Guidelines for fracture risk assessment and management of osteoporosis in postmenopausal women and men above the age of 50 in Qatar.

We present comprehensive guidelines for osteoporosis management in Qatar. Formulated by the Qatar Osteoporosis Association, the guidelines recommend the age-dependent Qatar fracture risk assessment tool for screening, emphasizing risk-based treatment strategies and discouraging routine dual-energy X-ray scans. They offer a vital resource for physicians managing osteoporosis and fragility fractures nationwide. PURPOSE: Osteoporosis and related fragility fractures are a growing public health issue with an impact on individuals and the healthcare system. We aimed to present guidelines providing unified guidance to all healthcare professionals in Qatar regarding the management of osteoporosis. METHODS: The Qatar Osteoporosis Association formulated guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men above the age of 50. A panel of six local rheumatologists who are experts in the field of osteoporosis met together and conducted an extensive review of published articles and local and international guidelines to formulate guidance for the screening and management of postmenopausal women and men older than 50 years in Qatar. RESULTS: The guidelines emphasize the use of the age-dependent hybrid model of the Qatar fracture risk assessment tool for screening osteoporosis and risk categorization. The guidelines include screening, risk stratification, investigations, treatment, and monitoring of patients with osteoporosis. The use of a dual-energy X-ray absorptiometry scan without any risk factors is discouraged. Treatment options are recommended based on risk stratification. CONCLUSION: Guidance is provided to all physicians across the country who are involved in the care of patients with osteoporosis and fragility fractures.

The Role of the Trabecular Bone Score in the Assessment of Osteoarticular Disorders in Patients with HFE-Hemochromatosis: A Single-Center Study from Poland.

Type 1 hereditary hemochromatosis (HH) is an autosomal, recessive genetic entity with systemic iron overload. Iron homeostasis disorders develop as a result of HFE gene mutations, which are associated with hepcidin arthropathy or osteoporosis and may cause permanent disability in HH patients despite a properly conducted treatment with phlebotomies. In this study, selected parameters of calcium and phosphate metabolism were analyzed in combination with the assessment of bone mineral density (BMD) disorders in patients from northern Poland with clinically overt HFE-HH. BMD was determined by a dual-energy X-ray absorptiometry (DXA) test with the use of the trabecular bone score (TBS) function. The study included 29 HH patients (mean age = 53.14 years) who were compared with 20 healthy volunteers. A significantly lower TBS parameter and serum 25-OH-D3 concentration, a higher concentration of intact parathormone and more a frequent occurrence of joint pain were found in HH patients compared with the control group. In HH patients, the diagnosis of liver cirrhosis was associated with lower serum 25-OH-D3 and osteocalcin concentrations. In HH, DXA with the TBS option is a valuable tool in the early assessment of the bone microarchitecture and fracture risk. A supplementation of vitamin D, monitoring its concentration, should be considered especially in HH patients with liver damage and liver cirrhosis.

Assessment of non-traumatic vertebral fractures in Cushing's syndrome patients.

PURPOSE: Hypercortisolism has detrimental effects on bone metabolism with the consequences of bone loss and bone fractures. We aimed to evaluate the frequency of vertebral fragility fractures and to determine the factors associated with Cushing's syndrome (CS). METHODS: A total of 135 patients diagnosed with Cushing's syndrome [108 patients with Cushing's disease and 27 patients with adrenocortical adenoma] and 107 healthy controls were included in this cross-sectional study. The available clinical, laboratory, and radiologic data of patients with CS were recorded, retrospectively. Lateral vertebral radiograms were evaluated for vertebral fragility fractures according to Genant's semi-quantitative method. Bone mineral density (BMD) was determined using a Dual-energy X-ray absorptiometry (DEXA). RESULTS: Vertebral fragility fractures (VFs) were observed in 75.3% (n = 61) of the patients. The median number of VFs was six (min-max: 2-12). All patients with vertebral fractures had thoracic VF, and 50.7% of the patients had lumbar fragility fractures. Thirty-three (40.7%) patients with vertebral fractures had normal bone densitometry values. Osteoporosis and osteopenia were observed in 16.2% and 40.7% of the patients, respectively. The duration of active disease, the presence of ACTH-secreting pituitary adenoma, and 24-h urinary cortisol did not influence the presence of vertebral fractures. Vertebral fractures were independently associated with age, FSH, LH levels, and lumbar BMD (R2 = 68.18%, p = 0.028). The femoral neck BMD (but not lumbar BMD) was independently associated with age, BMI, and PTH levels (R2 = 48.48%, p < 0.001). CONCLUSION: Vertebral fracture frequency was higher in CS patients. Most of the patients with vertebral fractures had multiple fractures. Although low lumbar BMD was associated with VF, patients with CS with normal bone densitometry could experience VF. Vertebral radiograph evaluations as a part of routine evaluation for silent vertebral fractures may help to prevent further fractures in patients with CS.

