Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry.

Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.

Decreased bone mineral density is associated with an increased number of teeth with periodontitis progression: a 5-year retrospective cohort study.

OBJECTIVE: Longitudinal studies on the systemic bone loss-periodontitis relationship are limited with disparate results. The aim of this study was to investigate the association between bone mineral density (BMD) and periodontitis progression, controlling for other covariables in a Thai population. MATERIALS AND METHODS: In 2,418 participants, BMD values of the lumbar spine, femoral neck, and total hip were measured with dual-energy X-ray absorptiometry at baseline. Each participant's BMD status was classified as normal, osteopenia, or osteoporosis. Full mouth periodontal examinations on 6 sites/tooth were performed at baseline and 5-year follow-up visits. Periodontitis progression was defined as a tooth presenting an additional proximal CAL loss of ≥ 3 mm or an additional lost tooth with a baseline CAL ≥ 5 mm. The risk effects of BMD status on the number of teeth with periodontitis progression were analyzed using multivariate Poisson regression. RESULTS: Baseline BMD status of osteoporosis was associated with an increased number of teeth with periodontitis progression in the subgroups of postmenopausal women, non-smokers, and participants with periodontitis stage III/IV with adjusted risk ratios of 1.31 (95% CI = 1.09-1.58), 1.19 (95% CI = 1.04-1.36), and 1.13 (95% CI = 1.00-1.28), respectively. CONCLUSION: Baseline BMD in the osteoporosis range increased the risk of having a greater number of teeth with periodontitis progression in specific participant subgroups. CLINICAL RELEVANCE: Decreased BMD is a potential factor affecting periodontitis progression risk in some individuals. Multidisciplinary approaches in educating and maintaining patients' bone-oral health may help improve their quality of life.

A Comparison of Bone Mineral Density and Its Predictors in HIV-Infected and HIV-Uninfected Older Men.

OBJECTIVE: Bone health in older individuals with HIV infection has not been well studied. This study aimed to compare bone mineral density (BMD), trabecular bone score (TBS), and bone markers between HIV-infected men and age- and body mass index (BMI)-matched HIV-uninfected men aged ≥60 years. We investigated the associations of risk factors related to fracture with BMD, TBS, and bone markers in HIV-infected men. METHODS: This cross-sectional study included 45 HIV-infected men receiving antiretroviral therapy and 42 HIV-uninfected men. Medical history, BMD and TBS measurements, and laboratory tests related to bone health were assessed in all the participants. HIV-related factors known to be associated with bone loss were assessed in the HIV-infected men. RESULTS: The mean BMD, TBS, and osteopenia or osteoporosis prevalence were similar among the cases and controls. The HIV-infected men had significantly higher mean N-terminal propeptide of type 1 procollagen and C-terminal cross-linking telopeptide of type I collagen levels. Stepwise multiple linear regression analysis demonstrated that low BMI (lumbar spine, P = .015; femoral neck, P = .018; and total hip, P = .005), high C-terminal cross-linking telopeptide of type I collagen concentration (total hip, P = .042; and TBS, P = .010), and low vitamin D supplementation (TBS, P = .035) were independently associated with low BMD and TBS. CONCLUSION: In older HIV-infected men with a low fracture risk, the mean BMD and TBS were similar to those of the age- and BMI-matched controls. The mean bone marker levels were higher in the HIV group. Traditional risk factors for fracture, including low BMI, high C-terminal cross-linking telopeptide of type I collagen level, and low vitamin D supplementation, were significant predictors of low BMD and TBS.

Precision and Effects of a Small Meal on DXA-Derived Visceral Adipose Tissue, Appendicular Lean Mass, and Other Body Composition Estimates In Nonobese Elderly Men.

