Can routine MRI spine T1 sequences be used for prediction of decreased bone density?

Background Bone marrow signal is ideally evaluated with magnetic resonance imaging (MRI) due to its high tissue contrast. While advanced MRI quantitative methods can be used for estimating bone density, there are no readily available parameters on routine clinical MRI sequences of the lumbar spine. Purpose To evaluate whether T1 signal intensity (SI) ratio of lumbar vertebral body (VB)/cerebrospinal fluid (CSF) may predict decreased bone density. Material and Methods A retrospective study was conducted. After use of inclusion/exclusion criteria, 36 patients who had an MRI scan of the lumbar spine and a DEXA scan performed as a part of annual health visit were selected. T1 SI of the lumbar vertebral bodies and adjacent CSF were recorded. Ratio of T1 SI of L1–L4 (VB)/CSF was calculated. The corresponding bone-density values on DEXA scan measured as g/cm2 were obtained. Pearson's r correlation statistic was used to determine the correlation between these variables. Results T1 VB/T1 CSF SI ratio was between 1.308 and 2.927 (mean = 2.028). Mean T1 SI value of vertebral bodies (L1–L4) was 264.9 and mean CSF SI value was 131.9. Bone density in g/cm2 was between 0.851 and 1.398 (mean = 1.081). Pearson correlation coefficient was r = −0.619 ( P=0.0001), which shows a negative moderate correlation between the T1 VB/T1 CSF SI ratio and bone density. Conclusion A high T1 VB/T1 CSF SI ratio on routine MRI sequences may indicate decreased bone density. This ratio may be of substantial benefit in unsuspected osteoporosis/osteopenia on routine MRI lumbar spine imaging.

Screening of Corticosteroid-Induced Osteoporosis in Patients with Immune Thrombocytopenia or Warm Autoimmune Hemolytic Anemia in the Outpatient Setting

Introduction: Corticosteroids (CS) are the standard first line treatment for immune thrombocytopenia (ITP) and warm autoimmune hemolytic anemia (WAIHA). Current guidelines advise against long-term CS (LTCS) use to minimize associated toxicities. Despite these guidelines, a number of patients remain on LTCS. For example, in a retrospective study of 53 patients with WAIHA, the mean duration of CS therapy was 15 months (mo) with 20% of patients with CS-induced diabetes, 10% with worsening of pre-existing diabetes, 10% with osteoporosis (OP) with fracture, and 4% with osteonecrosis of the femoral head (Roumier 2014). It is our observation that our hematology clinic patients may benefit from the application of guidelines for the prevention of CS-induced OP. The 2017 American College of Rheumatology (ACR) guidelines for prevention and treatment of CS-induced OP include a baseline clinical fracture risk assessment within 6 mo of the start of LTCS therapy (≥3 mo) followed by age and risk-adapted OP screening (Buckley 2017). Adults <40 years old (yo) with OP risk factors or prior OP fracture should undergo baseline bone mineral density (BMD) testing within 6 months of the start of CS therapy. For patients ≥40 yo, the Fracture Risk Assessment Tool (FRAX) with CS dose correction and BMD testing should be done within 6 mo of the start of CS therapy. With no similar national hematology guidelines, we applied 2017 American College of Rheumatology (ACR) guidelines for the prevention of CS-induced OP to our hematology clinic patients. The aim of the study was to improve screening for CS-induced OP in patients with ITP or WAIHA. Methods: We retrospectively identified patients with ITP or WAIHA by ICD-10 codes who were seen in the hematology clinic at LAC+USC Medical Center, Los Angeles, CA, from October 1, 2020 to March 31, 2021. The electronic medical record (EMR) was reviewed for demographic data and to confirm diagnosis. The relevant clinical history including CS dose/duration, common adverse events (AEs) from LTCS use, and BMD screening with a dual-energy X-ray absorptiometry (DEXA) scan. The patients were assessed for whether they underwent appropriate screening for CS-induced OP based on ACR guidelines. Results: Of the 2256 patient encounters in the hematology clinic during the 6-mo study period, 54 patients were identified with either ITP and/or WAIHA. The median age was 49 yo (range: 21-87), 74% were female (40/54) and 85.2% (46/54) were Hispanic. Of these 54 patients, 46 patients had prior or current CS therapy with either prednisone or dexamethasone. The most common AEs associated with CS included: weight gain (34.8%, 16/54), hypertriglyceridemia (34.8%, 16/54), worsening of diabetes (7.4%, 4/54), and worsening hypertension (3.7%, 2/54). Of the 15 patients <40 yo, 7 received LTCS therapy for ≥3 months and 42.9% (3/7) underwent screening with a DEXA scan. 1 had a normal BMD, 1 had osteopenia and 1 had OP. Of the 39 patients ≥40 years, 14 had received LTCS therapy for ≥3 months and 14.3% (2/14) had a screening DEXA scan; both demonstrated osteopenia. 2 patients with <3 months of CS therapy underwent screening - 1 for CS use, which showed osteopenia and one for age-appropriate screening of OP, which also showed osteopenia. Of the 6 patients with osteopenia or OP, 83.3% (5/6) were on vitamin D and calcium supplementation prior to screening. After diagnosis of osteopenia, one patient was not started on vitamin D and calcium supplementation. Bisphosphate therapy was initiated after diagnosis of OP in 1 patient. Conclusions: The majority of patients with ITP or WAIHA seen in our hematology clinic who were treated with LTCS ≥3 months did not receive a screening DEXA scan for OP as recommended by ACR guidelines. With this baseline data, we propose a quality improvement initiative in our clinic to ensure that all patients on LTCS are assessed for OP risk. Planned interventions include resident/fellow education, creation of a handout of the ACR guidelines posted in clinic, implementation of clinical fracture risk reassessment at baseline and every 12 months with BMD as indicated, and implementation of an EMR template to ensure uniform documentation. More broadly, our findings serve as a reminder of the importance for monitoring CS duration and suggest a need for a structured approach to monitoring for short and long-term toxicities of CS for the field of hematology. The creation of hematology-specific guidelines may be beneficial in this effort. Disclosures Piatek: Apellis: Research Funding; Alexion: Consultancy, Research Funding; Rigel: Consultancy, Research Funding; Dova: Consultancy, Speakers Bureau.

