Foreword...v Preface...vii Acknowledgments... xi Dedication... xiii Continuing Medical Education... xxv. Chapter 1: Densitometry Techniques...

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1 CONTENTS Foreword...v Preface...vii Acknowledgments... xi Dedication... xiii Continuing Medical Education... xxv Chapter 1: Densitometry Techniques... 1 Plain Radiography in the Assessment of Bone Density... 1 Qualitative Morphometry... 2 Qualitative Spinal Morphometry... 2 The Singh Index... 2 Quantitative Morphometric Techniques... 3 Calcar Femorale Thickness... 3 Radiogrammetry... 4 The Radiologic Osteoporosis Score... 5 Radiographic Photodensitometry... 5 Radiographic Absorptiometry... 6 Photon Absorptiometry Techniques... 9 Single-Photon Absorptiometry... 9 Dual-Photon Absorptiometry Dual-Energy X-Ray Absorptiometry Peripheral DXA Single-Energy X-Ray Absorptiometry Quantitative Computed Tomography Peripheral QCT Quantitative Ultrasound Bone Densitometry References Chapter 2: Skeletal Anatomy in Densitometry Characterizing the Skeleton in Densitometry The Axial and Appendicular Skeleton The Weight-Bearing and Nonweight-Bearing Skeleton The Central and Peripheral Skeleton The Trabecular/Cortical Composition of the Skeleton Forearm Composition Vertebral Composition Femoral Composition All Sites The Spine in Densitometry xv

2 xvi Contents Vertebral Anatomy Artifacts in PA or AP Spine Densitometry Vertebral Fractures Degenerative Changes and Dystrophic Calcification Effect of Osteophytes on BMD Effect of Aortic Calcification on BMD Effect of Facet Sclerosis on BMD The Vertebral Rotation and PA Lumbar Spine Bone Density Other Causes of Artifacts in PA and AP Lumbar Spine Studies The Spine in the Lateral Projection The Proximal Femur in Densitometry Proximal Femur Anatomy Effect of Rotation on BMD in the Proximal Femur Effect of Leg Dominance on BMD in the Proximal Femur Effect of Scoliosis, Osteoarthritis, Osteophytes, Surgery, and Fracture on BMD in the Proximal Femur The Forearm in Densitometry Nomenclature Effect of Arm Dominance on Forearm BMD Effect of Artifacts on BMD in the Forearm The Metacarpals, Phalanges, and Calcaneus Bone Physiology Bone Growth, Modeling, and Remodeling Bone Modeling Bone Remodeling The Basic Multicellular Unit in Bone Remodeling References Chapter 3: Statistics in Densitometry The Mean, Variance, and Standard Deviation The Mean The Variance and Standard Deviation Coefficient of Variation Standard Scores Z-Scores T-Scores Standard Scores on Bone Density Reports Measures of Risk Prevalence and Incidence Prevalence Incidence Absolute, Relative, and Attributable Risk Absolute Risk Relative Risk Attributable Risk Odds Ratios... 79

3 Contents xvii Confidence Intervals Accuracy and Precision Accuracy Precision Types of Data Quantitative Data Qualitative or Categorical Data Data and Variables Correlation Statistical Significance and the P Value Regression Analysis Statistical Evaluations of Diagnostic Tests Sensitivity and Specificity Likelihood Ratios Receiver Operating Characteristic Curves Regression to the Mean References Chapter 4: Quality Control Phantoms The European Spine Phantom The Bona Fide Spine Phantom The Hologic Spine and Hip Phantoms The Lunar Spine Phantom Using the Phantom to Create Control Tables and Charts Shewhart Rules and CUSUM Charts Shewhart Rules CUSUM Charts Automated Quality Control Procedures Replacing a Densitometer References Chapter 5: Bone Density Data: From DPA to DXA and Manufacturer to Manufacturer From DPA to DXA Hologic DXA and Lunar DPA Lunar DXA and Lunar DPA Hologic DXA, Lunar DXA, and Lunar DPA DXA: From Lunar to Hologic to Norland Hologic DXA and Norland DXA Lunar DXA and Hologic DXA Standardization of Absolute BMD Results Standardization of Central DXA Absolute BMD Values Standardization of DXA BMD Results for the Femoral Neck, Trochanter, and Ward s Area Standardization of Forearm DXA Results