BACKGROUND: Information on precision errors and the least significant change (LSC) of dual energy X-ray absorptiometry (DXA)-derived body composition estimates is scarce, particularly for the appendicular lean mass (ALM) and appendicular lean mass index (ALMI). Overnight fasting is recommended for body composition measurements but has not been well tolerated by some elderly patients. This study aimed to establish precision errors and LSC values of body composition estimates in all regions-including visceral adipose tissue (VAT) and ALM-and the ALMI to assess the effect of a small meal on body composition and to estimate the changes it incurred. METHODOLOGY: Our institutional review board approved the study protocol. Altogether, 36 non-obese men aged ≥60 years, having given written informed consent, underwent body composition assessment after fasting overnight except for water. They underwent DXA scans three times, each time with repositioning (to simulate the clinical setting), the last after consuming a standardized meal (210-250 g and 200 cc of water). RESULTS: Precision errors and LSC values of DXA-derived body composition estimates in these elderly men tended to be higher than those in reports on younger subjects. Coefficients of variation (CVs (%)) of total bone mass (Tb.BMC) and total lean mass (Tb.LM) were <1%, whereas those of total fat mass (Tb.FM) and total %fat mass (Tb.%FM) were <2%, with LSCs of 45.8 g, 706.52 g, 731.4 g, and 1.15%, respectively. The CVs (LSC) of VAT, ALM, and ALMI were 8.9% (150.65 g), 0.93% (501 g), and 0.94% (0.19), respectively. After meal consumption, the mean changes in Tb.FM, Tb.BMC, and Tb.LM were -100, -8.2, and 440 g, respectively. CONCLUSIONS: Effects of a small meal on most parameters were trivial, including those for VAT, ALM, and ALMI, where changes were not statistically significant. None exceeded the LSC of ALM and ALMI, suggesting that a small meal is allowable before these measurements.

Errors in Patient Positioning for Bone Mineral Density Assessment by Dual X-Ray Absorptiometry: Effect of Technologist Retraining.

Improper positioning is one of the factors that can lead to incorrect bone mineral density (BMD) results. This study aimed to assess the frequencies of erroneous positioning during three periods: before retraining of the technologists (BR), after retraining (AR), and at the current timepoint 8 years after retraining (C). The BMD images of the first 150 consecutive patients who underwent DXA of the lumbar spine and hip during each of the three periods were retrospectively reviewed. Patients were excluded if they had severe scoliosis, rendering proper positioning impossible. Each BMD image was assessed by an International Society of Clinical Densitometry certified clinical densitometrist who was blinded to the date of the initial examination. For the lumbar spine in the BR group, the criteria frequently not met were inclusion of both iliac crests (33.8%), straightness (30.3%), and midline positioning (20.4%); the respective frequencies were significantly reduced to 0.8%-5.6%, 2.1%-3.0%, and 0%-2.8% in the AR and C groups (p < 0.05). For the hip in the BR group, the criteria frequently not met were straightness (52.8%) and internal rotation (21.8%); the respective frequencies were significantly reduced to 0%-4.2% and 8.3%-8.4% in the AR and C groups (p < 0.05). Overall improper positioning in the BR group was 49.3% and 57.3% at the lumbar spine and the hip, respectively; the respective frequencies were reduced to 9.3% and 12.7% in the AR group, and to 2.7% and 7.3% in the C group. The least significant change values for the lumbar spine, femoral neck, and total hip also became smaller after retraining. Retraining the technologists improved patient positioning, as evidenced by the decreased frequencies of erroneous positioning and the improved least significant change values after the retraining.

Effect of Obesity on Left Ventricular Mass: Results from 320 Multi-Slices Computed Tomography.