P10 Treating osteoporosis, facing reality – adopting a holistic approach

Case report - Introduction Osteoporosis is a significant health problem; globally around 200 million women are affected. In Europe, osteoporosis is responsible for a higher disability encumber than cancer (with the exception of lung cancer). The treatment of osteoporosis is quite exacting. Although understanding of the diagnosis and treatment of osteoporosis has broadened considerably over the last few years, lack of bridging information still exists with guidance lacking on the appropriate management of complex comorbid clinical scenarios. Here we will present a scenario of a patient with osteoporosis and multiple risk factors and comorbidities, where choice of suitable anti osteoporotic treatment was quite challenging. Case report - Case description An 84-year-old lady with known osteoporosis with history of T-12 fracture (in 2009), sarcoidosis, coeliac disease (confirmed on duodenal biopsy), chronic hepatitis, history of acute kidney injury secondary to zoledronic acid infusion and urosepsis in 2017 was re-referred to the rheumatology clinic from respiratory team for optimisation of her bone protection. She was previously on risedronate for almost 5 years without any improvement of bone mineral density. She was last seen in rheumatology in 2018, because of ineffectiveness and intolerance to alendronate (gastritis) and intravenous zoledronate – a discussion about subcutaneous denosumab was had, but the patient refused that option because of needle phobia. So, the plan was to maintain her on optimisation of vitamin D and calcium level. She was discharged from the clinic. Her GP advised her against vitamin D or calcium supplements because of episodes of hypercalcaemia secondary to sarcoidosis. For the last 3 years she was not on any bone protection or even calcium or vitamin D supplements. Recently she noticed a worsening of exertional dyspnoea. She was reviewed by the respiratory team. Her lung function test showed slow progression of restrictive lung disease with FEV1/FVC ratio is 100.4%. In December 2020, she was started on prednisolone 30mg, which gradually stepped down; at the moment, she is on 15mg and will continue it as maintenance. The patient was an ex-smoker, and drinks alcohol at about 10 unit/week. Her mobility is slightly better compared to the last few years. She trys to keep active and is enjoy gardening in the sunny weather. It was difficult to convince her for blood tests; however, we succeeded after repeated counselling. Her blood tests showed microcytic anaemia, with normal inflammatory markers mild renal impairment with eGFR of 67, corrected calcium 2.19, alkaline phosphatase 78, vitamin D 49 (sub optimal) albumin 32. Case report - Discussion Considering her age, comorbidities, frailty, intolerance and doubt about the efficacy, selecting an appropriate bone protection for her was fairly hard. Starting denosumab had more risk than benefit and in future if it need to stop there is an increased chance of rebound fracture. Besides this, she re-expressed her reluctance to the subcutaneous option. Moreover, calcium and vitamin D level were low in her recent blood tests. She did not fulfil the criteria for considering teriperatide. We reviewed her DEXA scan in 2018, which showed an overall 19% reduction of BMD compared to 2009 (1.6% per year). She was on risedronate intermittently for about 4 years that time; however, she had not experienced any new fracture at that point. She had multiple hospital admissions during those years. Bone protection was withheld multiple times. Poor mobility, frailty status and other comorbidities during that period were also responsible for BMD decline. Her case was discussed with a consultant with special interest in metabolic bone disease. Treatment decisions should be individualised; risk versus benefit needs to be considered to ensure the best outcome for the patient. We have decided to put her back on risedronate for at least 3 years. She tolerated only this medication in the past. We have requested bone markers and a repeat DEXA scan. Case report - Key learning points Comorbidities adversely affect the management of osteoporosis. A comprehensive assessment of the comorbid list is necessary before considering changing a medication which suits the patient well and when there is limited option. Obstacles to offer high quality service are knowledge, expertise, and critical thinking from healthcare professionals, and knowledge and compliance to treatment from patients. Facing those challenges and treating patients judiciously will help to reduce the potential health and economic burden of osteoporosis.

