Comparison of Trabecular Bone Score-Adjusted Fracture Risk Assessment (TBS-FRAX) and FRAX Tools for Identification of High Fracture Risk among Taiwanese Adults Aged 50 to 90 Years with or without Prediabetes and Diabetes.

Background and Objectives: The burden of osteoporosis is projected to increase. Identification and prompt intervention for osteoporotic fractures are important. Adjusting the Fracture Risk Assessment (FRAX®) tool with trabecular bone score (TBS) could improve risk prediction. However, little is known about whether TBS-adjusted FRAX® would change the proportion of individuals qualified for osteoporosis intervention. Therefore, the aim of the present study was to compare the proportions of Taiwanese adults who qualified for intervention, according to the FRAX® and TBS-adjusted FRAX®, with stratification by sex, age group, and glucose regulation status. Materials and Methods: A medical record review on adults 50−90 years who had undergone a general health examination in a regional hospital in Taiwan was conducted. FRAX® and TBS-adjusted FRAX® were calculated. FRAX® cut-points of ≥ 20% for major osteoporotic fracture and ≥3% for hip fracture were adopted to identify individuals qualified for osteoporosis intervention. Individuals were classified as prediabetes and diabetes if their HbA1c was 5.7−6.4% and >6.4%, respectively. Results: A total of 8098 individuals with a mean age of 61.0 years were included. The proportion of men qualified for intervention for hip fracture was significantly lower according to TBS-adjusted FRAX® (17.2%) compared with FRAX® (20.7%) (p < 0.001), with a similar pattern across all three age groups and in those with prediabetes. In contrast, the proportion of women qualified for intervention for major osteoporotic fracture was significantly higher according to TBS-adjusted FRAX® (4.6%) compared with FRAX® (3.7%) (p < 0.001), particularly among those with prediabetes 60−69 years. Conclusions: TBS-adjusted FRAX® led to small but significant changes in the proportions of individuals qualified for intervention in specific age groups and glucose regulation status.

Changes in Bone Mineral Density and Trabecular Bone Score over Time between Vegetarian and Non-Vegetarian Middle-Aged and Older Women: A Three-Year Retrospective Medical Record Review.

The effect of a vegetarian diet on bone health remains controversial. This retrospective medical record review compared changes in bone mineral density (BMD) and trabecular bone score (TBS) between vegetarian and non-vegetarian middle-aged and older women who underwent two general health examinations (T1 and T2) that were approximately three years apart. Generalized estimating equations were used to compare the change in lumbar spine and bilateral hip BMD and TBS over time. At T1, the mean age of the patients was 56.6 years (standard deviation 9.7 years) and the mean interval between T1 and T2 was 2.7 years. For women aged 40-55 years, compared with non-vegetarians, vegetarians were significantly associated with a larger reduction in lumbar spine BMD (p < 0.001) and left hip femoral neck BMD (p = 0.015) over the three-year interval. On the contrary, changes in BMD were not significant at any site in women aged ≥ 56 years. Moreover, the changes in BMD and TBS over the three-year interval did not significantly differ between vegetarian and non-vegetarian women aged 65-90 years. In conclusion, for women aged 40-55 years, vegetarian diets reduced bone quantity, as measured by BMD, but not bone quality, as measured by TBS.

Association of Trabecular Bone Score-Adjusted Fracture Risk Assessment Tool with Coronary Artery Calcification in Women.

The trabecular bone score (TBS) was found to be significantly associated with moderate coronary artery calcification (CAC). The aim of this study was to further explore the association between TBS-adjusted Fracture Risk Assessment Tool (FRAX) and CAC score in women. The electronic medical record database of a regional teaching hospital in southern Taiwan yielded women who received both coronary computed tomography and bone mineral density (BMD) measurement during their general health examination. Health history, anthropomorphic measurements, laboratory results, BMD, and T-scores were obtained. TBS values were calculated from database spine dual-energy X-ray absorptiometry files. Linear regression analyses tested the association between CAC score and 10-year probability of major osteoporotic fracture (MOF) and hip fracture (HF) determined by TBS-adjusted FRAX. Of the 116 women (mean age 55.8 years) studied, 24.1% had osteoporosis. Simple linear regression showed a significant association of CAC score with an increase in MOF and HF risk as measured by TBS-adjusted FRAX. In multiple linear regression adjusted for potential confounders, CAC score remained significantly associated with TBS-adjusted FRAX for right MOF (p = 0.002), left MOF (p = 0 006), right HF (p = 0.005), and left HF (p = 0.015). In conclusion, clinicians should be vigilant to the potential increased risk of coronary events among women with increased TBS-adjusted FRAX for MOF and HF.