Objective: To determine effects of obesity and gender on left ventricular mass in normotensive and hypertensive Thai patients using 320-slice cardiac computed tomography (CT). Material and Method: Left ventricular mass (LVM) obtained from 320-slice coronary CT angiogram was compared in 597 normotensive subjects (175 men [65 obese] and 422 women [133 obese], aged 55±7 years) and 483 hypertensive patients (180 men [104 obese] and 303 women [170 obese], aged 60±7 years). Obesity in Asian population was defined by body mass index (BMI) ≥ 25 kg/m2 in both genders. LV mass was normalized for body surface area (BSA)and height2.7. Results: The upper normal limit of LVM/ height2.7 developed from 244 (197 women, 47 men) low risk subjects (non-smoking normal-weight adults free from hypertension, diabetes, coronary artery disease & dyslipidemia) was lower than the established criteria for left ventricular hypertrophy (LVH) (31 versus 44 g/m2.7 in women; 36 versus 48 g/m2.7 in men). There is statistical difference between men and women in all groups of analysis. Among both hypertensive and normotensive subjects, the prevalence of LVH and LVM/height2.7 are higher in the obese group than normal-weight group in both genders (LVM/height2.7p<0.001; prevalence of LVH ­ obese versus normal-weight hypertension: 58% versus 34% in women, 43% versus 14% in men; obese versus normal-weight normotension: 35% versus 16% in women, 40% versus 15% in men). The same differences between obese and normal-weight groups were also present when normalizing LVM for height but not with LVM/BSA. Logistic regression analysis revealed that systolic blood pressure and BMI were the main predictors of LVH in the entire population (p<0.001 in both genders). Equations for predicting LVH in men and women were: Risk of LVH = 1/(l+e-w) where w is as follows: w (men) = 0.02* systolic pressure + 0.25*BMI ­ 9.86, w (women) = 0.03* systolic pressure + 0.17*BMI ­ 8.82. Conclusion: Obesity is an independent stimulus to increase LVM in normo-tensive subjects, and its effect is additive in hypertensive patients. Gender and obesity affect LVM and prevalence of LVH.

Age-Adjusted Dual X-ray Absorptiometry-Derived Trabecular Bone Score Curve for the Lumbar Spine in Thai Females and Males.

Trabecular bone score (TBS), which has been shown to discriminate patients with fractures from healthy individuals, decreases with age. This study was conducted to derive an age-adjusted normative TBS curve for each gender aged 30-80 + years to serve as reference data for Thai males and females. A cross-sectional study was conducted among employees from the Electricity Generating Authority of Thailand cohorts, after excluding those with conditions potentially affecting bone metabolism and analysis. The values of TBS at L1-L4 vertebrae were analyzed using a commercial software. Age-adjusted TBS curves were constructed using segmental linear regression analysis for each gender. Additional analysis was also performed on TBS with age, body mass index, and body mineral density (BMD) at L1-L4 vertebrae as covariates. A database of 848 healthy subjects (341 females and 507 males) aged 30-80+ years was created. The BMDs of both male and female subjects in the youngest decade were not statistically different from previous reports (p = 0.31 and 0.22 for females and males, respectively). In this age group, the mean TBS was higher in females, albeit not statistically significant (p = 0.12). Between the ages of 30-80+ years, female and male TBS dropped by 19.8% (0.40% per year) and 10.1% (0.20% per year), respectively. The association with TBS was weak for body mass index and moderate for BMD (coefficients of about -0.01 and 0.4-0.5, respectively). The age-adjusted reference curves for healthy Thai females and males aged 30-80+ years have been established.

Simulated increased soft tissue thickness artefactually decreases trabecular bone score: a phantom study.

BACKGROUND: Trabecular bone score (TBS), which has been proposed to be used in complementary with bone mineral density (BMD) to improve the assessment of fracture risk, is negatively associated with body mass index (BMI). The effect of soft tissue, which is expected to be thicker in subjects with high BMI, on TBS was studied using three scan types: Hologic with fast array mode (Hfa), Hologic with high definition mode (Hhd), and GE-Lunar iDXA. METHODS: A spine phantom provided by Hologic for routine quality control procedure was scanned using three scan types: Hfa, Hhd, and iDXA. The phantom was scanned with an overlying soft tissue equivalent material (bolus used in radiotherapy) of 0 (without), 1, 2.5, 3.5, 5 and 7.5 cm thick. For each setting, 30 acquisitions were performed in the same way as for the quality control procedure. TBS was calculated using TBS iNsight® software version 2.1 on the same regions of interest as those used for lumbar spine BMD. RESULTS: Mean ± SD TBS of the phantom (without overlying soft tissue) were 1.379 ± 0.018, 1.430 ± 0.009, and 1.423 ± 0.005 using Hfa, Hhd, and iDXA, respectively. A one-way repeated measures ANOVA showed that there were statistically differences in TBS due to different thicknesses of soft tissue equivalent materials for all three scan types (p < 0.001). A Tukey post-hoc test revealed that the decrease in TBS was statistically significant (p < 0.001) when the soft tissue thickness was 1 cm (-0.0246 ± 0.0044, -0.0319 ± 0.0036, and -0.0552 ± 0.0015 for Hfa, Hhd, and iDXA, respectively). Although to a lesser degree, the effects were also statistically significant for BMD (p < 0.05): an increase for Hfa and Hhd but a decrease for iDXA. However, these changes did not exceed the least significant change (LSC) derived from patients. CONCLUSIONS: Increased soft tissue thickness results in lower TBS value. Although BMD is also affected, it is unlikely to pose a clinical problem because the change is unlikely to exceed the patient-derived LSC.