4 xviii Contents The Utility of the sbmd From DXA Machine to DXA Machine Within Manufacturers From Pencil-Beam to Fan-Array DXA Data Reference Databases References Chapter 6: The Effects of Age, Disease, Procedures, and Drugs on Bone Density Age-Related Changes in Bone Density Bone Density in Children Bone Density in Premenopausal Women Dissimilar BMDs Between Skeletal Sites at Peak and Prior to Menopause Bone Density in Perimenopausal Women Dissimilar Spine and Femoral BMDs in Perimenopausal Women Changes in Bone Density in Postmenopausal Women Changes in Bone Density in Men The Effect of Diseases and Procedures on Bone Density Acromegaly Ankylosing Spondylitis Alcoholism Amenorrhea Hyperandrogenic Amenorrhea Exercise-Induced Amenorrhea Anorexia Nervosa Cirrhosis Cushing s Syndrome Cystic Fibrosis Diabetes Insulin-Dependent Diabetes Mellitus Noninsulin-Dependent Diabetes Mellitus (NIDDM) Ehlers-Danlos Syndrome Estrogen Deficiency (Postmenopausal) Familial Dysautonomia Gastrectomy Type 1 Gaucher Disease Gluten-Sensitive Enteropathy Human Immunodeficiency Virus Infection Hypercalciuria Hyperparathyroidism Hyperprolactinemia Hyperthyroidism Inflammatory Bowel Disease Intravenous Drug Abuse Klinefelter s Syndrome Marfan s Syndrome Mastocytosis

5 Contents xix Multiple Myeloma Multiple Sclerosis Neurofibromatosis Osteoarthritis Paralysis Hemiplegia Paraplegia Parkinson s Disease Pregnancy and Lactation Radiotherapy Regional Migratory Osteoporosis Renal Failure Rheumatoid Arthritis Thalassemia Major Transient Osteoporosis of the Hip Transplantation Cardiac Transplantation Liver Transplantation Marrow Transplantation Renal Transplantation Weight Loss Wilson Disease The Effect of Drugs on Bone Density Alendronate Sodium Calcitriol Calcium and Vitamin D Corticosteroids Oral Corticosteroids Inhaled Corticosteroids Estrogen/Hormone Replacement Etidronate GnRH Agonists Heparin Ipriflavone Medroxyprogesterone Acetate Nandrolone Decanoate Raloxifene Risedronate Salmon Calcitonin Sodium Fluoride Tamoxifen Teriparatide Thyroid Hormone Tibolone Zoledronic Acid References

6 xx Contents Chapter 7: Selecting Patients for Bone Mass Measurements: Clinical Guidelines Clinical Guidelines National Osteoporosis Foundation Guidelines NOF Guidelines Guidelines of the International Society for Clinical Densitometry American Association of Clinical Endocrinologists Guidelines AACE Guidelines Guidelines from the European Foundation for Osteoporosis and Bone Disease ACOG Recommendations for Bone Density Screening for Osteoporosis North American Menopause Society Recommendations US Preventive Services Task Force Recommendations Guidelines for Bone Density Testing in Men World Health Organization Task Force Recommendations for Men and Women How Do the Guidelines Compare? References Chapter 8: Selecting Patients for Bone Mass Measurements: Self-Assessment Indices Simple Calculated Osteoporosis Risk Estimation Osteoporosis Risk Assessment Instrument The Study of Osteoporotic Fractures Simple Useful Risk Factor System ABONE The Osteoporosis Self-Assessment Tool Weight Selection Criteria The FRACTURE Index Comparing the Performance of Self-Assessment Questionnaires Summary References Chapter 9: Diagnosing Osteoporosis Guidelines of the Study Group of the WHO for the Diagnosis of Osteoporosis The 1999 WHO and 2000 IOF Recommendations The Clinical Dilemma Peripheral Site T-Score Equivalents for the Diagnosis of Osteopenia and Osteoporosis Changing the Definition of Osteoporosis Diagnosing Osteoporosis in Men Additional Considerations in Site Selection for Diagnosis References

