Radiomics Nomogram Based on Spectral CT Imaging to Diagnose Osteoporosis

Background: Osteoporosis is associated with a decrease of bone mineralized component as well as a increase of bone marrow fat. At present, there are few studies using radiomics nomogram based fat-water material decomposition (MD) images of spectral CT as an evaluation method of osteoporosis. This study aims to establish and validate a radiomics nomogram based the fat-water imaging of spectral CT in diagnosing osteoporosis.Methods: 95 patients who underwent spectral CT included T11-L2 and dual x-ray absorptiometry (DXA) were collected. The patients were divided into two groups according to T-score, normal bone mineral density (BMD) (T≥-1) and abnormally low BMD (T<-1). Radiomic features were selected from fat-water imaging of the spectral CT. Radscore was calculated by summing the selected features weighted by their coefficients. A nomogram combining the radiomics signature and significant clinical variables was built. The ROC curve was performed to evaluate the performance of the model. Finally, we used decision curve analysis (DCA) to evaluate the clinical usefulness of the model.Results: Five radiomic features based on fat-water imaging of spectral CT were constructed to distinguish abnormally low BMD from normal BMD, and its differential performance was high with an area under the curve (AUC) of 0.95 (95% CI, 0.89-1.00) in the training cohort and 0.97 (95% CI, 0.91-1.00) in the test cohort. The radiomics nomogram showed excellent differential ability with AUC of 0.96 (95%CI, 0.91-1.00) in the training cohort and 0.98 (95%CI, 0.93-1.00) in the test cohort, which performed better than the radiomics model and clinics model only. The DCA showed that the radiomics nomogram had a higher benefit in differentiating abnormally low BMD from normal BMD than the clinical model alone.Conclusion: The radiomics nomogram incorporated radiomics features and clinical factor based the fat-water imaging of spectral CT may serve as an efficient tool to identify abnormally low BMD from normal BMD well.

Impact of hypogonadism on bone mineral density and vertebral fractures in HIV-infected men

Purpose Hypogonadism and osteoporosis are frequently reported in HIV-infected men and, besides multifactorial pathogenesis, they might be directly linked because of testicular involvement in bone health. We evaluated the prevalence of osteoporosis and vertebral fractures (VFs) in HIV-infected men, and assessed their relationship with gonadal function. Methods We enrolled 168 HIV-infected men (median age 53). Osteoporosis and osteopenia were defined with T-score ≤ – 2.5SD and T-score between – 1 and – 2.5SD, respectively. VFs were assessed by quantitative morphometric analysis. Total testosterone (TT), calculated free testosterone (cFT), Sex Hormone Binding Globulin (SHBG), Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) were obtained; overt hypogonadism was defined on symptoms and low TT or cFT, and classified into primary and secondary according to gonadotropins; compensated hypogonadism was defined as normal TT and cFT with high LH levels. Results Overall, osteoporosis and osteopenia were found in 87.5% of patients, and VFs were detected in 25% of them; hypogonadism was identified in 26.2% of cases. Osteoporotic patients had higher SHBG vs those with normal bone mineral density (BMD). Fractured patients were more frequently hypogonadal and with higher SHBG. SHBG showed negative correlation with both spine and femoral BMD, and positive correlation with VFs. In multivariate models, FSH showed negative impact only on femoral BMD, whereas older age and higher SHBG predicted VFs. Conclusion We found a high burden of bone disease and hypogonadism in HIV-infected men, and we showed that the impact of gonadal function on bone health is more evident on VFs than on BMD.

A Study of Relationship of Bone Mineral Density with Age, Body Mass Index, Obesity and Serum Magnesium Level

BACKGROUND Menopause is defined as the permanent cessation of menstruation following loss of ovarian activity. One of the most important problems associated with menopause is osteoporosis. This study was conducted to evaluate the relationship between bone mineral density, body mass index, age, serum calcium, and serum magnesium in 120 women. METHODS Present study was an observational study done from Feb 2017 to July 2017 in Pt. J.N.M. Medical College to evaluate the relationship of bone mineral density with age, body mass index (BMI), obesity and serum magnesium in 120 postmenopausal women. A detailed medical, obstetrical, menstrual, and drug history was recorded in a proforma designed for the study. Past fracture history, family history of fracture and osteoporosis, socioeconomic status, occupation, educational level and weightbearing exercises were collected and recorded. RESULTS Average age of women with normal bone health was 30.5 + 0.58 years, while the age of osteopenic and osteoporotic women was 43.11 + 6.79 years and 54.64 + 11.92 years respectively. Most of the osteopenic women belonged to the age group of 40 – 49 years. Osteoporotic patients (78.57 %) had a high (> 0.85) waist-hip ratio, while women with normal bone mineral density had a normal waist-hip ratio. Most of the women with normal bone mineral density (100 %), osteopenia (85.29 %) and osteoporosis (57.14 %) had normal serum magnesium levels. CONCLUSIONS We found that the bone mineral density reduced with advancing age, decreasing BMI and obesity, while we found no correlation of serum magnesium level with bone mineral density (BMD). KEY WORDS Bone Mineral Density, Body Mass Index, Perimenopause, Magnesium, Calcium