The Optimal Cut-Points for Weight and Non-Weight Quantitative Ultrasound of the Calcaneus to Screen Osteoporosis in Postmenopausal Women.

OBJECTIVE: To determine the optimal cut-off point of quantitative ultrasound (QUS) of the calcaneus, and optimized position for QUS of the calcaneus, between non-weight (sitting) and weight (standing) position, to screen osteoporosis in postmenopausal women. MATERIAL AND METHOD: A cross-sectional study of postmenopausal women aged 65 years or older who came for bone mineral density (BMD) evaluation at the menopause unit, Department of Obstetrics and Gynecology, Ramathibodi Hospital between April 2013 and October 2015. Bone tissue was measured by using QUS of the calcaneus in the standard sitting (non-weight position) and in standing (weight position) consecutively of non-dominant calcaneus to compared with BMD that measured by dual energy X-ray absorptiometry (DXA) of lumbar spine and hip within the same visit of QUS measurement. The area under Receiver Operating Characteristic (ROC) curve and optimal of diagnostic properties to diagnosed osteoporosis were analyzed by sensitivity, specificity, positive and negative likelihood ratio (LR +/-). RESULTS: One hundred sixty one postmenopausal women were enrolled, median age was 70 (65, 94) years old, median time since menopause was 22 (10, 55) years. Ten point five percent of subjects had history of osteoporotic fracture at wrist. The prevalence of osteoporosis was 23% at lumbar spine and 30% at femoral neck respectively. Area under ROC curve for diagnosed osteoporosis was 0.73 in the non-weight QUS of the calcaneus and correlated well with using DXA at neck of femur (gold standard). However the weight or standing position did not improve the diagnostic power of QUS of the calcaneus. The optimal cut-point value of QUS of the calcaneus to screen osteoporosis at stiffness index was determined by T-score of ≤ -2.6 with 81.42%, 45.83%, 1.5, and 0.41 for the sensitivity, specificity, LR +/- respectively. CONCLUSION: QUS of the calcaneus was acceptable and promising to be alternative tool for screening osteoporosis in postmenopausal woman age older than 65 years by the optimal cut-point of stiffness index T-score at ≤ -2.6 measured in standard position or non-weight method.

Relationship of vitamin D status and bone mass according to vitamin D-binding protein genotypes.

BACKGROUND: Vitamin D-binding protein (DBP) may alter the biological activity of total 25-hydroxyvitamin D [25(OH)D]; this could influence on the effects of vitamin D in relation to bone mineral density (BMD) and fractures. Emerging data suggest that fetuin-A may be involved in bone metabolism. We aimed to investigate the influence of DBP gene polymorphism on the relationship of vitamin D status and fetuin-A levels to BMD and bone markers. METHODS: This cross-sectional study was part of a health survey of employees of the Electricity Generating Authority of Thailand (1,734 healthy subjects, 72% male). Fasting blood samples were assayed for 25(OH)D, fetuin-A, N-terminal propeptides of type 1 procollagen (P1NP), C-terminal cross-linking telopeptides of type I collagen (CTx-I), and DBP rs2282679 genotypes. L1-L4 lumbar spine and femoral BMD were measured using dual-energy X-ray absorptiometry. RESULTS: The DBP rs2282679 genotype distribution conformed to the Hardy-Weinberg equilibrium. There were no correlations between 25(OH)D levels and BMD and bone markers. But a trend of positive correlation was observed for the DBP genotypes with total hip BMD, and for the interaction between 25(OH)D and DBP genotypes with BMD at all femoral sites. We further analyzed data according to DBP genotypes. Only in subjects with the AA (common) genotype, 25(OH)D levels were positively related to BMD and bone markers, while fetuin-A was negatively related to total hip BMD, independently of age, gender and BMI. CONCLUSIONS: The interaction between vitamin D status, as measured by circulating 25(OH)D and DBP rs2282679 genotypes, modified the association between 25(OH)D and BMD and bone markers. Differences in DBP genotypes additionally influenced the correlation of fetuin-A levels with femoral BMD.

