Preguntas sobre osteoporosis para el Grupo de MBE de la SER
Preguntas sobre osteoporosis para el Grupo de MBE de la SER ... 1
1. Metodología ... 2
1.1. Búsqueda bibliográfica ... 2
1.2. Selección de los estudios ... 2
1.3. Clasificación de calidad de los estudios... 2
1.4. Elaboración de una tabla de evidencia ... 2
1.5. Grado de recomendación y nivel de evidencia ... 3
PREGUNTA 1. ¿El cribado poblacional mediante densitometría ósea de columna y/o cadera está indicado para el diagnóstico de osteoporosis?... 3
1.6. Estrategia de búsqueda... 3
PREGUNTA 2. ¿Cuál es la sensibilidad y especificidad (y valores predictivos positivos y negativos) para el diagnóstico de la osteoporosis con la densitometría por ultrasonidos de calcáneo? ... 6
1.7. ¿Cuál es la capacidad predictora de fractura de la densitometría por ultrasonidos de calcáneo?... 6
1.8. ¿Cuál es la concordancia diagnóstica entre la DEXA de cadera o columna y la densitometría por ultrasonidos de calcáneo? ... 13
PREGUNTA 3. ¿Cuál es la sensibilidad y especificidad (y valores predictivos positivos y negativos) para el seguimiento de la osteoporosis con la densitometría por ultrasonidos de calcáneo? ... 43
PREGUNTA 4. ¿Cuál es la sensibilidad y especificidad (valores predictivos positivos y negativos) para el diagnóstico de la osteoporosis con la densitometría de falange (ACCUDEXA)? ... 48
PREGUNTA 5. Valor predicitivo de los marcadores bioquímicos de remodelado (fosfatasa alcalina ósea, osteocalcina y telopéptidos amino y carboxiterminal del colágeno I (NTx y CTx)) para predecir el riesgo de fractura. ... 48
PREGUNTA 6. Valor de los marcadores bioquímicos de remodelado (fosfatasa alcalina ósea, osteocalcina y telopéptidos amino y carboxiterminal del colágeno I (NTx y CTx)) para el seguimiento del tratamiento... 48
PREGUNTA 7. Tratamiento del dolor de la fractura vertebral osteoporótica... 50
1.9. Estrategia de búsqueda... 50
9.1.1. ESTRATEGIA I (PubMed) ... 50
9.1.2. ESTRATEGIA II: MESH (PubMed) ... 50
PREGUNTA 8. ¿Cuál es la duración recomendada del tratamiento antiosteoporótico con antirreabsortivos: Calcitonina, raloxifeno, etidronato, THS, alendronato, risedronato?... 50
PREGUNTA 9. Rol de la terapia hormonal sustitutiva en el tratamiento de la osteoporosis postmenopáusica ... 51
9.1.3. Pregunta modificada ... 51
9.1.4. Consideraciones y definiciones previas... 51
9.1.5. Criterios de selección de estudios ... 52
9.1.6. Estrategia de búsqueda... 52
1.10. Conclusiones y grado de evidencia de las recomendaciones ... 58
1.11. Bibliografía ... 58
1. Metodología
1.1. Búsqueda bibliográfica
Los evaluadores han sido entrenados en la realización de búsquedas sistemáticas. Para poder contestar a las preguntas del panel, primero se realizó una conversión de las mismas según el modelo de pregunta PICO (Patient, Intervention, Comparison, Outcomes), en base a la cual elaboraban la estrategia de búsqueda. Las búsquedas se ejecutaban en PubMed/Medline, Cochrane Libray y Embase al menos. Además se realizó búsqueda secundaria de artículos y revisión de abstracts a congresos. Toda la bibliografía era descargada a una base de datos (ProCite).
1.2. Selección de los estudios
Si sobre la pregunta existe un meta-análisis se utiliza este como respuesta, no teniéndose en consideración los ensayos clínicos incluidos en el y revisándose únicamente de manera individual los ECA de calidad excelente (Ver clasificación) no incluidos.
1.3. Clasificación de calidad de los estudios
Se forman las siguientes categorías, siguiendo las guías de evaluación de la literatura médica de ensayos clínicos (Guyatt; Sackett, and Cook 1993) y meta-análisis (Oxman; Cook, and Guyatt 1994):
a) Excelente. Respuesta afirmativa a las preguntas de eliminación y las preguntas de detalle.
b) Moderada. Respuesta afirmativa a las preguntas de eliminación, pero respuesta dudosa o negativa a una o más de las de detalle.
c) Mala. Respuesta negativa en al menos una pregunta de eliminación.
1.4. Elaboración de una tabla de evidencia
Con los estudios seleccionados se intenta formar una tabla de evidencia, en la que se muestren los estudios más relevantes con sus características y conclusiones.
1.5. Grado de recomendación y nivel de evidencia
Para clasificar las recomendaciones y el nivel de evidencia de las conclusiones a la pregunta determinada, se utilizan los niveles de evidencia del NHS, en su revisión de marzo de 2002.
Estos niveles fueron crearon tras una serie de iteraciones entre miembros del NHS R&D Centre for Evidence-Based Medicine. Los grados de recomendación se dan con un nivel de evidencia.
Sin embargo los niveles hablan de la validez de un estudio, no de su aplicabilidad, por lo que necesitan tenerse en cuenta otros factores, como costes, facilidad de implementación, importancia de la enfermedad, etc, antes de determinar el grado.
PREGUNTA 1. ¿El cribado poblacional mediante densitometría ósea de columna y/o cadera está indicado para el diagnóstico de osteoporosis?
Esta pregunta fue asignada a Loreto Carmona.
La transformación de la pregunta según el modelo PICO es muy complicada. El hecho de que una prueba de screening poblacional esté indicada o no, depende del efecto que realizar esa prueba tenga sobre la mortalidad u otro “outcome” duro, en este caso fractura, pero la indicación puede tener muchas otras connotaciones. Se decidió orientar de la siguiente manera:
“¿En población sana, la utilización de la DEXA de cadera o columna para el screening de osteoporosis disminuye la incidencia de fracturas en la población?”.
En el caso de que una búsqueda específica para estudios de intervención, que sería el tipo de estudio adecuado para esta pregunta, no arrojara ningún resultado, se planteó realizar una segunda búsqueda de artículos que respondieran a preguntas del tipo:
a. ¿Cuántas fracturas se evitan suponiendo que todas las personas con OP densitométrica fueran tratadas?
b. ¿Es coste efectivo?
1.6. Estrategia de búsqueda
Se realizó en las bases de datos bibliográficas establecidas en métodos. Las siguientes tablas muestran las fases de la estrategia y los resultados en número de artículos.