Age-Specific Normative Values of Lumbar Spine Trabecular Bone Score (TBS) in Taiwanese Men and Women.

Trabecular bone score (TBS) is a novel method for assessing trabecular microarchitecture. Normative values of TBS are available for various populations of the world but are not yet available for Taiwanese adults. Therefore, the purpose of this study was to estimate age-specific, normative TBS curves for Taiwanese men and women. Medical records of general health examinations from a regional hospital in Southern Taiwan were reviewed. Individuals aged 30-90 years with data on lumbar spine bone mineral density (BMD) were included. TBS was retrospectively calculated from dual-energy X-ray absorptiometry scans using TBS iNsight software. Of the 12,028 patients included, 4533 (37.7%) were male and the mean age was 55.8 years. The mean TBS was 1.392 (standard deviation (SD) 0.089) for men and 1.344 (SD 0.107) for women. In women, TBS declined at a rate of 0.0004/year among those aged 30.0-45.9 years, 0.0106/year among those 46.0-60.7 years, and 0.0028/year among those 60.8-90.0 years. In men, TBS declined at a constant rate of 0.0023/year over the entire age range. In conclusion, age-adjusted, normative curves of TBS for Taiwanese men and women are presented, which could be used to facilitate the use of TBS in assessing bone status in clinical practice.

Bone Mineral Density and Hemoglobin Levels: Opposite Associations in Younger and Older Women.

This cross-sectional, retrospective medical record review study aimed to investigate the association between hemoglobin levels and bone mineral density (BMD) in adult women. Medical records obtained from general health examinations conducted from June 2014 to July 2020 at a regional hospital in southern Taiwan were reviewed. Anthropometric and laboratory data were recorded. BMD of the lumbar spine and bilateral femoral neck regions was assessed by dual energy X-ray absorptiometry. Linear regression analysis was used to assess the association between BMD and hemoglobin level with and without adjusting for other anthropometric and laboratory data. The study included 9606 female patients with a mean age of 55.9 years. Of these, 2756 (28.7%) were aged ≤ 50 years and 6850 (71.3%) were aged > 50 years. Results from multiple linear regression analysis showed that hemoglobin and femoral and lumbar spine BMD were significantly correlated. A higher hemoglobin level was significantly associated with a lower BMD level in females aged ≤ 50 years, but with a higher BMD level in those aged > 50 years. Given the relationship between bone metabolism and hematopoiesis, additional research is needed to elucidate the association between hemoglobin and BMD levels in different age groups, particularly in premenopausal and perimenopausal women.

Significant association factors of bone mineral density in Taiwan adults.

OBJECTIVE: To examine the biofactors associated with bone mineral density (BMD) in southern Taiwanese adults. MATERIALS AND METHODS: The medical records of 3242 adults who underwent health examinations between June 2014 and February 2018 at a regional hospital in southern Taiwan were reviewed. The data collected included health history, anthropomorphic characteristics, clinical laboratory results, biochemical parameters, and BMD. The data were used to identify the biofactors associated with BMD/T-scores at the lumbar spine and femoral neck by multivariate linear regression analysis with the stepwise method. RESULTS: The mean age of the patients was 58.1 years, and 71.4% were male. Factors positively correlated with BMD and the T-score included body mass index (BMI), male gender, calcium, and creatinine. Age, alkaline phosphatase (ALP), triiodothyronine, serum thyroxine, low-density lipoprotein cholesterol, and a history of hyperlipidemia were negatively correlated with BMD and the T-score. CONCLUSION: The associated biofactors reported here were similar to and had similar relationships as the biofactors identified in previous literature reports. Not all of the sites examined for BMD were influenced by the same association factors, except for BMI, male gender, age, and ALP, implying that the bone remodeling processes that shape BMD involve a complex regulatory network and demonstrating that our extracted factors are the most useful for clinical practice.