Five-component model validation of reference, laboratory and field methods of body composition assessment.

This study reports the validity of body fat percentage (BF%) estimates from several commonly employed techniques as compared with a five-component (5C) model criterion. Healthy adults (n 170) were assessed by dual-energy X-ray absorptiometry (DXA), air displacement plethysmography (ADP), multiple bioimpedance techniques and optical scanning. Output was also used to produce a criterion 5C model, multiple variants of three- and four-component models (3C; 4C) and anthropometry-based BF% estimates. Linear regression, Bland-Altman analysis and equivalence testing were performed alongside evaluation of the constant error (CE), total error (TE), se of the estimate (SEE) and coefficient of determination (R2). The major findings were (1) differences between 5C, 4C and 3C models utilising the same body volume (BV) and total body water (TBW) estimates are negligible (CE ≤ 0·2 %; SEE < 0·5 %; TE ≤ 0·5 %; R2 1·00; 95 % limits of agreement (LOA) ≤ 0·9 %); (2) moderate errors from alternate TBW or BV estimates in multi-component models were observed (CE ≤ 1·3 %; SEE ≤ 2·1 %; TE ≤ 2·2 %; R2 ≥ 0·95; 95 % LOA ≤ 4·2 %); (3) small differences between alternate DXA (i.e. tissue v. region) and ADP (i.e. Siri v. Brozek equations) estimates were observed, and both techniques generally performed well (CE < 3·0 %; SEE ≤ 2·3 %; TE ≤ 3·6 %; R2 ≥ 0·88; 95 % LOA ≤ 4·8 %); (4) bioimpedance technologies performed well but exhibited larger individual-level errors (CE < 1·0 %; SEE ≤ 3·1 %; TE ≤ 3·3 %; R2 ≥ 0·94; 95 % LOA ≤ 6·2 %) and (5) anthropometric equations generally performed poorly (CE 0·6- 5·7 %; SEE ≤ 5·1 %; TE ≤ 7·4 %; R2 ≥ 0·67; 95 % LOA ≤ 10·6 %). Collectively, the data presented in this manuscript can aid researchers and clinicians in selecting an appropriate body composition assessment method and understanding the associated errors when compared with a reference multi-component model.

Bone health assessment in clinical practice is infrequenty performed in patients with chronic pancreatitis.

BACKGROUND: Chronic pancreatitis (CP) patients have a high prevalence of osteoporotic fractures. In addition to prevalence of osteoporotic fractures, we evaluated how often bone health is assessed by dual-energy x-ray absorptiometry (DXA) in clinical practice, and the performance of Fracture Risk Assessment Tool (FRAX®) in predicting fracture risk in CP patients. METHODS: Medical records of CP patients age ≥40 years prospectively enrolled in the North American Pancreatitis Study 2 (NAPS2) from the University of Pittsburgh Medical Center from 2000 to 2014 were retrospectively reviewed to gather additional relevant data before, at, and after enrollment until December 2016. We determined if patients underwent DXA, compared their observed prevalence of fractures with published data from two large US studies based on administrative data, and their predicted fracture risk with US population based on FRAX®. RESULTS: Only 21% (49/239) patients were evaluated by DXA during their care. The observed cumulative prevalence of fragility fractures in NAPS2 CP patients (9.2%, 95% confidence interval 5.9-13.6) was significantly greater than in controls (1.46% and 2.16%, p ≤ 0.001 for each comparison) and CP patients (4.66%, and 5.13%, p < 0.005 for each comparison) in the two US administrative data studies. The FRAX® 10-year probability of major osteoporotic fracture of ≥20% (5.1% vs. 8.3%, p > 0.05) and for hip fracture of ≥3% (19.6% vs. 18.9%, p > 0.05) in NAPS2 CP patients did not differ from the US population. CONCLUSIONS: Despite their high risk of fragility fractures, bone health is infrequently assessed in CP patients. FRAX® may not adequately predict fracture risk in CP patients.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update.