Work- and travel-related physical activity and alcohol consumption: relationship with bone mineral density and calcaneal quantitative ultrasonometry.

A number of healthy workers rarely exercise because of a lack of time or resources. Physical activity related to work and everyday travel may be more feasible, but evidence of its beneficial effect on bone health is scarce. We assessed if this form of physical activity was associated with higher bone mineral density (BMD) and stiffness index (SI) when adjusted for recreational physical activity, age, body mass index, smoking, alcohol consumption, education, and serum level of 25-hydroxyvitamin D. Healthy workers, aged 25-54 yr, of the Electricity Generating Authority of Thailand were surveyed. The outcomes were BMD (lumbar spine, femoral neck, and total hip) and calcaneal SI. Physical activity was estimated using the global physical activity questionnaire and considered active when >600 metabolic equivalent tasks (min). Of 2268 subjects, 74% were men. Active male subjects had significantly higher BMD at the femoral neck and total hip (p<0.005). However, the association was not significant with male lumbar spine BMD, male SI, or any bone parameters in women (p>0.05). In men, work and travel physical activity seems beneficial to male bone health; hence, it should be encouraged. Furthermore, smoking appeared harmful while moderate alcohol consumption was beneficial.

Correlation between magnetic resonance imaging proton density fat fraction (MRI-PDFF) and liver biopsy to assess hepatic steatosis in obesity.

Obesity is highly associated with Non-alcoholic fatty liver disease (NAFLD) and increased risk of liver cirrhosis and liver cancer-related death. We determined the diagnostic performance of the complex-based chemical shift technique MRI-PDFF for quantifying liver fat and its correlation with histopathologic findings in an obese population within 24 h before bariatric surgery. This was a prospective, cross-sectional, Institutional Review Board-approved study of PDFF-MRI of the liver and MRI-DIXON image volume before bariatric surgery. Liver tissues were obtained during bariatric surgery. The prevalence of NAFLD in the investigated cohort was as high as 94%. Histologic hepatic steatosis grades 0, 1, 2, and 3 were observed in 3 (6%), 25 (50%), 14 (28%), and 8 (16%) of 50 obese patients, respectively. The mean percentages of MRI-PDFF from the anterior and posterior right hepatic lobe and left lobe vs. isolate left hepatic lobe were 15.6% (standard deviation [SD], 9.28%) vs. 16.29% (SD, 9.25%). There was a strong correlation between the percentage of steatotic hepatocytes and MRI-PDFF in the left hepatic lobe (r = 0.82, p < 0.001) and the mean value (r = 0.78, p < 0.001). There was a strong correlation between MRI-derived subcutaneous adipose tissue volume and total body fat mass by dual-energy X-ray absorptiometry, especially at the L2-3 and L4 level (r = 0.85, p < 0.001). MRI-PDFF showed good performance in assessing hepatic steatosis and was an excellent noninvasive technique for monitoring hepatic steatosis in an obese population.

Causal inference of the effect of adiposity on bone mineral density in adults.