Tabla 1. Estrategia y resultados en PubMed.
#1 "mass screening"[Mesh] 58573
#2 "Densitometry, X-Ray"[MAJR] 1480
#3 hip OR (spine OR lumbar OR spinal) 262818
#4 #1 AND #2 AND #3 11
Tabla 2. Estrategia y resultados en Embase.
#1 exp Mass Screening/ 6947
#2 exp Radiodensitometry/ 157
#3 (hip or (spine or lumbar or spinal)).mp. [mp=title, abstract, subject headings, drug trade name, original title,
device manufacturer, drug manufacturer name] 37121
#4 1 and 2 and 3 0
#5 densitometry.mp. [mp=title, abstract, subject headings, drug trade name, original title, device
manufacturer, drug manufacturer name] 3045
#6 1 and 3 and 5 4
Estrategia en DARE, NHS EED, HTA: Osteoporosis[All fields] AND screening [All Fields] 33 Ningún estudio recuperado era un ensayo clínico, siendo la mayoría revisiones sobre el tema y otros que no tenían verdadera relación con la pregunta. Los estudios revisiones que se muestran en la tabla 1 habían sido evaluadas además por el DARE (Dissemination Abstracts of Reviews of Effectiveness). Dos no pudieron ser localizados. La mayoría se trata de informes muy completos de agencias gubernamentales de evaluación, aunque no son estrictamente revisiones sistemáticas. También incluye modelizaciones matemáticas para estudios de coste-efectividad.
Sólo tres de los 13 estudios, ninguno de ellos informe de agencia, consideraban indicado la realización de un screening poblacional.
Las conclusiones más interesantes que se pueden extraer de la síntesis de la evidencia son:
1. No hay ensayos clínicos que avalen la efectividad del screening poblacional de osteoporosis para la prevención de fracturas.
2. No es más costo-efectivo realizar un screening poblacional seguido de THS, que sería el tratamiento más barato, que no hacer nada.
3. El screening de osteoporosis tiene un impacto favorable dependiendo de si afecta o no al cumplimiento del tratamiento y de si se utilizan terapias caras (más que la THS).
Dado que existen informes previos completos que sopesan todos los aspectos del cribado con DEXA, se desestima, por la complejidad, hacer una nueva revisión del tema.
En cuanto al grado de evidencia de cualquier recomendación al respecto de esta pregunta, esta sería de GRADO D, NIVEL 5
Tabla 3. Estudios más relevantes encontrados.
Autor Título Publicación Comentarios
1 Univ. of York. NHS
CRD Screening for osteoporosis to prevent fractures. Effective Health Care, 1992; 1 (1) 12. No hay ensayos clínicos que examinen la efectividad del screening poblacional de osteoporosis para la prevención de fracturas. La densitometría ósea tiene un valor predictivo bajo. Se estima que un programa para la prevención evita no más de 5% de fracturas en mujeres ancianas. No es recomendable.
2 Hailey D The effectiveness of bone density measurement and associates treatments for prevention of fractures: an international collaborative review.
Int J Technol Assess Health Care,
1998; 14(2) 237-54. No hay ensayos clínicos que examinen la efectividad del screening poblacional de osteoporosis para la prevención de fracturas. Se estima que un programa para la prevención evita entre el 1-7% de fracturas.
3 Samprieto-Colom L Bone densitometry assessment. Barcelona: Catalan Agency for Health Technology Assessment (CAHTA), 1993; 47.
No existe evidencia científica que apoye la necesidad de screening poblacional de OP.
4 Green CJ Bone mineral density testing: does the evidence
support its selective use in well women?. Vancouver: B.C. Office of Health Technology Assessment, Centre for Health Services and Policy Research, University of British Columbia. HSURC, 1998; 188.
No existe evidencia científica que apoye el screening poblacional de OP.
5 Tosteson A N A Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy.
Annals of Internal Medicine
1990;113(8):594-603. Comparan, por modelos matemáticos, el resultado de tratar tras screening a mujeres blancas con osteoporosis con THS frente a dar THS sin realizar screening previo durante 15 años. Resultados poco claros que no tienen en cuenta nuevos hallazgos sobre THS.
6 Garton M J Perimenopausal bone density screening: will it help
prevent osteoporosis? Maturitas 1997;26(1):35-43. El screening de osteoporosis tiene un impacto favorable dependiendo de si afecta o no al cumplimiento del tratamiento y de si se utilizan terapias caras (más que la THS).
7 Norlund A Prevention of osteoporosis: a cost-effectiveness
analysis regarding fractures. Scandinavian Journal of Rheumatology
1996;25 (Supplement 103):42-45. No es más costo-efectivo realizar un screening poblacional seguido de THS que no hacer nada.
8 Espallargues M Guidelines for the indication of bone densitometry in
the assessment of fracture risk. Catalan Agency for Health Technology Assessment (CAHTA) 1999 (BR99005):
19.
La osteoporosis es solo un factor más entre los relacionados con la fractura.
9 Black D M Screening and treatment in the elderly to reduce
osteoporotic fracture risk British Journal of Obstetrics and
Gynaecology 1996;103(13):2-8. Merece la pena hacer screening y tratar de acuerdo con el riesgo densitométrico de fractura.
10 Cummings S R Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis - status report
Osteoporosis Int 1998;8(Suppl 4):S1-
S85. Merece la pena hacer screening y tratar de acuerdo con el riesgo densitométrico de fractura.
11 Ankjaer-Jensen A Prevention of osteoporosis: cost-effectiveness of
different pharmaceutical treatments. Osteoporosis International
1996;6(4):265-275. Modelo de simulación de una cohorte de 1.000 mujeres de 50 años expuesta a distintos tratamientos para osteoporosis. El screening es costo-efectivo incluso si el
cumplimiento sólo llega al 50%.
12 German DIMDI The role of bone density measurement in prevention and therapy of osteoporosis – systematic review (project)
En preparación
13 Effectiveness of bone density measurement and associated terms for prevention of fractures – Statement of finding
(INAHTA project). International Network of Agencies for Health and Technology Assessment, 1996.
No localizado.
PREGUNTA 2. ¿Cuál es la sensibilidad y especificidad (y valores predictivos positivos y negativos) para el diagnóstico de la osteoporosis con la densitometría por ultrasonidos de calcáneo?
Esta pregunta fue asignada a Ramón Mazzuchelli. Le han ayudado en parte José Sanfélix y Ángel Elena.