PURPOSE OF REVIEW: The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures. RECENT FINDINGS: Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Assessment of muscle mass depletion in chronic liver disease: Dual-energy x-ray absorptiometry compared with computed tomography.

OBJECTIVES: The aim of this study was to perform intermethod comparisons between the following three measures of muscle mass depletion in patients eligible for liver transplantation: 1) fat-free mass index (FFMI) measured by dual-energy x-ray absorptiometry (DXA), 2) appendicular skeletal muscle mass index (ASMI) measured by DXA, and 3) skeletal muscle index (SMI) measured at the third lumbar level by computed tomography (CT). METHODS: The medical records of patients who received liver transplants between 2009 and 2012 at Karolinska University Hospital were retrospectively reviewed. Adult patients with a chronic liver disease who had both DXA and CT scans performed within a 30-d period during their pretransplant workup were included. RESULTS: Appendicular skeletal muscle mass index measured by DXA (ASMIDXA) and skeletal mass index measured by computed tomography (SMICT) provide similar results when assessing the presence of muscle mass depletion in patients with chronic liver diseases and FFMIDXA can be falsely high in patients with ascites. Both ASMIDXA and SMICT thus appear to be useful methods in the pretransplant evaluation of muscle mass depletion both for patients with and without ascites. CONCLUSIONS: ASMI measured with DXA is a useful alternative method to SMI measured with CT when a CT scan is not clinically indicated or available.

Methods for data analysis of resting energy expenditure measured using indirect calorimetry.

OBJECTIVES: The aim of this study was to test the accuracy of different methods of resting energy expenditure (REE) data analysis using indirect calorimetry (IC) during traditional (30 min) and abbreviated (10 min) protocols. METHODS: Fifteen women and 15 men (21-34 y of age) completed two consecutive 30-min IC measurements. Body composition was measured using dual-energy x-ray absorptiometry. The reference method for REE analysis was 5 min in steady state (SS) during 30 min (first 5 min discarded). REE measurements were randomized to define a reference or testing method. An interval method was defined using 25, 20, and 15 min (with first 5, 10, and 15 min discarded, respectively), during 30 min, and 5 min (first 5 min discarded) during 10-min intervals. The SS method was defined using 5 min in SS (first 5 min discarded) during 30 min, 5, 4, and 3 min in SS during 10-min (first 5 min discarded) intervals. RESULTS: Interval methods during 30 min and SS and interval methods during 10 min demonstrated large bias with significantly high REEs compared to the reference method (78.8-109.0 kcal/d, all P < 0.001). Testing methods demonstrated large upper limits of agreement between 225.2 and 322.8 kcal/d. No mean differences (P > 0.05), small bias (14.3 kcal/d), and narrow limits of agreement (-125.8 to 154.4 kcal/d) were observed between 5-min SS during 30 min and the reference method. CONCLUSIONS: All interval methods and SS methods during 10 min overestimated REE. We recommend using 5-min SS during 30 min. The measurement may be repeated until all participants achieve SS.

Socioeconomic status and risk of osteoporotic fractures and the use of DXA scans: data from the Danish population-based ROSE study.