Association of bone mineral density and trabecular bone score with cardiovascular disease.

Traditionally, osteoporosis and cardiovascular disease (CVD) are considered as separate chronic diseases. Increasing evidence now links osteoporosis with hypertension, abnormal lipid metabolism, atherosclerosis, vascular calcification (VC), and congestive heart failure. VC coexists with bone loss, and aortic calcification is a strong predictor of low bone mineral density (BMD) and fragility fractures. The same holds true for coronary artery calcification (CAC): the lower the BMD, the higher the CAC. Trabecular bone score (TBS) iNsight software can analyze the existing BMD database to obtain the bony microstructure score (TBS). Many TBS-related studies include fracture risk, normal aging, diabetes, potential genes, obesity, and asthma severity prediction. The inverse relationship of TBS to VC may provide insight into bone-vascular interactions in chronic kidney disease. A higher TBS has been associated with moderate, but not high, CAC. One explanation is that bone microstructural remodeling becomes more active during early coronary calcification. Increased risk of 10-year likelihood of hip fracture and major osteoporotic fracture as estimated by the fracture risk assessment tool FRAX® is significantly and independently associated with more severe CAC scores. Dual-energy X-ray absorptiometry and FRAX® can be used to predict fracture risk and CAC scores, identifying patients who may benefit from early intervention. This review will discuss the relationship and possible mechanism of BMD, TBS, and FRAX® with CVD and VC or CAC.

Low Hemoglobin Is Associated With Low Bone Mineral Density and High Risk of Bone Fracture in Male Adults: A Retrospective Medical Record Review Study.

The aim of this study was to examine the association between serum hemoglobin level, bone mineral density, and fracture risks based on the estimated score of the Fracture Risk Assessment Tool (FRAX) in Asian male adults. The medical records of 662 male patients who underwent health examinations at a regional teaching hospital in southern Taiwan were reviewed. The medical history, demographic characteristics, clinical laboratory results, and bone mineral density of the patients were ascertained from their medical records. Simple and multiple linear regression analyses were conducted to evaluate the association of hemoglobin levels with bone mineral density, the 10-year risk of hip fracture, and the 10-year risk of major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture) as assessed by FRAX. The mean age of the patients was 53.1 years. Results from simple linear regression analysis indicated that hemoglobin was positively associated with bone mineral density but inversely associated with both hip fracture risk and major osteoporotic fracture risk. Similar results were obtained when potential confounding variables were adjusted using multiple linear regression analysis. Low serum hemoglobin levels might be an important indicator for predicting bone mineral loss and the risk of both major osteoporotic fracture and hip fracture in male patients. Bone mineral density should be closely monitored in patients receiving treatment for anemia.

Age-adjusted Charlson Comorbidity Index scores predict major adverse cardiovascular events and all-cause mortality among systemic lupus erythematosus patients.

OBJECTIVE: Cardiovascular events are the most frequent cause of death or disability among people with systemic lupus erythematosus (SLE). However, the causes of this increased the risk of major adverse cardiovascular events (MACEs) are not completely understood. The Age-adjusted Charlson Comorbidity Index (ACCI) is a prognostic classification that was initially developed for patients who have a number of comorbid conditions and the ACCI has been validated in many clinical settings. MATERIALS AND METHODS: In this study, 5998 patients were enrolled from the National Health Research Institute Database of Taiwan. All the patients' sequential clinical data related to their diagnosis of SLE were reviewed from 2004 to 2007 to determine their risk of MACE occurrence and of all-cause mortality using their ACCI scores. RESULTS: The predictive accuracy of the ACCI scores in relation to MACE occurrence among SLE patients was estimated and the C-statistic for this curve was found to be 0.687 (95% confidence interval [CI]: 0.664-0.709). The distribution of ACCI scores for MACE patients was 4.7%, 10.3%, 11.4%, and 21.5% for those with ACCI scores in the ranges of 0-1, 2-3, 4-5, and >6, respectively. A plot of the cumulative risk also showed a much higher risk among SLE patients with an ACCI score of >6. When patients were divided into different groups based on their ACCI scores, those with ACCI scores of >6 had an adjusted hazards ratio of 4.88 (95% CI: 3.84-6.19; P < 0.001) as compared to those with ACCI scores of 0-1. CONCLUSION: SLE patients with higher ACCI scores have a significantly higher risk of a MACE and of all-cause mortality. Our results suggested that ACCI scores may be useful as an index for estimating global cardiovascular risk among patients with SLE.