Para la transformación de la pregunta según el modelo PICO, la búsqueda y la interpretación de los estudios, hay que tener en cuenta varios conceptos. Sensibilidad y especificidad son en realidad aspectos de la utilidad diagnóstica, quizás menos importantes que el likelihood ratio, por el cual se puede saber cuánto varía la probabilidad de tener una enfermedad antes y después de realizarse una prueba. El outcome en el modelo PICO sería aquí el gold standard, esto es el diagnóstico de osteoporosis por DEXA de cadera y/o columna. El valor predictivo depende de la población en que se realice la prueba (posmenopáusicas, sanas...). La pregunta quedaría orientada de esta manera:
“¿Cuál es la utilidad de la DMO por US de calcáneo para el diagnóstico de osteoporosis?”
Para la revisión se ha subdividido en dos preguntas, que se desarrollarán por separado.
1.7. ¿Cuál es la capacidad predictora de fractura de la densitometría por ultrasonidos de calcáneo?
Tabla 4. Estrategia de búsqueda en PubMed:
#1 diagnostic OR sensitivity and specificity OR predictive value of tests OR false positive reactions OR false negative reactions OR mass screening OR comparative study
3931112
#2 (((((("ultrasonography"[MeSH Subheading] OR "ultrasonography"[MeSH Terms]) OR ultrasonography[Text Word]) OR ((("ultrasonography"[MeSH Subheading] OR
"ultrasonography"[MeSH Terms]) OR "ultrasonics"[MeSH Terms]) OR ultrasound[Text Word])) OR ultrasonometry[All Fields]) OR BUA[All Fields]) AND ((("calcaneus"[MeSH Terms] OR calcaneus[Text Word]) OR calcaneal[All Fields]) OR ("heel"[MeSH Terms] OR heel[Text Word])))
742
#3 osteoporosis OR DXA OR DEXA OR fractures 114592
#4 #1 AND #2 AND #3 342
Tabla 5. Estrategia de búsqueda en Embase:
#1 diagnostic.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name]
43977
#2 (sensitivity and specificity).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer, drug manufacturer name]
15449
#3 predictive value of tests.mp. 33
#4 false positive reactions.mp. 144
#5 false negative reactions.mp. 33
#6 Mass Screening/ 1337
#7 Comparative Study/ 17709
#8 1 or 2 or 3 or 4 or 5 or 6 or 7 73288
#9 ultrasonography.mp. or Echography/ 16650
#10 ultrasonics.mp. or Ultrasound/ 5600
#11 ultrasonometry.mp. 23
#12 BUA.mp. 92
#13 9 or 10 or 11 or 12 21773
#14 CALCANEUS/ or calcaneus.mp. 325
#15 calcaneal.mp. 135
#16 heel.mp. or HEEL/ 493
#17 14 or 15 or 16 810
#18 13 and 17 128
#19 POSTMENOPAUSE OSTEOPOROSIS/ or osteoporosis.mp. or OSTEOPOROSIS/ 14350
#20 DXA.mp. or Dual Energy X Ray Absorptiometry/ 2318
#23 DEXA.mp. or Dual Energy X Ray Absorptiometry/ 2392
#24 fractures.mp. or Fracture/ 6704
#25 19 or 20 or 21 or 22 19525
#26 8 and 18 and 23 6
En Cohrane Library y abstracts ACR: “Quantitative Ultrasound”
Criterios de selección:
- Tipo de estudio: cohortes. ( se han excluido los estudios de casos y controles) - Población de estudio: sana o con fracturas. Adultos. (Se han excluido los
estudios realizados en grupos de enfermos asi como en niños y jóvenes sanos) - Outcome: fracturas (cualquiera)
Los estudios seleccionados se muestran en la Tabla 6, con su abstract. Los principales datos de los estudios analizados quedan expresados en la tabla de evidencia (tabla 7)
Tabla 6. Estudios seleccionados con abstracts para la pregunta. Por orden de calidad. Son todos estudios de cohortes encontrados en la búsqueda original en PubMed.
Referencia completa abstract Calidad excelente
McGrother CW,
Donaldson MM, Clayton D, Abrams KR, Clarke M.
Evaluation of a hip fracture risk score for assessing elderly women: the Melton Osteoporotic Fracture (MOF) study. Osteoporos Int. 2002;13:89-96.
Risk assessment for osteoporotic fracture within a primary care context, in old age, has received little attention. We aimed to develop such a risk score and assess its feasibility and validity. This was a 100% population-based, prospective cohort study, with a minimum 5 1/2 year follow-up among women aged 70 years and over, set in a large single general practice in Melton Mowbray, Leicestershire, UK.
The main outcome measures were hip fracture, death and migration. Baseline measures included calcaneal broadband ultrasound attenuation (BUA), reported falls, balance, previous fracture history, medical problems, visual acuity, foot problems, body size, lifestyle factors and cognitive impairment. Seventy percent of the sample (1289) participated, including those in residential accommodation.
Independent predictors of hip fracture over 3 years were low weight, kyphosis, poor circulation in the foot, epilepsy, short-term use of steroids and poor trunk maneuver. Using the highest tertile, a risk score based on these variables identified 84% (95% CI: 70% to 98%) of the hip fractures with a specificity of 68% (95% CI: 65% to 71%). BUA did not independently predict hip fracture in women of this age group. This study shows that a combination of readily obtained risk factors can identify elderly women who will sustain a hip fracture in the next 3 years more accurately than bone measurements alone in younger women. It also suggests that a risk score approach to universal assessment in the elderly is a feasible proposition in the primary care setting.
Pluijm SM, Graafmans WC, Bouter LM, Lips P.
Ultrasound measurements for the prediction of osteoporotic fractures in elderly people.
Osteoporos Int.
1999;9:550-6.
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.
Porter RW, Miller CG, Grainger D, Palmer SB.
Prediction of hip fracture in elderly women: a
prospective study. BMJ.
1990;301:638-41.
OBJECTIVE--To assess the relative importance of osteoporosis of the os calcis, cognisance, and mobility in the risk of subsequent fracture of the hip in elderly women. DESIGN--Prospective study of elderly women in residential care over two years. SETTING--21 Private or 38 local authority residential homes for the elderly and 4 geriatric hospitals in Doncaster and Hull. SUBJECTS--1414 Ambulant women aged over 69, in private or local authority residential care or geriatric care. Those who had had bilateral hip surgery were
excluded. MAIN OUTCOME MEASURES-- Broad band ultrasonic attenuation (BUA) index, Clifton assessment procedures for the elderly test (for cognisance), and mobility on a six point scale, and fracture of the hip in the subsequent two year period. RESULTS--73 Women fractured their hip during the two years. Their mean age was not significantly different from that of the women who did not have a fracture (85.3 (SD 5.6) v 83.9 (6.3); p = 0.07), but their mean BUA index (40.3 (19.3) v 50.9 (22.2) db/MH2), and score for cognisance (median 19 (interquartile range 10.5-27.0) v 24 (17-30)) were significantly lower (both p less than 0.001). These variables had independent
associations with fracture of the hip. Women with fractures had a significantly lower score for the psychomotor component of the cognisance test (4.5 (1-8) v 7 (2-10); p less than 0.0025 and were significantly more mobile (1(1-3) v 3 (1-6); p less than 0.02).