OBJECTIVE: The causal effect of adipose tissue on bone mass and the direction of its net influence have not been directly assessed in adult humans. Using the Mendelian randomization analysis, we assessed the causality of adiposity in measurements of bone mass in adult males and females. DESIGN AND METHODS: Subjects consisted of 2154 adults aged 25-54 years from a cross-sectional cohort of the employees of the Electricity Generating Authority of Thailand. Body composition was determined after at least 3 h of fasting using multifrequency bioelectrical impedance analysis. Bone mineral density (BMD) was assessed by dual energy X-ray absorptiometry. A polymorphism in the fat mass and obesity-associated gene (FTO rs9939609) was used as an instrument in the Mendelian randomization analysis. RESULTS: The genotype distribution of the FTO rs9939609 polymorphism was 61·1% TT, 33·9% AT and 5·0% AA. The average body mass index (BMI), body fat mass and percentage body fat were 23·9 kg/m(2) (SD = 3·6), 17·9 kg (SD = 6·6) and 26·8% (SD = 7·2), respectively. The FTO rs9939609 polymorphism was significantly correlated with BMI (coefficient = 0·673 kg/m(2) , P < 0·001), body fat mass (coefficient = 0·948 kg, P < 0·001) and percentage body fat (coefficient = 0·759%, P < 0·01). An instrumental variable (IV) regression model, using BMI as the intermediate phenotype, suggested that FTO was a strong IV. Also, the FTO-BMI polymorphism was significantly associated with total hip and femoral neck BMD but was not correlated with total spine BMD, with estimated correlation coefficients of 0·0189 (95% CI: 0·0046, 0·0332), 0·0149 (95% CI: 0·0030, 0·0268) and 0·0025 (95% CI: -0·0131, 0·0136) g/cm(2) , respectively. The variances of BMDs explained by the FTO-BMI were 19·0%, 21·3% and 1·1%, respectively. Similar trends were also observed for the FTO-body fat mass and FTO-percentage body fat correlations. CONCLUSIONS: Mendelian randomization analysis suggests that adiposity might be causally related to BMD at the femur but not at the spine.

Serum uric acid levels in relation to bone-related phenotypes in men and women.

Serum uric acid levels have recently been found to be associated with bone mineral density (BMD) in elderly males. The purpose of the present study was to investigate the relationship between bone-related phenotypes and serum uric acid levels in young and middle-aged males and females. Subjects consisted of 1320 males and 485 females aged 25-54 yr. Bone densitometry and quantitative ultrasonometry (QUS) were performed on each subject. Serum uric acid and biochemical markers of bone turnover were measured in fasting serum samples. When adjusted for covariates including age, body weight, and serum creatinine in multiple linear regression models, it was found that there was a positive association between uric acid levels and BMD in males at the lumbar spine (p < 0.05). The association between uric acid levels and BMD was found in females after controlling for age, body weight, and serum creatinine at the femoral neck, but in the opposite direction (p < 0.05). Uric acid levels were related to the stiffness index (SI) as assessed by QUS in males, independent of age, body weight, and serum creatinine (p < 0.05). No association between uric acid and SI in females was found. The present study demonstrated a positive association in males between serum uric acid levels and BMD, and SI from QUS, suggesting a beneficial influence of uric acid on both the quantity and quality of bone in males.

131I-rituximab treatment in patient with relapsed non-Hodgkin's lymphoma: the first case report in Thailand.

Radioimmunotherapy (RIT) with 131-rituximab is a safe and effective treatment in patients with relapsed, refractory follicular lymphoma. The authors demonstrated the first case of 131-rituximab treatment in the patient with relapsed non-Hodgkin's lymphoma (NHL) in Thailand. There was no immediate complication after treatment. Impressive treatment response occurred.

Summary of the Thai Osteoporosis Foundation (TOPF) Clinical Practice Guideline on the diagnosis and management of osteoporosis 2021.

Objectives: The Thai Osteoporosis Foundation (TOPF) is an academic organization that consists of a multidisciplinary group of healthcare professionals managing osteoporosis. The first clinical practice guideline for diagnosing and managing osteoporosis in Thailand was published by the TOPF in 2010, then updated in 2016 and 2021. This paper presents important updates of the guideline for the diagnosis and management of osteoporosis in Thailand. Methods: A panel of experts in the field of osteoporosis was recruited by the TOPF to review and update the TOPF position statement from 2016. Evidence was searched using the MEDLINE database through PubMed. Primary writers submitted their first drafts, which were reviewed, discussed, and integrated into the final document. Recommendations are based on reviews of the clinical evidence and experts' opinions. The recommendations are classified using the Grading of Recommendations, Assessment, Development, and Evaluation classification system. Results: The updated guideline comprises 90 recommendations divided into 12 main topics. This paper summarizes the recommendations focused on 4 main topics: the diagnosis and evaluation of osteoporosis, fracture risk assessment and indications for bone mineral density measurement, fracture risk categorization, management according to fracture risk, and pharmacological management of osteoporosis. Conclusions: This updated clinical practice guideline is a practical tool to assist healthcare professionals in diagnosing, evaluating, and managing osteoporosis in Thailand.