There is a need of studies exploring the link between socioeconomic status and DXA scans and osteoporotic fracture, which was the aim of the present study. No differences in socioeconomic status and risk of osteoporotic fractures were found. However, women with further/higher education and higher income are more often DXA-scanned. INTRODUCTION: Lower socioeconomic status is known to be associated with a range of chronic conditions and with access to health care services. The link between socioeconomic status and the use of DXA scans and osteoporotic fracture, however, needs to be explored more closely. Therefore, the aim of this study was to examine the relationship between socioeconomic status and both DXA scan utilization and major osteoporotic fractures (MOF) using a population-based cohort of Danish women and national registers. METHODS: The study included 17,155 women (65-81 years) sampled from the Risk-stratified Osteoporosis Strategy Evaluation study (ROSE). Information on socioeconomic background, DXA scans, and MOFs was retrieved from national registers. Competing-risk regression analyses were performed. Mean follow-up was 4.8 years. RESULTS: A total of 4245 women had a DXA scan (24.7%) and 1719 (10.0%) had an incident MOF during follow-up. Analyses showed that women with basic education had a lower probability of undergoing DXA scans than women with further or higher education (greater than upper secondary education and vocational training education) (subhazard ratio (SHR) = 0.82; 95% CI 0.75-0.89, adjusted for age and comorbidity). Moreover, women with disposable income in the low and medium tertiles had a lower probability of undergoing DXA scans than women in the high-income tertile (SHR = 0.90; 95% CI 0.84-0.97 and SHR = 0.88, 95% CI 0.82-0.95, respectively, adjusted for age and comorbidity). No association between socioeconomic background and probability of DXA was found in adjusted analyses. CONCLUSION: The study found no differences in risk of osteoporotic fractures depending on socioeconomic status. However, women with further or higher education as well as higher income are more often DXA-scanned.

Association of high-density lipoprotein, triglycerides, and homocysteine with bone mineral density in young Indian tribal women.

This study investigated association between lipids and homocysteine (Hcy) with bone mineral density (BMD) in young women as opposed to previous studies on elderly women. HDL, triglyceride, and Hcy are significantly associated with BMD in young women and tobacco and alcohol consumption have no effect on this association. PURPOSE: The present study investigates whether the association of serum lipids and homocysteine (Hcy) with bone mineral density (BMD) reported mostly in elderly population can be generalized to young or premenopausal women, consequently suggesting screening of young women with low BMD for dyslipidemia or any cardiovascular events and vice versa. METHODS: Women (n = 293, aged 20-47 years) from Northeast India belonging to Tibeto-Burman origin were enrolled. Information about their physical and clinical attributes were collected by a structured questionnaire. Their BMDs at lumbar spine and femur were measured by dual-energy X-ray absorptiometry (DXA) and sera were profiled for lipid parameters and Hcy by auto-analyzer and ELISA, respectively. Women consuming tobacco and/or alcohol were grouped as consumers and others as non-consumers for the analysis. RESULTS: Positive correlation of BMD with HDL (spine and femur r = 0.38, p < 0.0001) and triglyceride (spine r = 0.534, p < 0.0001; femur r = 0.423, p < 0.0001) was observed, whereas Hcy correlated negatively with BMD (spine r = - 0.189, p = 0.0026; femur r = - 0.273, p < 0.0001). LDL showed a weak negative correlation with BMD (spine r = - 0.128, p = 0.0283; femur r = - 0.199, p = 0.0006). However, after adjusting for age, BMI, and consumption, HDL, triglyceride, and Hcy continued to show significant correlation with BMD at both the sites. Logistic regression analyses indicated that HDL, triglyceride, and Hcy were significant predictors of osteopenia and osteoporosis in our study cohort; however, consumption did not contribute to its prediction. CONCLUSION: Low levels of HDL and triglyceride and high levels of Hcy are significantly associated with osteopenia and osteoporosis in young Northeast Indian women.

Validity of the Body Adiposity Index in Predicting Body Fat in Adults: A Systematic Review.