Subdividing women according to high, medium, and low scores for BUA index and cognisance testing disclosed a high risk group (118 women) with low BUA index and cognisance score, whose incidence of fracture was 12.8%; in the group at lowest risk (136 women) with high BUA index and cognisance score, the incidence of fracture was only 1.5% (relative risk 8.4 (95% confidence interval -2.0 to 35.5].
Further analysis showed that those most at risk were, additionally, most mobile but that less mobile women with good cognisance had a
low incidence of fractures, regardless of the BUA index, (1.2%, high index, v 0.9%, low index). CONCLUSIONS--Elderly women most at risk of sustaining hip fractures were those with low BUA index, low cognisance test score, and high mobility. Improving bone strength and cognisance in elderly women may reduce their incidence of hip fracture.
Calidad moderada Huang C, Ross PD, Yates AJ, Walker RE, Imose K, Emi K et al. Prediction of fracture risk by
radiographic absorptiometry and quantitative ultrasound: a prospective study. Calcif Tissue Int. 1998;63:380-4.
Recent developments in computer-assisted radiographic absorptiometry (RA) and quantitative ultrasound techniques (QUS) provide readily accessible and relatively inexpensive methods for assessing bone mineral status. However, few population-based studies have investigated the ability of RA and ultrasound to predict fracture risk prospectively. We explored the ability of RA and QUS to predict fracture risk among 560 postmenopausal women from the Hawaii Osteoporosis Study; average follow-up was 2.7 years. An incident vertebral fracture was defined as a decrease of more than 15% in vertebral heights on subsequent films. Self-reported nonspine fractures were verified by medical records. The prospective associations of vertebral fractures, nonspine fractures, and any (spine or nonspine) fractures with bone measurements were examined using logistic regression, adjusting for age. Both phalangeal bone mineral density (BMD) and metacarpal BMD, measured using RA, predicted future fracture risk. The age-adjusted odds ratios (corresponding to 1 SD decrease in BMD) for vertebral fractures, nonspine fractures, and any fractures were 3.41, 1.50, and 1.91, respectively, for phalangeal BMD, and 1.71, 1.49, 1.55, respectively for metacarpal BMD. Calcaneal broadband ultrasound attenuation (BUA) also showed significant association with fracture risk, with age-adjusted odds ratios of 1.50, 1.89, and 1.72 for vertebral fractures, nonspine fractures, and any fractures, respectively. We conclude that hand RA and calcaneal BUA are significant predictors of nonspine fracture, vertebral fracture, and overall fracture risk. The attractive features of these techniques, such as portability, relatively low cost, and ease of use, make them promising alternatives to conventional bone measurement techniques used for the assessment of fracture risk.
Garnero P, Dargent- Molina P, Hans D, Schott AM, Breart G, Meunier PJ et al. Do markers of bone resorption add to bone mineral density and ultrasonographic heel measurement for the prediction of hip fracture in elderly women? The EPIDOS prospective study. Osteoporos Int.
1998;8:563-9.
We have previously shown that hip bone mineral density (BMD), heel broadband ultrasound attenuation (BUA) and bone resorption markers are independent predictors of hip fracture in elderly women. We investigated whether a combination of these three parameters could improve the predictive value of a single test in a nested case-control analysis (75 hip fractures and 228 age-matched controls) of the EPIDOS prospective study comprising 7598 healthy women 75 years of age and older followed prospectively for a mean 22 months.
At baseline, prior fracture, femoral neck BMD by dual-energy X-ray absorptiometry (DXA), heel BUA and urinary type I collagen C- telopeptide breakdown products (CTX) were assessed. The area under the receiver operating characteristic curve was significant for the three diagnostic tests, heel BUA being the best single predictor. The added value of urinary CTX to either BMD or BUA depends on the cutoff point chosen to define patients at risk and on the therapeutic strategy that is considered. Defining patients at risk as those with low BMD (or low BUA) or high CTX resulted in a significant increase in the sensitivity compared with BMD or BUA alone--a strategy that could be applied when a broad treatment is considered. However, this increased sensitivity was also obtained simply by increasing the BMD and BUA cutoffs, suggesting that a combination of CTX with BMD/BUA is not useful for that type of treatment strategy. Conversely, defining patients at risk as those with both low BMD and high CTX increases the specificity (88% vs 78%) with a similar number of hip fracture patients being identified (30% vs 32%)--a combination that could be useful when the strategy is to target treatment to a subset of high-risk patients. This strategy appears to be more cost-effective than bone mass measurement alone as indicated by the 37% fewer patients who need to be treated to avoid one fracture per year. If DXA or ultrasound is not available, the combination of a bone resorption marker with a history of any type of fracture after the age of 50 years gave a predictive value similar to that obtained with femoral neck BMD or heel BUA alone, for both types of treatment strategy. We conclude that the combination of urinary CTX with hip BMD could be useful for the identification of elderly women at high risk for hip fracture, resulting in higher specificity for a given sensitivity threshold than BMD measurement alone. If DXA is not available, the combination of history of fracture and urinary CTX performs as well as hip BMD to assess hip fracture risk in elderly women.
Bauer DC, Gluer CC, Cauley JA, Vogt TM, Ensrud KE, Genant HK et al. Broadband ultrasound attenuation predicts fractures strongly and independently of
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
densitometry in older women. A prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med. 1997;157:629- 34.
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.
Hans D, Dargent-Molina P, Schott AM, Sebert JL, Cormier C, Kotzki PO et al. Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study. Lancet.
1996;348:511-4.
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.
Siris ES, Miller PD, Barrett-Connor E,
Faulkner KG, Wehren LE, Abbott TA et al.
Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA.
2001;286:2815-22.
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.