Dialysate Magnesium and Coronary Artery Calcification, Bone Mineral Density, and Cramping in Maintenance Hemodialysis: A Quasi-experimental Study.

RATIONALE & OBJECTIVE: Recent evidence suggests a role for magnesium as a calcification inhibitor. Increased magnesium abundance may attenuate vascular calcification and promote bone formation. STUDY DESIGN: Parallel-group, 1:1-allocation-ratio, quasi-experimental study. SETTING & PARTICIPANTS: The study was conducted at hemodialysis centers in Bangkok, Thailand. Patients receiving maintenance hemodialysis were screened for coronary artery calcification (CAC) and bone mineral density (BMD), and those with a CAC score of ≥300 were included and matched according to the initial CAC score. The intervention and control groups consisted of 20 patients in each arm. INTERVENTIONS: A high (1.75 mEq/L) or standard (0.7 mEq/L) dialysate magnesium concentration was delivered for 26 weeks. OUTCOMES: Changes in the CAC score and BMD and the progression of CAC. The safety outcomes included occurrence of cramps recorded as per usual care. RESULTS: The median CAC score of all patients was 1,792. Serum and ionized magnesium concentrations increased substantially in the high dialysate magnesium group. At the end of the study, the CAC score increased significantly in both the groups, with no significant difference between the groups. The number of participants with CAC progression was comparable between the 2 groups. In exploratory subgroup analyses stratified by the median CAC score, a significant decline in CAC and fewer participants with CAC progression were observed in the subgroup with lower CAC scores that received the high dialysis magnesium concentration. Bone mineral density was largely unchanged in both groups. The number of participants experiencing cramps and the number of episodes of muscle cramps were markedly lower among patients who received the high dialysis magnesium concentration. LIMITATIONS: The participants had severe vascular calcification at baseline; therefore, the findings might not apply to those with less-established calcification. Moreover, cramps were not systematically ascertained. CONCLUSIONS: The high dialysis magnesium concentration did not alleviate the progression of CAC or improve BMD in patients with severe calcification receiving hemodialysis; however, muscle cramps were less frequent among those treated with high dialysate magnesium. Further study is required to determine a possible favorable effect of high dialysis magnesium concentration in individuals with mild-to-moderate calcification.

Risk-stratified papillary thyroid microcarcinoma: post-operative management and treatment outcome in a single center.

PURPOSE: This article aims to review and assess the post-operative management and treatment outcomes of papillary thyroid microcarcinoma (PTMC) in risk-stratified patients. METHODS: We retrospectively analyzed the data of PTMC patients who underwent thyroid surgery with or without radioactive iodine treatment (RAI) in a single center between January 2011 and December 2017. Demographic and clinicopathologic data were collected. Risk stratification according to the 2015 American Thyroid Association guideline was applied. RESULTS: Three hundred forty PTMC patients were included. Post-operative RAI was performed in 216/340 (63.53%) patients. In the non-RAI scenario, there were 122 low-risk and two intermediate-risk patients. In total, 261 (76.77%), 57 (16.76%), and 22 (6.47%) patients were classified as low, intermediate, and high risk, respectively. With a median follow-up time of 36 months (interquartile range: 23, 52), we found unfavorable outcomes (evidenced by imaging or out-of-range serum tumor marker levels: high thyroglobulin [Tg] or rising Tg antibody [TgAb] levels) in 8/340 (2.35%) patients, all of which received RAI. PTMC patients with unfavorable outcomes were stratified as low risk (4/261 [1.53%]), intermediate risk (1/57 [1.75%]), or high risk (3/22 [13.64%]). One death occurred in a patient with initial distant metastasis in the high-risk group. Initial high-risk stratification and initial stimulated Tg (of at least 10 ng/mL) were demonstrated as independent predictors for PTMC unfavorable outcomes (persistent or recurrent disease). Five patients with unfavorable outcomes (four with persistent disease and one with recurrent disease) had abnormal Tg or TgAb values despite unremarkable imaging findings. Moreover, 79/124 (63.71%) patients in the non-RAI scenario were only followed up with neck ultrasound. CONCLUSIONS: In general, at least 98% of low-risk and intermediate-risk PTMC patients showed favorable outcomes without persistent or recurrent disease, defined by either imaging or serum tumor markers. Nevertheless, aggressive disease could occur in few PTMC patients. Decisions on post-operative management and follow-up may be guided by initial high-risk stratification and initial stimulated Tg levels (≥10 ng/mL) as independent predictors for PTMC unfavorable outcomes. Monitoring using both imaging and serum tumor markers is crucial and should be implemented for patients with PTMC.

