High prevalence of undiagnosed vertebral fractures in patients suffering from hip fracture at their hospital admission: weak concordance among observers.

BACKGROUND: Vertebral fracture is often underdiagnosed. Patients with hip fracture may suffer from vertebral fracture without knowing it. The diagnosis of vertebral fracture is sometimes difficult because there is no consensus regarding the definition of osteoporotic vertebral fracture, and several indexes may be used to diagnose it and the concordance between several observers may not be optimal. OBJECTIVE: To study the concordance in the diagnosis of vertebral fracture done by three different doctors: an orthopedic surgeon, a radiologist, and a bone mineral metabolism expert. METHODS: A lateral thoracic-lumbar spine X-Ray was performed in 177 patients suffering from hip fracture to assess the presence or absence of vertebral fractures. Three different observers applied Genant's criteria for it. Concordance between observers was measured using Cohen's kappa coefficient. RESULTS: Patients suffering from hip fractures have undiagnosed vertebral fractures in a range that varies from 41.8 to 47.5% depending on the observer. The concordance in the diagnosis of vertebral fractures is quite low, ranging a Cohen's kappa coefficient from 0.43 to 0.55 and a percentage of concordance varying from 64 to 72%. The best concordance was found between observers 1 and 3. DISCUSSION: Depending on the observer who made the diagnosis, the prevalence of previously undiagnosed vertebral fractures in patients with HF varied widely. We selected three different observers to assess the possible differences in the diagnosis of vertebral fractures among these patients and using the same method (Genant's semi-quantitative assessment), surprisingly, there was little concordance among the three of them. CONCLUSION: Patients with hip fracture have high prevalence of undiagnosed vertebral fractures. The diagnosis of these fractures varies widely depending on the observers and the Cohen's kappa coefficient and percentage of concordance is rather low.

Discriminative ability of heel quantitative ultrasound in postmenopausal women with prevalent vertebral fractures: application of optimal threshold cutoff values using classification and regression tree models.

Quantitative ultrasound (QUS) of the heel has been proposed as a screening tool to evaluate the bone status and risk of osteoporotic fragility fractures. The aim of this study was to define threshold values that would maximize the predictive ability of QUS to discriminate subjects with vertebral fractures using the classification and regression trees (CART) models. A cross-sectional analysis was made of a cohort of 1,132 postmenopausal women with a mean age of 58 years. A total of 205 women (18.1 %) presented with a history of vertebral fracture. For all patients, a questionnaire of osteoporosis risk factors was given and measurements of the heel QUS and bone mineral density at the lumbar spine and the proximal femur, obtained by dual-energy X-ray absorptiometry (DXA), were made. Spinal radiographs were assessed for vertebral fractures. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operator characteristics (ROC) curve QUS values were calculated using the optimal threshold identified in the CART models. Cutoff values calculated from best CART model (i.e., a QUS index >90.5 %) yielded a sensitivity of 80.3 % (95 % CI 69.2-88.1), a negative predictive value of 94 % (95 % CI 90.1-96.5), and a specificity of 68.8 % (95 % CI 63.3-73.8). This cutoff value would obviate the need to perform DXA in 32.8 % of the women of our population at risk for vertebral fractures. The area under the ROC curve of the best model was 0.8071. QUS was shown to discriminate between women with and without a history of vertebral fracture and constitutes a useful tool for assessing vertebral fracture risk. The application of decision trees (CART analyses) was helpful to define the optimal threshold QUS values.

Discriminative ability of heel quantitative ultrasound in postmenopausal women with prevalent low-trauma fractures: application of optimal threshold cutoff values using CART models.