Calidad mala
Stewart A, Torgerson DJ, Reid DM. Prediction of fractures in
perimenopausal women: a comparison of dual energy
OBJECTIVE: To consider whether bone mineral density (BMD) measurements can predict traumatic fractures occurring in
perimenopausal women. METHODS: One thousand perimenopausal women called up for screening underwent both dual energy x ray absorptiometry (DXA) of the spine and hip, and broadband ultrasound attenuation (BUA) of the heel. Two years later, they were sent a questionnaire to discover those who had since had a fracture, and compare them with those who had not. RESULTS: About 2% of the women had sustained a fracture in the two years since attendance for screening. Fractures in this age group can be predicted weakly,
x ray absorptiometry and broadband ultrasound attenuation. Ann Rheum Dis. 1996;55:140-2.
but significantly, by bone mass measurements using DXA and BUA (odds ratios from 1.4 to 2.1). The lumbar spine appeared to be one of the best predictive sites (odds ratio for 1 SD reduction in BMD 2.1 (95% confidence interval 1.2 to 3.8)), but no significant differences were found between the areas under the curve in receiver operator characteristic (ROC) analysis. CONCLUSION: In this preliminary study it appeared that bone mass measurements are predictive of perimenopausal traumatic fractures in addition to postmenopausal fractures related to osteoporosis. DXA of the lumbar spine did not perform significantly better than BUA. The number of fractures occurring was low, however, and further long term follow up is required to confirm the finding.
Tabla 7. Síntesis de la evidencia.
Ultrasonido de calcáneo
Fx cadera Todas fx no vertebrales Fx vertebrales
Cohorte
Grupo de edad o media de edad Seguimi
ento N Pto de
corte RR por 1 SD
(CI) Prob si “bajo
riesgo” Prob si “alto
riesgo” RR por 1 SD
(CI) Prob si “bajo
riesgo” Prob si “alto
riesgo” RR por 1 SD
(CI) Prob si “bajo
riesgo” Prob si “alto riesgo 6,189 Cuartil
inferior 2.0
(1.5, 2.7) .006 .018
RR= 3 1.3
(1.2- 1.5) SOF(1) ≥ 65 1.8 a 2.9
años
6,189 QUS 50 .006 .023
RR= 3,83 EPIDOS (2;3) > 75 2 años 5,662 Media
(100.9 dB/MHz)
2.0 (1.6, 2.4) .0122 .0285 RR= 2,36 Aberdeen-
(Porter)(7) > 70 2 años 1,414 Tercil
inferior .0352 .0838
RR= 2,38 Aberdeen
(Stewart)(7;9) 45–49 2 años 790 No especificad o
1.43
(1.2, 2.4) .017 .024 RR= 1,41
HOS (4) 73,7 2.7 años 560 1.89
(1.3, 2.9) 1,50 (1.05-
2.16) MOF (5) > 70 años
77,9 (70- 103)
5,5 años 1,289 1,1(0,77-
1,58) Pluijm SMF(6) > 70 años
82,8 2,8 años 710 2,3 (1,4-3,7) 1,6 (1,2-2,1)
Se realizó un metaanálisis con todos los estudios en la tabla 7. El resultado es el siguiente.
1: de fracturas de cadera (ver gráfico) Meta-analysis (exponential form)
| Pooled 95% CI Asymptotic No. of Method | Est Lower Upper z_value p_value studies ---+--- Fixed | 1.838 1.591 2.124 8.258 0.000 4 Random | 1.782 1.341 2.367 3.987 0.000
Test for heterogeneity: Q= 9.640 on 3 degrees of freedom (p= 0.022) Moment-based estimate of between studies variance = 0.056
.767909 RR 3.73908
Combined plujirn smf mof epidos sof
2. de todas las fracturas menos vertebrales:
Meta-analysis (exponential form)
| Pooled 95% CI Asymptotic No. of Method | Est Lower Upper z_value p_value studies ---+--- Fixed | 1.372 1.246 1.510 6.425 0.000 4 Random | 1.444 1.237 1.685 4.648 0.000
Test for heterogeneity: Q= 4.560 on 3 degrees of freedom (p= 0.207) Moment-based estimate of between studies variance = 0.009
1 RR 2.82286 Combined
pluijrn hos aberdeen sof
Las conclusiones que pueden extraerse de la revisión son:
1. La densitometría por ultrasonidos de calcáneo muestra una buena capacidad para predecir fractura de cadera (RR ponderado de 1,8) y fracturas no vertebrales (RR ponderado 1,3), que es similar a la capacidad que muestra la DEXA de columna lumbar (odds ratio de 1,8) e inferior a la DEXA de cadera (odds ratio de 2,6).
2. Esta capacidad predictora de fractura de los ultrasonidos de calcáneo es aplicable a mujeres mayores de 65 años. Tan solo 1 estudio de cohortes valora en mujeres perimenopaúsicas. Solo en 1 de los trabajos analizados había participación masculina (aprox 130 varones).
3. En el tiempo, la capacidad predictora de fractura, existe evidencia de esta entre 2 y 3 años. En el único estudio a más largo plazo (5,5 años) no encontraron asociación.
En cuanto al grado de evidencia, el nivel de evidencia para estas afirmaciones es GRADO B, NIVEL 2a (estudios de cohortes).
1.8. ¿Cuál es la concordancia diagnóstica entre la DEXA de cadera o columna y la densitometría por ultrasonidos de calcáneo?
Se utilizó la misma estrategia de búsqueda que en la primera parte de la pregunta, variando en este punto los criterios de selección:
a. Estudios de corte trasversal o estudios de casos y controles que incluyeran densitometría de ultrasonidos de calcáneo y medida con DXA en cadera o columna y que aportaran alguno de los siguientes datos:
i. Índice de correlación entre pruebas
ii. Sensibilidad y especificidad para distintos puntos de corte para el diagnóstico de osteoporosis según criterios OMS.
iii. Área bajo la curva ROC para la clasificación de pacientes con osteoporosis según criterios OMS.
b. Estudios en humanos y población sana.
Los estudios seleccionados se muestran en la tabla 8.
Tabla 8. Estudios seleccionados con sus resúmenes. Por orden de calidad.
Referencia completa abstract Excelente
Frost ML, Blake GM, Fogelman I. Does quantitative ultrasound imaging enhance precision and discrimination?
Osteoporos Int.
2000;11:425*,†
The aim of this study was to compare quantitative ultrasound (QUS) measurements obtained using a new calcaneal QUS imaging device with a conventional non-imaging device using fixed transducers. The study group consisted of 340 healthy women with no risk factors associated with osteoporosis (176 premenopausal and 164 postmenopausal) and 83 women with one or more vertebral fractures. All women had QUS measurements performed on the Osteometer DTU-one (imaging) and Walker-Sonix UBA575+ (non-imaging) devices and bone mineral density (BMD) measurements performed at the spine and hip.