SP9.1.12 Bone protection in neck of femur fracture patients in a DGH without a fracture liaison service

Introduction In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management. Method Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or DEXA scanning for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e. if parental hip fracture status was not known. Results A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate or high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation. Conclusion Following a local meeting; a proforma was piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid patients long-term wellbeing.

861 Bone Protection in Neck of Femur Patients in A DGH Without A Fracture Liaison Service

Introduction In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and is a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management. Method Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or require a DEXA scan for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e., if parental hip fracture status was not known. Results A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate/high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation. Conclusions Following a local meeting; a proforma has been piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid a patient’s long-term wellbeing.

Early benefits of a secondary fracture prevention programme

Introduction: The most successful programme for secondary fracture prevention is the FLS (fracture liaison service) model. Our orthopaedic department carried out a prospective randomised study to measure the effectiveness of a 4-step intervention programme. The findings in this study reveal important additional clinical benefits to having an orthopaedic-based FLS programme and evaluates the usefulness of fracture risk tools. Methods: We carried out a prospective study to evaluate patients with a fragility fracture of the hip. There were 2 groups, intervention and control (each 100 patients). Of these, 20 were either removed from the study or dropped out, leaving 180 for analysis. In addition to routine preoperative blood tests, albumin and thyroid function levels were obtained and PTH (parathyroid hormone) levels when indicated. The intervention group (83 patients) had a dual-energy x-ray absorptiometry (DEXA) scan performed and fracture risk (FRAX) was calculated. Results: 12 patients (6.7%) had blood results which showed a potentially treatable cause for osteoporosis and 36 (20%) had blood results that changed their medical care. FRAX scores (180 patients) showed that the major osteoporotic fracture score correctly predicted the hip fracture in only 49%. The hip fracture score correctly predicted the hip fracture in 83%. DEXA scores (65 patients) showed osteoporosis in only 46% of hips and in only 26% of spines. An abnormal FRAX score or DEXA scan would have predicted a fragility fracture 93% of the time. Conclusions: In addition to reducing secondary fractures, FLS programmes can provide fundamental benefits to the health of the patient. The intervention programme in this study identified patients with underlying treatable causes, correctable clinical conditions and patients with an unusually low bone density. When used together, FRAX and DEXA are more sensitive predictors for hip fracture risk than either are individually. Trial registry: 201497CTIL ( https://clinicaltrials.gov/ct2/show/NCT02239523 )