POS1110 RELIABILITY OF VERTEBRAL FRACTURE ASSESSMENT ON DUAL-ENERGY X-RAY ABSORPTIOMETRY

Background:Vertebral Fracture Assessment (VFA) is a new feature available on modern densitometers. Yet, the assessment of vertebral fracture (VF) status has not become standard practice.Objectives:Our study aimed to evaluate the reliability of VFA as assessed by a rheumatologist and a radiology technician.Methods:We conducted a cross-sectional study assessing the performance of low-radiation single energy x-ray absorptiometry VFA for the detection of VF. We selected patients who were assessed for osteoporosis according to screening protocols. Bone mineral densitometry was measured using standard methods over the lumbar spine L1-L4, the total proximal femur, and results were expressed as T-scores. All VFA were independently evaluated by 2 experienced readers: a rheumatologist and a radiology technician for the identification of VF (T4-L4). VF was classified according to the Genant grading system: grade 1 for an anterior, mid or posterior reduction of 20–25% in vertebral height; grade 2 for a reduction of 25– 40% and grade 3 for a reduction of more than 40% in vertebral height. A score for the inter-rater reliability between the readers was expressed using the kappa statistic.Results:One hundred patients were included with a mean age of 66.9 ± 9.5 years [46.7-83] years. There was a female predominance (91%). Nearly half of patients had osteopenia (48.9%), 27.7% had osteoporosis and 23.4% had a normal bone mineral density. On VFA scans, the non-visible vertebra was mostly located in the upper thoracic spine (60%). The mean number of VF was 1.2 [0-3] for both readers. According to the doctor’s evaluation, 25% of patients had at least one VF, of which 75.9% had a Genant grade 1, 17.2% had a Genant 2, and 6.9% had a VF grade 3. According to the technician evaluation, at least one VF was found in 36% of patients. A grade 1 was assessed in 91.7% of cases, a grade 2 in 8.3% of patients but no VF grade 3 was assessed. A kappa score for the inter-rater reliability between the readers for VFA was 0.545 (p=0.000). The overall agreement by grade between the readers was 0.785 (p=0,000). The exclusion of non-visible vertebra resulted in a better agreement (k=0.853). Further analysis excluding vertebra T4 to D10, revealed a very good agreement (k=0.9).Conclusion:Our study showed a low agreement between the readers on VFA and a better agreement when non-visible vertebrae were excluded. Thus, caution should be advocated when relying exclusively on this device.Disclosure of Interests:None declared.

Bilateral Sacral Stress Fracture in Pregnancy without Osteoporosis - A Case Report and Literature Review

Purpose: Sacral stress fractures are rare complications which can arise during pregnancy or in the early postpartum period. We report a case and discuss the findings of a confirmed postpartum sacral stress fracture in a 39-year-old multiparous woman and review previous case reports in the literature of sacral stress fracture related to pregnancy. Methods: A review of the literature was conducted to examine the main characteristics of sacral stress fractures related to pregnancy. The Ovid/Medline, Embase and Google Scholar databases were searched with the inclusion criteria: human studies, English language, intrapartum, postpartum (within 6 months of parturition), sacrum and stress fracture. Our exclusion criteria included pubic fractures, vertebral fractures and non-English articles. The search terms included “stress fracture”, “postpartum”, “pregnancy”, “atraumatic” and the wildcard “sacr*”. 34 cases were found and summarised in Table 2. Results: 65% of patients had onset of symptoms postpartum. Most patients did not have risk factors for sacral stress fractures including macrosomia, excessive pregnancy weight gain, heparin exposure, rapid vaginal delivery or predisposition to accelerated osteoporosis. Lumbar radiculopathy can be a feature of sacral stress fracture and it is more common (17.6%) than reported in the literature (2%). MRI is the preferred imaging modality for its safety profile in pregnancy and high sensitivity. 70% of reported normal bone mineral density (BMD). The mainstay treatment for sacral stress fractures includes relative bedrest, analgesia and modified weight bearing exercises. Most patients have favourable outcome with complete symptom resolution. Conclusion: Sacral stress fractures in the absence of osteoporosis are rare complications of pregnancy that can present with lumbar radiculopathy. Conservative management often produces good clinical outcomes.