Trabecular Bone Score Reflects Trabecular Microarchitecture Deterioration and Fragility Fracture in Female Adult Patients Receiving Glucocorticoid Therapy: A Pre-Post Controlled Study.

A recently developed diagnostic tool, trabecular bone score (TBS), can provide quality of trabecular microarchitecture based on images obtained from dual-energy X-ray absorptiometry (DXA). Since patients receiving glucocorticoid are at a higher risk of developing secondary osteoporosis, assessment of bone microarchitecture may be used to evaluate risk of fragility fractures of osteoporosis. In this pre-post study of female patients, TBS and fracture risk assessment tool (FRAX) adjusted with TBS (T-FRAX) were evaluated along with bone mineral density (BMD) and FRAX. Medical records of patients with (n = 30) and without (n = 16) glucocorticoid treatment were retrospectively reviewed. All patients had undergone DXA twice within a 12- to 24-month interval. Analysis of covariance was conducted to compare the outcomes between the two groups of patients, adjusting for age and baseline values. Results showed that a significant lower adjusted mean of TBS (p = 0.035) and a significant higher adjusted mean of T-FRAX for major osteoporotic fracture (p = 0.006) were observed in the glucocorticoid group. Conversely, no significant differences were observed in the adjusted means for BMD and FRAX. These findings suggested that TBS and T-FRAX could be used as an adjunct in the evaluation of risk of fragility fractures in patients receiving glucocorticoid therapy.

FRAX® Fracture Risks Are Associated with Coronary Artery Calcification Score.

PURPOSE: To examine the association between fracture risk assessment tool (FRAX) scores and coronary artery calcification (CAC) score in adults. METHODS: The medical records of 81 adults who underwent both coronary computed tomography and bone mineral density (BMD) studies in a package during their health exams were reviewed at a regional hospital in Southern Taiwan. Data collected included health history, anthropomorphic characteristics, clinical laboratory results, and BMD. Fracture risk was determined using FRAX. Univariate and multivariate linear regression analysis were used to assess the association between CAC score and 10-year probability of hip fracture (HF) and major osteoporotic fracture (MOF) determined by FRAX. RESULTS: The mean age of the patients was 55.8 years, and 63.0% were male. Univariate linear regression analysis showed that increases in MOF and HF risks, as measured by FRAX, were significantly and positively associated with CAC score. Multiple linear regression analysis adjusting for potential confounders showed that CAC score remained significantly associated with four FRAX indicators, including right MOF (r = 0.45, P < 0.001), left MOF (r = 0.31, P = 0.021), right HF (r = 0.38, P = 0.001), and left HF (r = 0.23, P = 0.049). CONCLUSIONS: Increased risks of MOF and HF as determined by FRAX were significantly and independently associated with CAC score.

CHADS 2 Scores in the Prediction of Major Adverse Cardiovascular Events in Patients with Cushing's Syndrome.

Vascular events are one of the major causes of death in case of Cushing's syndrome (CS). However, due to the relative low frequency of CS, it is hard to perform a risk assessment for these events. As represented congestive heart failure (C), hypertension (H), age (A), diabetes (D), and stroke (S), the CHADS2 score is now accepted to classify the risk of major adverse cardiovascular events (MACEs) in patients with atrial fibrillation. In this study, participants were enrolled from the National Health Research Institute Database (NHIRD) of Taiwan, and we reviewed 551 patients with their sequential clinically diagnosed CS data between 2002 and 2009 in relation to MACEs risk using CHADS2 score. Good correlation could be identified between the CS and CHADS2 score (AUC = 0.795). Our results show that patients with CS show significantly higher risk of vascular events and the CHADS2 score could be applied for MACEs evaluation. Adequate lifestyle modifications and aggressive cardiovascular risks treatment are suggested for CS patients with higher CHADS2 score.