Quantitative ultrasound (QUS) of the heel has been proposed as a screening tool to evaluate the bone status and risk of osteoporotic fragility fractures. The aim of this study was to define threshold values of QUS that would maximize the predictive ability of this technique to discriminate subjects with fragility fractures. A cross-sectional analysis was made of a cohort of 1132 postmenopausal women with a mean age of 58 yr. A total of 361 women (31.9%) presented with a history of osteoporotic fracture. Most fractures (74.1%) were nonvertebral. For all patients, a questionnaire of osteoporosis risk factors and measurements of the heel QUS and bone mineral density at the lumbar spine and the proximal femur obtained by dual-energy X-ray absorptiometry (DXA) were assessed. Spinal radiographs were assessed for fractures and historical nonvertebral fragility fractures. Sensitivity, specificity, predictive values, likelihood ratios, and receiver operator characteristic (ROC) curve QUS values were calculated using the optimal threshold identified in the classification and regression trees (CART) models. Cutoff values calculated from the best CART model (i.e., a quantitative ultrasound index (QUI) greater than 88.5% in women aged 58 yr or older) yielded 88.8% (95% confidence interval [CI]: 81.4-93.5) for sensitivity, a negative predictive value of 93.8 (95% CI: 89.4-96.4), and 70.4% (95% CI: 64.6-75.7) for specificity. This cutoff value would obviate the need to perform DXA in 43.1% of the population. The area under the ROC curve of the best model was 0.8363 (95% CI: 0.8249-0.8477). In conclusion, QUS was shown to discriminate between women with and without a history of fragility fracture and constitutes a useful tool for assessing fracture risk. The application of decision trees (CART analyses) was helpful to define the optimal threshold QUS values.

Beta-blocker use is associated with fragility fractures in postmenopausal women with coronary heart disease.

BACKGROUND AND AIMS: An association between cardiovascular disease and osteoporosis is described. A number of drugs often used by patients with coronary heart disease, such as thiazides, statins and beta-blockers, have shown controversial effects on bone. 1) To study the possible association between coronary heart disease (CHD) and bone mass density (BMD), quantitative ultrasound measurements (QUS) and the prevalence of fragility and vertebral fractures. 2) To study the possible influence of a number of drugs, statins, thiazides and beta-blockers, on BMD and fractures. METHODS: Case-control study performed on 74 postmenopausal women who had recently suffered from CHD, and 111 age-matched controls. BMD was measured by Dual X-Ray Absorptiometry (DXA) at the lumbar spine and proximal femur. Quantitative Ultrasound (QUS) was also measured at the heel. Vertebral fractures were diagnosed by lateral, thoracic and lumbar X-rays. The occurrence of non-vertebral fractures was determined by examination of medical records. RESULTS: Patients with CHD had higher values of BMI. They had a higher prevalence of arterial hypertension and hyperlipidemia, and consequently higher consumption of beta-blockers and statins, but not of thiazides, and had lower alcohol consumption. Patients with CHD had higher BMD values, measured by DXA at the proximal femur, than controls, but there were no differences in DXA values at the lumbar spine or QUS at the heel between the two groups. The prevalence of all fragility factures was slightly higher in patients with CHD, but not to a significant extent. The prevalence of vertebral fractures was similar in the two groups. In a logistic analysis to identify factors associated with all fractures, beta-blockers were positively associated with fragility fractures, and DXA at the femoral neck was inversely associated with fragility fractures. CONCLUSIONS: Postmenopausal women with CHD have higher values of BMD at the proximal femur but, despite this, show a slight but non-significant increase in the prevalence of fragility fractures. Beta-blockers are independently associated with fragility fractures, but thiazides and statins are not.

Serum lipids and estrogen receptor gene polymorphisms in male-to-female transsexuals: effects of estrogen treatment.

The effects of chronic administration of estrogens on the lipid profile in males are not fully understood. We have studied the effect of chronic administration of estrogens on the lipid profile in a group of transsexual (TS) Canarian men who were taking estrogens and anti-androgens for a minimum of 3 years. In this cross-sectional study of cases (n=27) and controls (n=26), plasma lipid profile and selected biochemical and hormonal features were studied. TS subjects had shorter stature than controls, and, after adjusting for height and weight, we found that they had lower values of serum free testosterone (FT) and higher estradiol (E2) levels than controls. The TS group had lower total and low-density lipoprotein (LDL) cholesterol and lower apoprotein B (Apo B) levels than the control group. Biochemistry was similar in both groups. The distribution of estrogen receptor gene polymorphisms (ER-Pvu and ER-Xba) was also similar in both groups. Serum Apo B concentration was related to ER-Xba polymorphism. No other association between lipid profile and the distribution of ER-Pvu and ER-Xba was found. We conclude that the chronic administration of estrogens in men could produce an increase in serum estradiol, a decrease in free testosterone levels, and a reduction in total cholesterol, LDL-cholesterol, and Apo B levels. The ER-Xba polymorphism may influence the Apo B response to exogenous estrogen in males.