Bone Mineral Density and Trabecular Bone Score in Predicting Vertebral Fractures in Male Employees of the Electricity Generating Authority of Thailand.

Purpose: Osteoporotic VF is frequently asymptomatic and affects not only women but also men. Identifying patients at risk is essential for early management and prevention. BMD and the TBS are measurements of bone strength and trabecular microarchitecture, respectively. Their role in VF prediction in men is less well-studied. We determined the BMD and TBS predictive ability for osteoporotic VF in men. Methods: A total of 115 male participants of the Electricity Generating Authority of Thailand (EGAT) cohorts without a history of VF who completed the baseline BMD and TBS measurements in 2012 and a thoracolumbar spine radiograph in 2017 were recruited. The VF was assessed using the Genant semiquantitative method. Logistic regression analysis was performed to identify factors associated with the fracture. The area under the receiving operator curve (AUC) was analyzed to define VF predictive ability. Results: Forty subjects (34.78%) had VFs. The unadjusted relative risks (95% confidence interval) for VF for one standard deviation decrease in the TBS and low TBS were 1.319 (1.157-1.506) and 2.347 (1.496-3.682), respectively, and remained significant after BMD and age adjustment. For VF prediction, combined models had a greater AUC than models predicted from a single variable. The use of low TBS, femoral neck BMD, and age provided the best AUC (0.693). Conclusion: BMD and the TBS could predict osteoporotic VF in male EGAT employees. The use of both BMD and the TBS in the VF prediction process improved predictive ability.

Normal data of left ventricular parameters in non-hypertensive patients using 320-slice cardiac CT: a study on intra- and interobserver variability.

OBJECTIVE: Delineate normal data in a Thai population for global left ventricular function, left ventricular mass (LVM), and LV mass index (LVMI) by gated volumetric CT angiography (CTA). MATERIAL AND METHOD: Two hundred twenty seven patients with intermediate risk factors for CAD were referred for CT coronary angiography. The non-hypertensive and non-diabetic asymptomatic group was selected with negative coronary CTA. Pre-condition of mild stenosis or less than 50% area stenosis was consistently met for inclusion in the present study. One hundred fifteen patients were included (31 males, 84 females, age range 38-76 years, mean 54.6 +/- 7.2 for males and 54.0 +/- 6.8 for females respectively). RESULTS: Mean EDV, ESV, SV, CO, and EF in male and females were EDV 122.6 +/- 17.3 vs. 94.9 +/- 16.6ml, ESV 48.2 +/- 9.9 vs. 34.1 +/- 9.1 ml, SV 74.5 +/- 14.2 vs. 60.8 +/- 10.6 ml, CO 4.2 +/- 0.8vs. 3.6 +/- 0.7 Land EF 60.6 +/- 6.6 vs. 64.3 +/- 5.6% respectively The mean LVM and LVMI were higher in males than females (LVM 134.6 +/- 21.4 vs. 96 9 +/- 20.3 g, and LVMI 76.8 +/- 12.4 vs. 61.1 +/- 11.56 g/m2). Altman and Bland plot for each of them showed that the mean and standard deviation of the differences was constant throughout the range of measurements. Each histogram of differences showed that these differences correspond to approximately normal distribution, indicating that the required assumptions held for the use of 95% limits of agreement are valid. CONCLUSION: Data from this group represents healthy volunteers and this may serve as an important source of information representing normal reference values to be used for Thai patients.