7 Contents xxi Chapter 10: Predicting Fracture Risk The Prevalence of Fracture at Different Levels of BMD Fracture Risk Prediction Site-Specific and Global Fracture Risk Prediction Relative Risk Fracture Data Global Fracture Relative Risk Data Site-Specific Spine Fracture Relative Risk Data Site-Specific Hip Fracture Relative Risk Data Applying Relative Risk Data in Clinical Practice Lifetime Risk of Fracture Year Fracture Probability Remaining Lifetime Fracture Probability The Fracture Threshold Qualitative Risk Assessments Predicting Fracture Risk in Men Using Skeletal Morphometry from Densitometry to Predict Fracture Risk Vertebral Morphometry and Fractures The Relationship Between Prevalent Spine Fractures and Future Fracture Risk Diagnosing Vertebral Fractures Vertebral Fracture Assessment with Genant s Semiquantitative Technique Quantitative Techniques Performance Comparisons of Semiquantitative and Quantitative Techniques Fan-Array Spine Imaging with DXA Proximal Femur Morphometry Hip Axis Length The Femoral Neck-Shaft Angle Femoral Neck Width The Upper Femoral Neck Hip Strength Analysis Combining Clinical Risk Factors with BMD to Predict Fracture Risk References Chapter 11: Monitoring Changes in Bone Density The Concept of Precision Performing a Precision Study Short-Term Precision Studies Mathematical Procedures Used to Calculate Precision Step Step Long-Term Precision Studies Applying the Precision Value to Serial Measurements The Determination of LSC A Case in Point

8 xxii Contents More Sophisticated Issues of Statistical Confidence for the Measured Change Determining the Level of Confidence for Any Change and Precision The Confidence Interval (CI) for the Change in BMD Between Two Measurements The Importance of Precision Which Skeletal Sites Should Be Used for Monitoring? How Frequently Should Measurements Be Repeated? Regression to the Mean and Monitoring A Final Consideration References Chapter 12: Reporting Densitometry Elements of Densitometry Reports Requested by Primary Care Physicians US Densitometry Center Reporting Practices Recommendations from the Canadian Panel of the ISCD for Bone Density Reporting Reporting the Diagnosis Reporting Fracture Risk Recommending Evaluations for Secondary Causes of Bone Loss Treatment Recommendations Recommending a Follow-Up Densitometry Study Assessment of Risk Factors Reporting Serial Studies The Challenge in Reporting Densitometry Results References Chapter 13: FDA-Approved Densitometry Devices Computer-Enhanced Radiogrammetry Sectra Osteoporosis Package IDS5 Workstation Clinical Application Computer-Enhanced Radiographic Absorptiometry Automated OsteoGram MetriScan Central X-Ray Densitometers Delphi Discovery DPX-IQ DPX MD DPX MD DPX-NT Excell Excell plus EXPERT -XL Prodigy QDR 4500 A

9 Contents xxiii QDR 4500 C QDR 4500 SL QDR 4500 W XR Peripheral X-Ray Densitometers accudexa Apollo DexaCare G DTX-200 DexaCare pdexa PIXI (Peripheral Instantaneous X-Ray Imager) XCT Ultrasound Bone Densitometers Achilles Achilles Express Achilles InSight DTU-one UltraSure McCue C.U.B.A.Clinical (Contact Ultrasound Bone Analyzer) Omnisense 7000S Ultrasound Bone Sonometer QUS-2 Calcaneal Ultrasonometer Sahara Clinical Bone Sonometer Appendix I: Contacts for Bone Densitometry Manufacturers and Organizations of Interest Appendix II: Conversion Formulas Appendix III: Formulas and Tables Used in Serial Bone Density Measurements Appendix IV: World Health Organization Criteria for the Diagnosis of Osteoporosis Based on the Measurement of Bone Density Appendix V: Recent Guidelines for Bone Density Testing Appendix VI: Bone Mass Measurement Act of Appendix VII: CPT Codes for Bone Densitometry Appendix VIII: 2002 Medicare Reimbursement Rates Appendix IX: NHANES III Proximal Femur Reference Data Appendix X: Norland DXA Reference Data Appendix XI: Hologic DXA Reference Data Appendix XII: Lunar DXA Reference Data

10 xxiv Contents Appendix XIII: Densitometry Patient Questionnaire Appendix XIV: The CD-ROM Companion Index

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Prevalence of Osteoporosis p. 262 Consequences of Osteoporosis p. 263 Risk Factors for Osteoporosis p. 264 Attainment of Peak Bone Density p.

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