A subgroup of 81 women had additional dual-energy X-ray absorptiometry (DXA) scans at the calcaneus. Short-term standardized precision (SP = SD/young adult SD) based on duplicate measurements was significantly better on the DTU for broadband ultrasound attenuation (BUA) (SP: DTU 0.15 vs UBA 0.21,p = 0.01) and speed of sound (SOS) (SP: DTU 0.14 vs UBA 0.18, p = 0.01). However, long-term SP of the DTU was comparable to or significantly poorer than the SP of the UBA device. The BUA and SOS measurements obtained on the DTU and UBA were significantly correlated (r = 0.76 and 0.89 for BUA and SOS measurements respectively). The correlations between QUS and BMD measurements were all significant, ranging from 0.53 to 0.72. No significant improvements in the correlation with axial or peripheral BMD were observed using the imaging device. All the QUS measurement parameters showed a significant negative relationship between age and years since menopause in the postmenopausal group. Annual losses were lower for the DTU for BUA (DTU 0.22 dB/MHz per year vs UBA 0.44 dB/MHz per year) but comparable for SOS (DTU 0.29 m/s per-year vs UBA 0.22 m/s per year). However, when these figures were standardized to take into account the clinical range, the annual losses were similar on the DTU and UBA. Age- adjusted odds ratios for each SD decline were similar on the DTU for BUA (DTU 3.2 vs UBA 3.3) and SOS (DTU 3.4 vs UBA 5.1). The corresponding odds ratios for BMD at the lumbar spine, femoral neck and total hip were 2.7, 2.9 and 3.3 respectively.
Age-adjusted receiver-operating characteristics analysis yielded values for the area under the curve (AUC) ranging from 0.74 to 0.83. The DTU BUA AUC of 0.83 was significantly greater than the AUC obtained for UBA BUA and BMD measurements at the lumbar spine and femoral neck. Ultrasound imaging at the calcaneus was found to improve the standardized precision of BUA and SOS measurements in the short term but not in the long term. Neither the correlation with BMD nor the discriminatory ability of QUS was improved by utilizing QUS images at the calcaneus. The inconsistencies of the imaging system used for this study demonstrate that further development is required before it will be possible to show improvements in long-term precision.
Greenspan SL, Cheng S, Miller PD, Orwoll ES.
Clinical performance of a highly portable, scanning calcaneal ultrasonometer.
Osteoporos Int.
2001;12:391-8.
Notes: CORPORATE
NAME: QUS-2 PMA Trials Group. *,†
The aim of this study was to establish a normative database, assess precision, and evaluate the ability to identify women with low bone mass and to discriminate women with fracture from those without for a highly portable, scanning calcaneal ultrasonometer: the QUS-2. Fourteen hundred and one Caucasian women were recruited for the study. Among them were 794 healthy women 25-84 years of age evenly distributed per 10-year period to establish a normative database. Of these, 171 aged 25-34 years were defined as the young normal group for the purpose of T-score determination. Precision was assessed within 1 day (short-term) and over a 16-week period (long-term) in 79 women aged 25-84 years. Five hundred twenty-eight women ranging from 50 to 84 years of age with or without prevalent fractures of the spine, hip or forearm were measured to compare the QUS-2 with bone mineral density (BMD) of the hip and spine. Mean calcaneal broadband ultrasound attenuation (BUA) was constant in healthy women from 25 to 54 years of age and decreased with increasing age thereafter. Short-term precision, with and without repositioning of the heel, and long-term precision yielded comparable results (BUA SDs of 2.1-2.4 dB/MHz, coefficients of variations (CVs) of 2.5-2.9%). Calcaneal BUA was significantly correlated with BMD of the total hip (TH), femoral neck (FN) and lumbar spine (LS) in 698 women (r = 0.6-0.7, all p < 0.0001). A similar relationship was observed for LS BMD compared with either TH or FN BMD (r = 0.7, p < 0.0001). Prevalence of osteoporosis in our population (WHO criteria) was 20%, 17%, 21%, and 24% for BUA, BMD of the TH, FN and LS, respectively. Age-adjusted values for a 1 SD reduction in calcaneal BUA and TH and FN BMD predicted prevalent fractures of the spine, forearm, and hip with significant (p < 0.05) odds ratios of 2.3, 2.0 and 2.1, respectively. Areas under the receiver operating characteristic curves for age-adjusted bone mass
values predicting prevalent fracture were 0.62 for BUA, 0.59 for TH BMD, 0.60 for FN BMD, and 0.57 for LS BMD; all statistically equivalent. We conclude that the QUS-2 calcaneal ultrasonometer exhibits reproducible clinical performance that is similar to BMD of the spine and hip in identifying women with low bone mass and discriminating women with fracture from those without.
Ross P, Huang C, Davis J, Imose K, Yates J, Vogel J et al. Predicting vertebral deformity using bone densitometry at various skeletal sites and calcaneus ultrasound.
Bone. 1995;16:325-32. *,†
We investigated the usefulness of bone density measurements from multiple skeletal sites and calcaneus ultrasound for evaluating the probability of vertebral deformation. Bone mineral density (BMD) was measured at the second metacarpal and middle phalanges using radiographic absorptiometry of hand radiographs, and at the lumbar spine using dual-energy x-ray absorptiometry. Distal radius and proximal radius were measured using single-energy x-ray absorptiometry (SXA), expressed as bone mineral content (BMC, grams per centimeter), and as BMD (grams per square centimeter). The calcaneus was measured using both SXA (BMD) and broadband ultrasound attenuation (BUA). Among the women in this study (mean age 74, SD = 5), 84 women developed new vertebral deformations (57 cases with one and 27 cases with two or more deformations), which were identified on serial radiographs during an average of 9 years prior to the measurements of bone density. Logistic regression analysis was used to calculate odds ratios for risk of deformation corresponding to a 1-SD difference in density or ultrasound, adjusted for age. All bone measurements were significantly associated with vertebral deformation, with odds ratios (95% confidence intervals) ranging from 1.40 (1.10, 1.78) for proximal radius BMD to 1.88 (1.45, 2.44) for calcaneus BMD measurements. Measurements of calcaneal BUA, calcaneal BMD, and hand BMD generally remained significant when included simultaneously with another measurement in the same model, suggesting that spine or radius BMD may not provide much additional information about risk of deformation. It appears that all of the measurements of bone density and ultrasound provide useful information regarding the probability of deformation. These findings await confirmation in a prospective study.
van Daele PL, Burger H, Algra D, Hofman A, Grobbee DE, Birkenhager JC et al. Age-associated changes in ultrasound measurements of the calcaneus in men and women: the Rotterdam Study. J Bone Miner Res.