Hypervitaminosis A: A Rare Cause of Hypercalcemia

Introduction: Hypercalcemia is a rather common clinical problem and a majority of cases are found to be secondary to primary hyperparathyroidism and malignancy. A rare cause of hypercalcemia is associated with high levels of vitamin A and thought to be secondary to the effect of vitamin A on bone to stimulate osteoclastic resorption or inhibit osteoblastic formation. Clinical Case: A 54 year-old male with a past medical history of CKD stage 3 secondary to medullary sponge kidney presented for hypercalcemia. He complained of chronic constipation, joint pain, mood changes and recurrent kidney stones. Reported multivitamin use (including 1000mcg of vitamin A) for years but was discontinued one year prior to visit. Lab work showed calcium of 11.5 mg/dL (8.7–10.2mg/dL), albumin 4.9 g/dL (3.8–4.9g/dL), elevated 24h urine calcium, eGFR 40 mL/min/1.73, parathyroid hormone 5 pg/mL (15-65pg/mL,) normal 1,25-OH vit D and 25-OH vit D, PTHrP &lt;2.0 pmol/L, serum protein electrophoresis unremarkable. His vitamin A level was elevated to 103 ug/dL (20.1–62.0ug/dL). CT chest showed no findings concerning for sarcoidosis. Bone density scan showed normal bone mineral density. Patient diagnosed with hypercalcemia secondary to elevated vitamin A levels. Current limited literature shows stopping the vitamin A supplement will normalize vitamin A levels and correct the hypercalcemia. This patient had discontinued his multivitamin 1 year prior and vitamin A remained elevated, thought to be due to his poor kidney function. Treatment was targeted at improving his hypercalcemia and reducing his symptoms. He was prescribed a one-week course of prednisone 40 mg daily. His calcium level improved to 10.5 mg/dL. Prednisone was reduced to 20 mg daily with normalization of calcium to 10.3 mg/dL (8.7–10.2mg/dL). Conclusion: Hypercalcemia is a rare but known complication of vitamin D toxicity. The liver, kidney and adrenal glands store vitamin A and it is excreted in the urine. Liver and kidney disease pose higher risk of vitamin A toxicity. We present a unique case of Hypercalcemia secondary to elevated vitamin A levels in a patient with moderate chronic kidney disease who was not taking excessive amounts of vitamin A and whose calcium and vitamin A did not normalize once vitamin A supplements were discontinued. The CKD 3 may have reduced vitamin A clearance and increased its toxicity. Hypercalcemia is not the only concern regarding vitamin A toxicity, the increasing use of dietary supplements and over the counter medications may pose significant risks for osteoporosis and bone fractures. A high clinical suspicion and thorough workup to exclude other causes of hypercalcemia is warranted to diagnose hypervitaminosis A as the etiology. Steroids can reduce gastrointestinal absorption of calcium, however, its role in vitamin A toxicity remains unclear. Further research is needed to investigate the appropriate treatment for these patients.

Essentiality of Manganese for Bone Health: An Overview and Update

The evidence regarding a deficiency of manganese (Mn) in humans is scarce. So the aim of this narrative review was to consider the state of the art on the relation between manganese and bone health in humans and the effectiveness of manganese supplementation (alone or with other micronutrients) on bone mineralization. This review included 4 eligible studies. All the literature published is in agreement in showing that osteoporotic women have lower serum Mn levels than women with normal bone mineral density, thus confirming the essential role of manganese in the synthesis of cartilage and bone collagen, as well as in bone mineralization and confirming the studies on the animal model. Considering the human studies that evaluated the effectiveness of an oral Mn supplement for a long period (2 years) on the bone mineral density of menopausal women, both of the clinical trials showed that bone loss was significantly greater in the placebo group than in the group taking supplementation, equal to 5.0 mg Mn/day in the study by Strause, and equal to 2.5 mg Mn/day in the study by Saltman, considering, however, that supplementation was represented by a set of microelements (Mn, copper, and zinc) and by calcium.

Vitamin D Metabolites and Sex Steroid Indices in Postmenopausal Women with and without Low Bone Mass

While the independent roles of vitamin D and sex hormones in skeletal health are well established, the associations of vitamin D and its metabolites to sex hormones and their indices are less investigated. In this observational study, clinical information of 189 Saudi postmenopausal women aged ≥50 years old [N = 80 with normal bone mineral density (BMD), aged 53.3 ± 7.7 years with body mass index (BMI)= 34.1kg/m2 ± 5.8, and N = 109 with low BMD (T-score −1.0 to −2.5), aged 57.0 ± 8.2 years, BMI = 32.4kg/m2 ± 6.2] was extracted from an existing capital-wide osteoporosis registry in Riyadh, Saudi Arabia. Data included were BMD scores, serum total 25(OH)D, sex hormones, and bone turnover markers which were measured using commercially available assays. Age- and BMI-adjusted comparisons revealed significantly higher parathyroid hormone (PTH) levels as well as significantly lower testosterone and bioavailable testosterone in the low BMD group than the normal BMD group (p-values 0.04, 0.02, and 0.03, respectively). Stepwise linear regression showed that circulating testosterone levels accounted for 9.7% and 8.9% of the variances perceived in bioavailable 25(OH)D and free 25(OH)D, respectively (p < 0.01), independent of other sex hormones, sex hormone indices, and bone turnover markers. Our study suggests that androgens are significantly associated with non-conventional vitamin D metabolites and these associations may have clinical relevance in assessing risk for low BMD and osteoporosis in Arab postmenopausal women.