Factors that affect self-care behaviour of female high school students with dysmenorrhoea: a cluster sampling study.

The purpose of this study was to identify factors that affect the self-care behaviour of female high school students with dysmenorrhoea. This cross-sectional study utilized a questionnaire-based survey to understand the self-care behaviour of female high school students dysmenorrhoeal, along with the factors that affect this behaviour. A cluster random sampling method was adopted and questionnaires were used for data collection. Study participants experienced a moderate level of discomfort from dysmenorrhoea, and perceived dysmenorrhoea as serious. This investigation finds that cues to action raised perceived susceptibility to dysmenorrhoea and the perceived effectiveness of self-care behaviour and, therefore, increased the adoption of self-care behaviour. Hence, school nurses should offer female high school students numerous resources to apply correct self-care behaviour.

Effectiveness of implementation of a new drug storage label and error-reducing process on the accuracy of drug dispensing.

This study evaluated the effectiveness of implementation of an improved storage label and an error-reducing process on the incidence of drug-dispensing errors. A total of 27 pharmacists (11 male and 16 female) were included. Questionnaires were distributed to pharmacists to measure their degree of satisfaction with the format and content of the labels. The questionnaires were completed before and one month after implementation of new label. Pharmacists were also requested to follow a new error-reducing dispensing process by circling the following items on the new storage label: drug name, appearance, packaging, dose, and formulation. The pharmacists' degrees of satisfaction increased significantly after implementation of the new label with respect to these questionnaire items: all label format items, edition appropriateness, use of capital fonts to distinguish similar drug names, reminder images to help with drug differentiation, and complete label information. The outpatient monthly drug-dispensing error rate was significantly decreased.

Technetium-99m-labeled autologous serum albumin: a personal-exclusive source of serum component.

Technetium-99m human serum albumin ((99m)Tc-HSA) is an important radiopharmaceutical required in nuclear medicine studies. However, the risk of transfusion-transmitted infection remains a major safety concern. Autopreparation of serum component acquired from patient provides a "personal-exclusive" source for radiolabeling. This paper is to evaluate the practicality of on-site elusion and subsequent radiolabeling efficacy for serum albumin. Results showed that the autologous elute contained more albumin fraction than serum without extraction procedure. Good radiochemical purity and stability were demonstrated after radiolabeling. Biodistribution study showed that labeled albumin accumulated immediately in the lung, liver, and kidney. It was cleared steadily and excreted in the urine. The biologic half-life was defined, and all samples passed the pyrogenicity and sterility tests. In conclusion, autoalbumin could be extracted and radiolabeled properly in a nuclear medicine setting. Moreover, the risk of transfusion-transmitted infection associated with nonautologous, multisource (99m)Tc-HSA agents can be reduced.

Development of pictographs depicting medication use instructions for low-literacy medical clinic ambulatory patients.

