Clinical risk factors as predictors of postmenopausal osteoporosis in general practice.

BACKGROUND: Case-finding strategies to identify women with high risk for osteoporotic fractures have recently been proposed, but little information about such an approach in general practice is known. AIM: To study the validity of the proposed case-finding strategy for osteoporosis. DESIGN OF STUDY: Survey using case-finding strategy. SETTING: Seven hundred and twelve women aged between 55 and 84 years, randomly selected from a general practice in The Netherlands. METHOD: Of the 712 randomly selected women, 449 women participated. Information was obtained from a questionnaire, direct questioning, and computerised patients files. Bone mineral density of the femoral neck was measured by dual energy X-ray absorptiometry and vertebral morphometry was performed on lateral X-rays of the spine. Osteoporosis was defined by a bone mineral density T-score of less than 2.5 and/or the presence of severe vertebral deformities. Sensitivity, specificity, and predictive values were calculated for the whole set of risk factors; those significantly associated with osteoporosis and in logistic models. RESULTS: Clinical risk factors were present in 55% of the women and identified 68% of the women with osteoporosis. Three risk factors--a low body mass index, fragility fractures, and severe kyphosis and/or loss of height--were associated significantly with osteoporosis; they were present in 33% of the women and identified 60% of those with osteoporosis. A logistic model based on age and fragility fractures selected 32% of the women and identified 76%. CONCLUSION: No single risk factor could assist in identifying women with osteoporosis. A simplified case-finding strategy using only three risk factors, that is suitable for primary care, reduces the number of women to be evaluated by two-thirds; however, this is at the cost of missing the diagnosis in 40% of the women with osteoporosis. Addition of spine radiographs to the case-finding approach helped to obtain a better risk profile of the women and had also practical consequences for the management of some. We propose that radiographs should be included in any case-finding strategy.

The relationship between phalangeal bone density and vertebral deformities.

Radiographic absorptiometry (RA) of the phalanges is a convenient and reliable technique for measuring bone mineral density (BMD). It needs only a radiograph of the hand, which can be sent for evaluation to a central facility, whereas other techniques require specialized equipment. We assessed the relationship between RA measurements and the presence of vertebral deformities in a population-based cohort of postmenopausal women, and to compare the results with simultaneously obtained BMD of the hip by dual-energy X-ray absorptiometry (DXA). A total of 389 women aged 55-84 (mean age 67.2 years, SD 8.7) were randomly selected from a large general practice. RA, DXA of the hip, and vertebral deformities in the lateral spine X-rays by vertebral morphometry were assessed. Thirty-eight women (9.8%) had severe (grade II) vertebral deformities, and their BMD at the phalanges and femoral neck was significantly lower than that of women without severe vertebral deformities. Odds ratios for the presence of severe vertebral deformities of 1.5 (95% CI: 1.1-2.1) for RA and 1.3 (95% CI: 0.9-1. 9) for DXA, together with similar receiver operating characteristics curves, were found using age-adjusted logistic regression. Phalangeal BMD is related to vertebral deformities at least as closely as BMD of the femoral neck BMD. RA may therefore help to evaluate fracture risk, especially if no DXA equipment is available.

Radiographic absorptiometry of the phalanges as a screening instrument to detect osteoporosis of the hip.

OBJECTIVE: To determine the validity of radiographic absorptiometry (RA) of the phalanges in detecting osteoporosis of the femoral neck, measured by dual energy X-ray absorptiometry (DXA). MATERIAL AND METHODS: In a group practice, 494 Caucasian women aged 55 to 84 years were recruited. Hand radiographs and DXA measurements of the hip were performed in 449 women. 409 (91.1%) hand radiographs had sufficient quality for analysis by RA. Change of bone mass by age was obtained by using linear regression. Correlations between RA and DXA were calculated. Sensitivity and specificity of RA were calculated for several RA cut-off levels. RESULTS: The mean bone mineral density at the femoral neck was 0.866 g/cm2 and 92.57 arbitrary units at the phalanges. A moderate correlation of 0.53 (p<0.01) was found between RA and DXA. Depending on the cut-off level used, the sensitivity and specificity of RA in detecting osteoporosis at the femoral neck was 0.84-0.55 and 0.61-0.88, respectively. CONCLUSION: RA may be used as a screening technique to detect osteoporosis, but confirmation is necessary in the subgroup with a positive outcome on RA.

