.5, P<0.05). Our data suggest that BUA of the calcaneus is a valuable tool in the management of osteoporosis. Being a fast, radiation-free investigation method of good acceptance, it may be well suited for an assessment of the skeletal status in patients with AN.