1994;9:1751-7. *, †
Broadband ultrasound attenuation (BUA) and speed of sound (SOS) of the os calcis were measured in a sample of 1405 persons (628 men), aged 55-93 years, from the cohort of the Rotterdam Study, a population-based study of diseases in the elderly. We studied the effect of age, body mass index, age at menopause, current use of thiazides, loop diuretics, and estrogens, smoking, and disability on SOS and BUA. Comparisons were made between ultrasound measurements and bone mineral density (BMD) measurements of the lumbar spine and proximal femur using DXA. We found a significant decline with age in SOS and BUA in men (-0.4 and -0.1 %/year, respectively) and women (-1.3 and -0.4%/year, respectively), which persisted after adjustment for body mass index. Age at menopause was not associated with SOS or BUA. Pack-years of smoking was negatively related to SOS in both sexes and to BUA in men. Severe disability was associated with lower SOS and BUA in men, but not in women. Despite the small number of exposed persons, current corticosteroid use was associated with lower BUA in men. The other risk factors examined did not affect the ultrasound measurements. We observed modest correlations between SOS or BUA, on the one hand, and BMD of the lumbar spine, on the other hand (r = 0.32-0.42). Similar correlations were found between ultrasound measurements and BMD measurements of the proximal femur. We conclude that in persons 55 years or over (1) there is a significant age-related decline of BUA and SOS, which is about three times higher in women compared with men, and (2) ultrasound measurements are not able to predict low BMD in hip or spine.
Nairus J, Ahmadi S, Baker S, Baran D. Quantitative ultrasound: an indicator of
osteoporosis in
perimenopausal women. J Clin Densitom. 2000;3:141- 7. *,†
The key to effective treatment of osteoporosis is early detection; however, the disease in perimenopausal women is frequently undiagnosed. To assess the utility of quantitative ultrasound (QUS) at the calcaneus in perimenopausal women, broadband ultrasound attenuation (BUA); speed of sound (SOS); quantitative ultra-sound index (QUI), an algorithm of BUA and SOS; and bone mineral density by dual X-ray absorptiometry (DXA) of the posteroanteiror spine, femoral neck, and total hip were measured in 420 women (ages 45-55 yr). Thirty (7.1%) of the women were found to be osteoporotic by DXA. All QUS measurements were predictors of osteoporosis. QUS values did not differ between postmenopausal women on estrogen replacement therapy (ERT) and those not on ERT. There were no differences among BUA, SOS, and QUI in the area under the receiver operating characteristic curves for predicting osteoporotic vs nonosteoporotic cases. At a QUI of 89, ultrasound had an 80% sensitivity for the diagnosis of osteoporosis, but only a 74% specificity. The use of QUS in perimenopausal women will facilitate the identification of women with osteoporosis. However, the high false-positive rate (26%) limits the utility of QUS as the sole diagnostic technique on which to base therapeutic decisions. Nevertheless, low QUS measurements may provide a
means for targeting those women who would benefit most from more extensive evaluation (e. g., DXA).
Massie A, Reid DM, Porter RW. Screening for osteoporosis: comparison between dual energy X-ray absorptiometry and broadband ultrasound attenuation in 1000 perimenopausal women.
Osteoporos Int.
1993;3:107-10. *, †
This paper compares dual-energy X-ray absorptiometry (DXA) of the spine and hip and broadband ultrasound attenuation (BUA) of the os calcis in 1000 perimenopausal women aged between 45 and 49 years who attended a randomized Osteoporosis Screening Programme. Significant correlations were found between all DXA results and BUA, with the trochanter giving the best numerical correlation with BUA (r = 0.354, p < 0.0001). BUA was not successful in predicting women with low DXA measurements, with only 44.0% of the women whose spinal DXA falls within the lowest quartile being in the lowest quartile of BUA. Although BUA is a poor predictor of spinal and hip bone mineral density it may provide additional structural information important in fracture prediction.
Moderado
Adler RA, Funkhouser HL, Holt CM. Utility of heel ultrasound bone density in men. J Clin Densitom.
2001;4:225-30.*,†
In women, heel ultrasound (US) bone mineral density (BMD) has been shown to predict fracture risk, but the usefulness of this screening tool in men is not known. We measured the heel quantitative ultrasound index (QUI( in a convenience sample 185 of men (136 Caucasian, 1 Asian, and 48 African-American) with an average age of 63 yr (range of 25-85) undergoing BMD of the spine and hip by dual X-ray absorptiometry (DXA) to determine whether the heel measurement could predict central BMD. The average DXA T-score was -0.97, -1.20, and -1.61 for the spine, total hip, and femoral neck, respectively. The mean heel US BMD T-score (using the only available T-score, which was defined for Caucasian postmenopausal women) was -0.92. There were significant correlations among the various DXA measurements and the heel US BMD T-score (r = 0.373-0.483, p <
0.001). We defined arbitrarily osteopenia as a spine, total hip, or femoral neck T-score by DXA of < -1.5. We also made two different arbitrary definitions of osteoporosis by DXA: < -2.0 and < -2.5. Using these numbers as disease definitions, we determined the specificity, sensitivity, as well as positive and negative predictive values of using the heel US T-score to predict osteopenia or osteoporosis. Using various cutoffs for the heel T-score, we found that increasing the cutoff toward 0 increased the sensitivity but lowered the specificity. No cutoff was found that provided both good sensitivity and specificity. By analyzing the men by ethnic and age groups, we found that the best set of receiver operating characteristic (ROC) curves was derived from data using heel US to predict osteopenia and osteoporosis in men younger than age 65, although the areas under the ROC curve were approx 0.8. In conclusion, despite a strong correlation between the heel QUI and the spine and hip BMD by DXA, no heel T-score could predict osteopenia or osteoporosis with satisfactory sensitivity and specificity. It is possible that the use of risk factor assessment plus heel QUI might have better predictive value, and further studies are needed to determine whether heel QUI or other US determination is an independent risk factor for fracture in men.
Brooke-Wavell K, Jones PR, Pye DW. Ultrasound
and dual X-ray
absorptiometry
measurement of the calcaneus: influence of region of interest location.
Calcif Tissue Int.