Usefulness of armspan and height comparison in detecting vertebral deformities in women.

The prevalence of vertebral fractures in women increases with age but only about one third of these fractures are symptomatic. On the other hand, the presence of vertebral fractures is an independent risk factor for new osteoporotic fractures. In the present study we examined the hypothesis that differences between armspan and height are related to the presence of vertebral deformities in a cohort of 494 women aged between 55 and 84 years (mean age 67.6 years, SD 8.2 years) who were randomly selected from a large general practice in The Netherlands. Height and armspan were measured and vertebral morphometry of lateral radiographs of the spine was performed. Both height and armspan decreased significantly with age. The correlation between armspan and height was 0.83. Vertebral deformities were present in 32.7% of the women (grade I in 22.4% and grade II in 10.3%). Only the prevalence of grade II deformities rose with age. The variation of the difference between armspan and height in the groups with or without grade II vertebral deformities was comparable and relatively large (range > 15 cm). The difference in mean values was small between those groups (1.6 cm) and could not differentiate between women with and without vertebral deformities. Our data show that the presence of vertebral deformities cannot be detected by the difference between armspan and height.

[Prevalence of osteoporosis in postmenopausal women in family practice]. / Prevalentie van osteoporose bij postmenopauzale vrouwen in een huisartspraktijk.

OBJECTIVE: To assess the prevalence of osteopenia, osteoporosis and severe vertebral deformities in general practice. DESIGN: Cross-sectional study. METHODS: Of a randomly selected group of 712 women aged 55 to 84 years in a general practice in Noordwijk, the Netherlands, 449 (63%) participated in a study in 1996, in which Dual Energy X-ray Absorptiometry (DXA) of the femoral neck was performed: in 428 women vertebral morphometry of lateral radiographs of the spine was also done. The World Health Organization definitions of osteopenia and osteoporosis were used. RESULTS: The mean bone mineral density (BMD) was 0.866 g/cm2 (SD: 0.135). With increasing age the BMD decreased statistically significantly by 0.0073 g/cm2/year. There were 189 women with osteopenia (42%). 33 (7%) with osteoporosis and 44 (10%) with one or more severe vertebral deformities. A significantly lower mean BMD was found in those with severe vertebral deformities than in those without.

[Prevalence of chronic fatigue syndrome in 4 family practices in Leiden]. / Prevalentie van chronische-vermoeidheidsyndroom in 4 huisartspraktijken in de regio Leiden.

OBJECTIVE: To determine the prevalence of chronic fatigue syndrome (CFS) in general practice. DESIGN: Descriptive. SETTING: General practice and primary health care centres in Leyden region, the Netherlands. METHOD: RNUH-LEO is a computerized database which contains the anonymous patient information of one general practice (with two practitioners) and four primary health care centres. The fourteen participating general practitioners were asked what International Classification of Primary Care (ICPC) code they used to indicate a patient with chronic fatigue or with CFS. With these codes and with the code for depression patients were selected from the database. It then was determined whether these patients met the criteria of CFS by Holmes et al. RESULTS: The general practitioners used 10 codes. Including the code for depression a total of 601 patients were preselected from a total of 23,000 patients in the database. Based on the information from the patients' records in the database, 42 of the preselected patients were selected who might fulfill the Holmes' criteria of CFS. According to the patients' own general practitioner, 25 of the 42 patients would fulfil the Holmes' criteria. The men:women ratio was 1:5. The prevalence of CFS in the population surveyed was estimated to be at least 1.1 per 1,000 patients.