AB0618 GLUCOCORTICOID INDUCED OSTEOPOROSIS PREVENTION IN THE OUTPATIENT RHEUMATOLOGY CLINIC

Background:Patients with rheumatic disease are at risk of developing glucocorticoid induced osteoporosis (GIOP) as many are prescribed systemic oral glucocorticoids as an adjunct to their maintenance therapy. Based on the 2017 ACR Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis, a good practice recommendation exists that “initial clinical fracture risk assessment should be performed as soon as possible, but at least within six months of the initiation of long term glucocorticoid treatment.1” Long-term glucocorticoid use is defined by duration of 3 months or greater. Fracture risk assessment should include dual energy-ray absorptiometry (DEXA) scan. Patients on greater than or equal to 2.5 mg of prednisone should be treated with an optimal dose of calcium and vitamin D and may benefit from oral bisphosphonate as primary prevention against GIOP if their fracture risk is moderate to high.1Objectives:The aim of this Quality Improvement Project is to assess the current status of provider implementation of GIOP recommendations in the rheumatology clinic. Ultimate goal is to improve osteoporosis prevention in the rheumatology clinic.Methods:We conducted a retrospective chart review of 60 patients in two outpatient rheumatology clinics. Clinic 1 follows patients with lower socioeconomic status and Clinic 2 follows patients with higher socioeconomics. Inclusion criteria were patients on long-term glucocorticoid use, defined as at least 3 months of corticosteroid use of at least 2.5 mg prednisone daily, as well as age less than 65. Females aged 65 or older were omitted to prevent overlap of the United States Preventative Taskforce recommendation for all women ≥ 65 years to be screened for osteoporosis with DEXA scans.2 DEXA scan orders, calcium and vitamin D prescriptions, and osteoporosis medication prescriptions were abstracted. After baseline data obtained, intervention of education of the rheumatology fellows and faculty, and internal medicine residents in the guidelines for GIOP prevention was implemented. In addition, a smartphrase in the electronic medical record was created for provider use when treating patients on chronic corticosteroids. Subsequently, two audit cycles were completed for retrospective chart review.Results:Upon completion of second audit cycle, there was no change in percentage of DEXA scan orders at Clinic 1, however there was a 10% overall improvement in DEXA scan orders in the Clinic 2.In terms of Calcium and Vitamin D prescriptions, there was an overall improvement in both clinics of 19.7% and 13.3% in Clinics 1 and 2 respectfully after the second audit cycle.Additionally, there was a 3.4% increase in osteoporosis medication prescriptions overall subsequent to the second audit cycle in Clinic 1. However in Clinic 2 there was an overall decrease in osteoporosis medication prescriptions of 6.6%.Clinic 1Prior to AuditAudit cycle 1Audit cycle 2Patient percentage without DEXA scan orders30%33.30%30%Patient percentage without Vitamin D/Calcium orders26.40%8.30%6.70%Patient percentage with osteoporosis medication orders23.30%8.30%26.70%Clinic 2Patient percentage without DEXA scan orders50%37.00%40%Patient percentage without Vitamin D/Calcium orders30%26.00%16.70%Patient percentage with osteoporosis medication orders23.30%11.10%16.70%Conclusion:Overall, the results of the intervention were strongest for improvements in Vitamin D and Calcium orders in both clinics. Improvements in DEXA scan orders and osteoporosis medications were present in Clinic 2 and not present in Clinic 1. This reveals continued efforts and education of providers need to be made for improvement in bone health monitoring.References:[1]Buckley, Lenore, et al. “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.” Arthritis & Rheumatology, vol. 69, no. 8, June 2017, pp. 1521–1537., doi:10.1002/art.40137.[2]Final Recommendation Statement: Osteoporosis to Prevent Fractures: Screening. U.S. Preventive Services Task Force. July 2019.Disclosure of Interests:None declared.

COMPARATIVE STUDY OF DIGITAL X-RAY L-S SPINE AND DEXA L-S SPINE IN THE EVALUATION OF OSTEOPOROSIS

AIMS & OBJECTIVES- The aim of the study was to compare the sensitivity of Digital X-ray of L.S.Spine in relation to DEXA Scan in the detection of reduced bone mass (osteopenia/ osteoporosis) and evaluate the association of osteoporosis/ osteopenia with certain factors like age, height, weight, smoking, alcoholism and awareness. MATERIALS AND METHOD- This Prospective, this prospective observational study included 100 patients of both sexes between 40 – 80 years age , who presented to in the Department of Radiodiagnosis, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly (Uttar Pradesh) with presenting symptoms of non- inammatory low back pain and underwent dexa scan of L.S. Spine and X-Ray of L.S.Spine. A detailed history including demographic feature and social factor (history of smoking and alcoholism and education/ knowledge status). The investigation ndings were recorded and tabulated and data were analyzed statistically. RESULTS- The DXR L.S.Spine shows the sensitivity 75.29%, specicity 78.95%, and accuracy was 77.01% in compression to dexa scan in patients with osteopenia/ osteoporosis. There was negative correlation between weight and height and knowledge of the patient with osteopenia/ osteoporosis and no signicant correlation between history of smoking and alcoholism. CONCLUSION- In conclusion, DXR and DEXA measurements shows fair agreement. Our results suggest DXR to be a promising screening tool for detecting low bone quality or osteoporosis.