The Body Adiposity Index (BAI) is a practical anthropometric method used to measure body fat (BF) percentage (BF%). Recently developed, the validity and precision of BAI has been studied with adult samples of men and women, populations from different countries and ethnicities, varying amounts of BF, and sensitivity to detecting change over time. However, it is still necessary to determine its potential use in clinical practice and epidemiologic studies. Thus, our objective was to verify, through a systematic review, the validity of the BAI in predicting BF% in adults. Two independent researchers performed a search using PubMed, Web of Science, Science Direct, and Scopus databases. In order to be included, the studies had to use dual-energy X-ray absorptiometry (DXA) as a reference method. We excluded studies with samples from individuals with diseases or syndromes that alter the regional distribution of BF%. We included 19 studies with samples on individuals from different continents, varied ethnicities, both sexes, and a wide age range (18-83 y). The concordance of the BAI with DXA assessed by Lin's concordance correlation coefficient showed results classified as poor (pc < 0.90). Bland-Altman plots showed that the BAI produced large individual errors when predicting BF% in all studies using this analysis. The studies were consistent in affirming that the BAI showed limited capacity to estimate BF% in adults. The BAI shows wide individual errors, in agreement with the reference method, and a lack of sensitivity in detecting change in BF% over time. The method presents a systematic error of BF% overestimation in individuals with ≤20% of BF, and underestimation in individuals with >30% of BF, regardless of sex, age, and ethnicity. The results of this systematic review show enough evidence that the BAI does not present satisfying results, and its use is not recommended for BF% determination in adults.

Use of Breast Cancer Screening and Its Association with Later Use of Preventive Services among Medicare Beneficiaries.

Purpose To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. Materials and Methods U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. Results The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. Conclusion In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening.

Stop the war on DXA!

Dual-energy X-ray absorptiometry (DXA) is a versatile technology that is widely used in clinical practice in the management of osteoporosis and other skeletal diseases. It is a safe and inexpensive procedure that measures bone mineral density (BMD) to diagnose osteoporosis, assess fracture risk, and monitor osteoporosis treatment. However, DXA has been subjected to recurring claims that it is overutilized, too expensive, and not helpful in patient management. In recent years, there has been a decline in the number of office-based DXA facilities, a reduction in BMD tests performed, and fewer women being diagnosed and treated for osteoporosis, despite aging of the population with more people at risk for fractures. Here, we identify some of the challenges to DXA, which in the aggregate amount to a disturbing war on DXA and, as a result, a threat to good patient care. We suggest potential strategies to restore DXA to its proper role in osteoporosis management.

Do reductions in out-of-pocket expenses for dual energy X-ray absorptiometry scans translate to reduced fracture incidence amongst older Australians? A population-based study.

This study aimed to compare fracture incidence in the elderly pre- and post-revision of bone density scan reimbursement guidelines, which changed in 2007. Fracture incidence by age group was calculated using population-specific data. Guideline changes did not appear to reduce fracture incidence in the study region located in south-eastern Australia. PURPOSE: In 2007, Medicare Australia revised reimbursement guidelines whereby individuals aged 70 years and over received reduced out-of-pocket expenses for dual energy X-ray absorptiometry (DXA) scans. The current study aims to determine whether fracture incidence in the elderly has changed since the revision of reimbursement guidelines. METHOD: Keyword searches of the two major radiological centres servicing the Barwon Statistical Division (BSD) were used to identify incident fractures for residents aged 75 years and over for 2006 and 2012. Pathological fractures were excluded. Fracture incidence by age strata (75-79 years, 80-84 years and 85+ years) were calculated using population-specific data from the Australian Bureau of Statistics (2006 and 2012). Standardised fracture ratios were calculated for men and women. RESULTS: In total, 996 fracture events were identified for BSD residents during 2006 and 1260 identified in 2012. The standardised fracture ratios between 2006 and 2012 were 1.12 (95%CI 1.11, 1.25) for men and 1.08 (95%CI 1.11, 1.16) for women. CONCLUSION: The change in reimbursement guidelines appears to have had little impact on reducing fracture incidence during this time frame for elderly men and women, in fact, fracture rates increased. Future research should investigate osteoporosis management following DXA over a longer time frame.