BACKGROUND: One approach to help elderly and low-literacy patients understand instructions for medication use is to use pictographs or pictorial diagrams. However, most of these pictographs are designed by medical professionals and may not be optimal for such patients. OBJECTIVE: To compare low-literacy patients with medical staff in dimensions of preference and comprehension of pictographs intended to illustrate medication use instructions for medical clinic ambulatory patients. METHODS: Following 2 pilot tests, the first with small samples (5 pharmacists and 5 patients) and the second with 100 patients with low literacy, a survey of pictograph understanding and preference was conducted between May and October 2008. The survey used a third version of 3 sets of pictographs in 4 medication instruction categories for 250 low-literacy patients and 250 members of the medical staff in a teaching hospital in southern Taiwan. The 4 medication instruction categories were (a) route of administration for external use; (b) time of day for medication administration; (c) medication administration before, after, or with meals; and (d) administration quantity. The measure of preference was which pictograph in each subset best described the instruction, and the measure of comprehension was the percentage of participants who understood the meaning of the pictograph. Differences between the 2 groups in pictograph choice and comprehension were calculated using Fisher's exact test. RESULTS: All patients were considered low literacy (never attended school or grade 6 education or less). The preference of pictographs was significantly different between patients and medical staff for each of the 12 sets of pictographs. Comprehension was significantly different between patients and medical staff for pictographs in the categories of medication administration time of day and medication administration associated with meals. For pictographs representing "at bedtime," "after meals," and "with meals," the percentage of patients who chose "do not understand" was significantly higher than the percentage of medical staff choosing this item. The 3 patient age groups were 60 years or younger (43.2%), aged 61 to 70 years (26.4%), and aged 71 years or older (30.4%). Preference was found to be significantly different among the 3 patient age groups in pictographs for medication administration time "before meals" (P = 0.002), "after meals" (P = 0.007), "with meals"(P = 0.037), and in the pictographs representing "half tablet" (P = 0.012) in the category of administration quantity. Comprehension was found to differ among the 3 patient age groups in pictographs representing "at bedtime" (P = 0.040), "before meal" (P = 0.022), "after meals" (P = 0.025), and "with meals" (P = 0.014) and for "one, two, or three tablets" (P = 0.041). CONCLUSION: Patients and medical staff had significant differences in preference for all categories of medical instruction pictographs and had significant differences in comprehension for the pictographs in the categories of medication administration time of day and medication administration associated with meals. Patients' preferences for and comprehension RESEARCH of the medical instruction pictographs were age-related. For successful development of a comprehensible prescription drug label, a diverse sample of patients should be consulted to ensure that the pictographs depicting medication use instructions are useful to all individuals, including those with low literacy.

Stability of the mixture of technetium-99m human serum albumin and lidocaine hydrochloride for clinical application.

AIM: To evaluate the stability of the mixture of technetium-99m (99mTc) human serum albumin (HSA) with the local anesthetic lidocaine hydrochloride. MATERIALS AND METHODS: We assessed three preparations of the radiotracer, 99mTc-HSA, filtered 99mTc-HSA, and a mixture of 99mTc-HSA with lidocaine hydrochloride and then filtered. Time sequence evaluation was performed on all the specimens (n= 10) at 0, 30, 60, 90, 120, 150, and 180 min after preparation. Measurements of radiochemical purity as labeling stability and pH value change were conducted for each group of specimens. RESULTS: We found no definite difference in the stability before and after the filtering procedure for 99mTc-HSA. However, we showed a decline of stability in the mixture of 99mTc-HSA with lidocaine. The filtered specimens showed a relatively higher pH value, towards a more neutral status, as compared with the unfiltered specimens. CONCLUSION: Though pain relief for the patient receiving sentinel lymph node mapping is important, a preparation of a mixture of 99mTc-HSA and lidocaine may cause radiolabeling instability. Furthermore, compared with the filtered 99mTc-sulfur colloid, a filtering procedure does not change the labeling stability of the 99mTc-HSA. On the contrary, the filtered preparation was neutralized closer to the physiologic condition. For lymphoscintigraphic studies,our results suggested that pretreatment with local anesthesia followed by subdermal injection of a filtered 99mTc-HSA rather than a pre-mixture with lidocaine is appropriate for clinical application.

Outcome of surgical resection for protein-losing enteropathy in systemic lupus erythematosus.

Protein-losing enteropathy (PLE) is an uncommon manifestation associated with systemic lupus erythematosus (SLE). Here, a case with SLE and concomitant hypoalbuminemia is reported. Technetium-99m albumin scintigraphy demonstrated a localized lesion in the ascending colon, and the diagnosis of SLE-related PLE was established. Due to a poor response to medical treatment, this patient received surgical resection, but relapse still developed later on. Recurrent protein-lose from the remaining of the colon was documented by repeated images. This report discusses the management of SLE-related PLE and the role of nuclear medicine scintigraphy in the investigation of PLE.