1995;57:20-4. *,†
Ultrasound measurements of the calcaneus are related to incidence of osteoporotic fracture. Such measurements are generally made at fixed coordinates relative to a footplate. This study compares measurements at an anatomically located region of interest (ROIanat) and at fixed coordinates (ROIfixed), with bone mineral density measurements, in 84 postmenopausal women. Bone mineral density (BMD) was assessed using dual energy X-ray absorptiometry at both ROIs as well as at lumbar spine and femoral neck. Broadband ultrasound attenuation and velocity of sound were measured using a CUBA system at ROIanat and ROIfixed. Additionally, broadband ultrasound attenuation at ROIfixed was measured using a Walker Sonix instrument. Mean bone mineral density, broadband ultrasound attenuation and velocity of sound did not differ significantly between ROIfixed and ROIanat, although broadband ultrasound attenuation by Walker Sonix (81.4 +/- 14.6 dBMHz-1) was significantly (P < 0.001) greater than that by CUBA (63.7 +/- 14.2 dBMHz-1). The relationship between broadband ultrasound attenuation and BMD differed significantly between the 2 ROIs and the correlation of this relationship was significantly greater at ROIfixed than at ROIanat(r = 0.74 versus 0.46, P < 0.01). The differing relationship may reflect structural variation at different regions. ROI selection may thus be a possible confounding factor in ultrasound measurement.
Cetin A, Erturk H, Celiker
R, Sivri A, Hascelik Z. The The aim of this study was to establish whether quantitative ultrasound (QUS) parameters could identify patients classified as osteoporotic and osteopenic on the basis of dual energy X-ray absorptiometry (DEXA). One hundred and twenty-three patients
role of quantitative ultrasound in predicting osteoporosis defined by dual X-ray absorptiometry.
Rheumatol Int. 2001;20:55- 9. *,†
(39 male, 84 female) with osteoporosis and suspected of having osteoporosis were included in this study. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured and bone mineral densities (BMD) of the lumbar spine and left hip was measured by DEXA. Subjects were classified into three groups (normal, osteopenic and osteoporotic) on the basis of BMD T-scores measured by DEXA. QUS parameters of the osteoporotic group were significantly lower than those of osteopenic and normal groups; there was no difference in QUS parameters between the normal and osteopenic groups.
Correlations of both right and left SOS and BUA with the spine and femoral neck BMD were moderate (r = 0.343-0.539, P <
0.001). There was also reasonable correlation between DEXA and QUS T-scores (r = 0.364-0.510, P < 0.001). QUS had a sensitivity of 21% and a specificity of 95% for diagnosing osteoporosis. We concluded that, although DEXA and QUS parameters were significantly correlated, QUS parameters can not predict osteopenia as defined by DEXA, and sensitivities and specificities of QUS parameters were not sufficiently high for QUS to be used as an alternative to DEXA.
Damilakis J, Papadakis A,
Perisinakis K,
Gourtsoyiannis N.
Broadband ultrasound attenuation imaging:
influence of location of region of measurement.
Eur Radiol. 2001;11:1117- 22. *,†
The aim of the study was to investigate the effect of three different regions of interest (ROIs) varying in size and shape on broadband ultrasound attenuation (BUA) measurements of the calcaneus. Two hundred and sixty-five postmenopausal Caucasian women participated in this study. In 43 women osteoporotic fractures were documented on spinal radiographs. Bone mineral density (BMD) measurements of the lumbar spine and the femur were made using dual-energy X-ray absorptiometry.
BUA measurements were obtained at a circular ROI automatically determined by the imaging system (ROIc), at a manually traced irregular ROI encompassing the posterior part of the calcaneus (ROIi), and at an anatomical square ROI located in the posterior part of the calcaneus (ROIs). Reproducibility was better in ROIc than in ROIi and ROIs. High correlations were found between BUA measurements with ROIc and ROIs (r = 0.981, P < 0.0001) as well as between those with ROIc and ROIi (r = 0.965, P < 0.0001). There were no significant differences between the correlations of BUA with axial BMD at ROIc compared with ROIi and ROIs. No significant difference was found between the areas under the ROC curve at ROIi, ROIc, and ROIs for women with fractures. The results show that superior reproducibility makes ROIc the most appropriate region of BUA measurement in a comparison with ROIi and ROIs.
Damilakis J, Perisinakis K, Gourtsoyiannis N. Imaging ultrasonometry of the calcaneus: optimum T- score thresholds for the identification of osteoporotic subjects.
Calcif Tissue Int.
2001;68:219-24. *,†
The purpose of the present study was to (1) examine the age dependence of T-score results for calcaneal imaging ultrasonometry and dual X-ray absorptiometry of the axial skeleton and (2) determine the optimum T-score thresholds appropriate for broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements. A total of 453 healthy women aged 20-9 years were included in the study. All study participants underwent bone mineral density (BMD) measurements of the lumbar spine, femoral neck, total hip and calcaneal measurements of the BUA and SOS. An imaging ultrasound device (UBIS, DMS, France) was used for the ultrasound measurements. T-scores were calculated using a subgroup of 71 healthy women aged 20-35 years to estimate the mean value of young normals and SD for BUA, SOS, and BMD. The age-related decline in both BUA and SOS T-scores was slower than that in the equivalent figures obtained by BMD measurements. The optimum T-score thresholds estimated by receiver operating characteristic (ROC) analysis were 1.3 for BUA and 1.5 for SOS. Using the optimum threshold, the sensitivity and specificity for BUA was 68% and 83%, respectively.
Corresponding values for SOS were 63% and 79%. Utilizing calculated optimum T score thresholds for BUA and SOS, the agreement among BUA, SOS, and BMD at the femoral neck was improved compared with that found using the T-score of < or
= -2.5 criterion. In conclusion, the definition of osteoporosis by a T-score of , or = -2.5 was not applicable to imaging ultrasonometry of the calcaneus. Optimum T-score thresholds were determined for both BUA and SOS suitable to Ubis QUS device.
Ekman A, Michaelsson K, Petren-Mallmin M, Ljunghall S, Mallmin H.
Dual X-ray absorptiometry of hip, heel ultrasound, and densitometry of fingers can discriminate male patients
Few studies have examined different bone densitometry techniques to determine male hip fracture risk. We conducted a case- control study of 31 noninstitutionalized men, mean age 77 yr, with a first hip fracture and compared the results with 68 randomly selected age-matched control subjects. The methods used were dual X-ray absorptiometry (DXA) of the proximal femur, quantitative ultrasound (QUS) of the heel and fingers, and radiographic absorptiometry of the fingers. Case patients had significantly lower values (4-17%; p < 0.01) for all methods. The odds ratios for every SD reduction in bone values were 4.8 (95% confidence interval [CI]: 2.3-9.9) for DXA of the femoral neck, 2.2 (95% CI: 1.2-3.9) for QUS of the heel, 2.0 (95% CI: 1.2- 3.3) for QUS of the phalanges, and 3.1 (95% CI: 1.5-6.6) for radiographic absorptiometry of the phalanges. The results indicate