Appropriateness of bone density measurement in Switzerland: a cross-sectional study.

BACKGROUND: According to the WHO, osteoporosis is one of the most important non- communicable diseases worldwide. Different screening procedures are controversially discussed, especially concerning the concomitant issues of overdiagnosis and harm caused by inappropriate Dual X-ray Absorptiometry (DXA). The aim of this study was to evaluate the frequency and appropriateness of DXA as screening measure in Switzerland considering individual risk factors and to evaluate covariates independently associated with potentially inappropriate DXA screening. METHODS: Retrospective cross-sectional study using insurance claim data of 2013. Among all patients with DXA screening, women < 65 and men < 70 years without osteoporosis or risk factors for osteoporosis were defined as receiving potentially inappropriate DXA. Statistics included descriptive measures and multivariable regressions to estimate associations of relevant covariates with potentially inappropriate DXA screening. RESULTS: Of 1,131,092 patients, 552,973 were eligible. Among those 2637 of 10,000 (26.4%) underwent potentially inappropriate DXA screening. Female sex (Odds ratio 6.47, CI 6.41-6.54) and higher age showed the strongest association with any DXA screening. Female gender (Odds ratio 1.84, CI 1.49-2.26) and an income among the highest 5% (Odds ratio 1.40, CI 1.01-1.98) were significantly positively associated with potentially inappropriate DXA screening, number of chronic conditions (Odds ratio 0.67, CI 0.65-0.70) and living in the central region of Switzerland (Odds ratio 0.67, CI 0.48-0.95) negatively. CONCLUSION: One out of four DXAs for screening purpose is potentially inappropriate. Stakeholders of osteoporosis screening campaigns should focus on providing more detailed information on appropriateness of DXA screening indications (e.g. age thresholds) in order to avoid DXA overuse.

Hip fracture trends in the United States, 2002 to 2015.

An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures. INTRODUCTION: Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. METHODS: We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. RESULTS: We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. CONCLUSIONS: The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.

Effect of implementation of guidelines on assessment and diagnosis of vertebral fractures in patients older than 50 years with a recent non-vertebral fracture.

We evaluated the impact of a new Dutch guideline on systematic implementation of densitometric Vertebral Fracture Assessment (VFA) in patients with a recent non-vertebral fracture. Systematic implementation resulted in a significant increase of VFA, diagnosis of vertebral fractures (VFs), and percentage of patients eligible for treatment. INTRODUCTION: VFs are underdiagnosed although they are important predictors of fracture risk, independent of age and bone mineral density (BMD). The Dutch guideline on osteoporosis and fracture prevention recommends VFA in all patients aged >50 years with a recent non-VF. Our aim was to evaluate the effect of systematic implementation of densitometric VFA in patients with a recent non-VF at the fracture liaison service (FLS). METHODS: VFA was performed on lateral images of the spine using dual-energy X-ray absorptiometry (DXA) and graded according to Genant using Spine Analyzer software. RESULTS: We evaluated 582 patients before and 484 after implementation (mean age 67 and 66 years; 71 and 74% women, respectively). Performing VFA increased from 4.6 to 97.1% (p < 0.001) and the diagnosis of VFs from 2.2 to 26.2% for grade ≥ 1 (p < 0.001) and from 0.9 to 14.7% for grade ≥ 2 (p < 0.001). Prevalence of VFs increased with age (5.2% in 50-59-year olds to 27.8% in 80+-year olds, p < 0.001), but was similar for both genders, non-VF locations, and BMD. Including patients with osteopenia and a VF increased the percentage of patients eligible for treatment by a quarter, from 31.0% in the pre-guideline to 38.4% in the post-guideline cohort. CONCLUSIONS: Systematic guideline implementation resulted in a significant increase of VFA, diagnosis of VFs, and percentage of patients eligible for treatment. VFA contributes to documenting the high prevalence of VFs in patients visiting the FLS with a non-VF in both genders, at any age, non-VF location, and BMD.

Variations in Radiographic Procedure Use for Medicare Patients With Rheumatoid Arthritis.

OBJECTIVE: In 2013, the American College of Rheumatology published its Choosing Wisely list, which identified 2 radiographic procedures (peripheral joint magnetic resonance imaging [MRI] and dual x-ray absorptiometry [DXA] scans) that were at risk for overuse. METHODS: We performed a retrospective cross-sectional cohort study to measure the use of peripheral joint MRI, peripheral joint radiographs, and DXA scans in a national cohort of Medicare patients with rheumatoid arthritis (RA) during 2008-2009, before the start of the Choosing Wisely campaign. Diagnoses were identified via International Classification of Diseases, Ninth Revision, codes; utilization was calculated using Current Procedural Terminology codes. Utilization was analyzed at the individual level and at the regional level (by hospital referral region [HRR]). RESULTS: There were 8,051 patients with RA who were included: 81% were women, and the mean age was 76 years. Over a 2-year period, the mean number of peripheral joint MRIs per beneficiary was 0.3 (median 0 [range 0-50]), peripheral joint radiographs per beneficiary was 2.6 (median 1 [range 0-33]), and DXA scans per beneficiary was 0.7 (median 0 [range 0-11]). Only 6.8% of patients received >1 peripheral joint MRI, and 6% of HRRs had a mean number of peripheral joint MRIs >1. CONCLUSION: There is variation in the use of peripheral joint MRI, peripheral joint radiographs, and DXA scans among Medicare patients with RA, although only a small number of HRRs have consistently high utilization. Although we cannot judge the appropriateness of each procedure, variation in use across regions signals the need for investigations to examine potential overutilization.

Assessment of EchoMRI-AH versus dual-energy X-ray absorptiometry by iDXA to measure human body composition.

Comparison of percent fat mass across different body composition analysis devices is important given variation in technology accuracy and precision, as well as the growing need for cross-validation of devices often applied across longitudinal studies. We compared EchoMRI-AH and Lunar iDXA quantification of percent body fat (PBF) in 84 adults (43M, 41F), with the mean age 39.7±15.9 years and body mass index (BMI) 26.2±5.3 kg/m2. PBF correlated strongly between devices (r>0.95, P<0.0001). A prediction equation was derived in half of the subjects, and the other half were used to cross-validate the proposed equation (EchoMRI-AH PBF=[(0.94 × iDXA PBF)+(0.14 × Age)+(3.3 × Female)-8.83). The mean PBF difference (predicted-measured) in the validation group was not different from 0 (diff=0.27%, 95% confidence interval: -0.42-0.96, P=0.430). Bland-Altman plots showed a bias with higher measured PBF on EchoMRI-AH versus iDXA in all 84 subjects (ß=0.13, P<0.0001). The proposed prediction equation was valid in our cross-validation sample, and it has the potential to be applied across multicenter studies.

Sarcopenia in daily practice: assessment and management.

BACKGROUND: Sarcopenia is increasingly recognized as a correlate of ageing and is associated with increased likelihood of adverse outcomes including falls, fractures, frailty and mortality. Several tools have been recommended to assess muscle mass, muscle strength and physical performance in clinical trials. Whilst these tools have proven to be accurate and reliable in investigational settings, many are not easily applied to daily practice. METHODS: This paper is based on literature reviews performed by members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) working group on frailty and sarcopenia. Face-to-face meetings were afterwards organized for the whole group to make amendments and discuss further recommendations. RESULTS: This paper proposes some user-friendly and inexpensive methods that can be used to assess sarcopenia in real-life settings. Healthcare providers, particularly in primary care, should consider an assessment of sarcopenia in individuals at increased risk; suggested tools for assessing risk include the Red Flag Method, the SARC-F questionnaire, the SMI method or different prediction equations. Management of sarcopenia should primarily be patient centered and involve the combination of both resistance and endurance based activity programmes with or without dietary interventions. Development of a number of pharmacological interventions is also in progress. CONCLUSIONS: Assessment of sarcopenia in individuals with risk factors, symptoms and/or conditions exposing them to the risk of disability will become particularly important in the near future.