Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi...

Transcript of Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi...

Internal MedicineWeekly Conference

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BONE MINERAL DENSITY

Alimohammad Fatemi

Assistant Professor of Rheumatology

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1392Why Diagnosis Is Important?

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• The most common metabolic bone disease− 1/3 of women > 50− 1/5 of men > 50

• High Morbidity and Mortality

• Asymptomatic− 30-50% of vertebral fracture

Why Diagnosis Is Important?

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1392OSTEOPOROSIS

• A skeletal Disorder:

– Compromised Bone Strength

– Increased Risk of Fracture

Adams, Nat Rev Endocrinol. 2013

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1392BONE STRENGTH

Bone Mineral Bone Quality Bone Material

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1392BONE STRENGTH

Bone MineralDXA

Quantitative CT

Bone Material

Bone Quality

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1392BONE STRENGTH

Bone MineralDXA

Quantitative CT

Bone QualityDXA

Quantitative CTBone Turnover Markers

High Resolution CT/MRI

Bone Material

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1392BONE STRENGTH

Bone MineralDXA

Quantitative CT

Bone QualityDXA

Quantitative CTBone Turnover Markers

High Resolution CT/MRI

Bone MaterialNano Imaging

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1392Dual Energy X-ray Absorptiometry

(Gold Standard)

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1392Dual Energy X-ray Absorptiometry

(Gold Standard)

• Epidemiologic Studies

• Pharmacological Studies

• Reproducibility

• Safety− Low Radiation : 1/10 of Chest x-ray

• Diagnostic Criteria

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1392DEXA MACHINE

• X-ray Source (Tube)

• X-ray Collimators

• X-ray Detectors

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1392DXA MACHINE

X-ray Source

Patient

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1392DXA MACHINE

X-ray Source

(2 photon energies with different attenuation profiles)

Photons

Patient

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1392DXA MACHINE

X-ray Source

Photons

Patient

Collimator

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1392DXA MACHINE

X-ray Source

Photons

Patient

Collimator

Detector (detects 2 tissue types - bone and soft tissue)

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1392DEXA MACHINE

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1392DIFFERENT MACHINE

• MACHINES

– Hologic

– Lunar

– Norland

–MedLink

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1392Which Bones?

• Spine

• Femur

• Forearm

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1392SPINE

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1392FEMUR

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1392FOREARM

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1392What DXA Really Measures?

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• BMD

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• BMD

Bone Mineral Content (g) /Area (cm )2

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1392SPINE

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• BMD g/cm²

• %

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1392BMD

0

0.1

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10 15 20 25 30 35 40 45 50 55 60 65 70 75

Patient’s BMD

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1392BMD

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PBM(Peak Bone Mass)

Patient’s BMD

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1392BMD

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PBM(Peak Bone Mass)

Patient’s BMD

The reference standard is calculated is the female, white, age 20-29 years, NHANES III

database

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1392Comparison to Young Adult

BMD × 100

PBM

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1392SPINE

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• BMD g/cm²

• %

• T-Score

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1392T-SCORE

(Patient’s BMD) – (Young-Adult Mean BMD) 1 SD of Young-Adult Mean BMD

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1392T-SCORE

(Patient’s BMD) – (Young-Adult Mean BMD) 1 SD of Young-Adult Mean BMD

T-score =0.7 g/cm2 - 1.0 g/cm2

0.1 g/cm2

- 3.0 =

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1392SPINE

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• BMD g/cm²

• %

• T-Score

• Z-Score

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Patient’s BMD

Age-Matched BMD

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1392Comparison to Same Age/Sex(Z-SCORE)

Patient’s BMD – Age-Matched Mean BMD

1 SD of Age-Matched Mean BMD

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1392SPINE

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1392DEFINITIONS

• Normal Bone− -1 ≤ T-Score < +1

• Osteopenia− -2.4 < T-Score < -1

• Osteoporosis− T-Score ≤ -2.5

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1392When We Should Use Z-Score?

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• 0

• 0.1

• 0.2

• 0.3

• 0.4

• 0.5

• 0.6

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• 0.8

• 0.9

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• 10• 15• 20• 25• 30• 35• 40• 45• 50• 55• 60• 65• 70• 75

PBM(Peak Bone Mass)

Patient’s BMD

Age-Matched BMD

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• In children − Z < -2 Low BMD for chronological age

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• In children − Z < -2 Low BMD for chronological age

• Secondary osteoporosis

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• 0

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• 0.2

• 0.3

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• 10• 15• 20• 25• 30• 35• 40• 45• 50• 55• 60• 65• 70• 75

PBM(Peak Bone Mass)

Patient’s BMD

Age-Matched BMD

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1392Using T-scores vs. Z-scores

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• T-scores –WHO diagnostic

Postmenopausal women and Men ≥ 50

– Not for:

Healthy premenopausal women Men <50 Children

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• T-scores –WHO diagnostic

Postmenopausal women and Men ≥ 50

– Not for:

• Z-scores – Used for:

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1392Which Skeletal Sites Should Be Measured?

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Which Skeletal Sites Should Be Measured?

Every Patient• Spine– L1-L4

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• Hip– Total Hip– Femoral Neck

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1392What Is Ward’s Area?

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• A small calculated area – the mid portion of the femoral neck – BMD is the lowest

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• Overestimate the prevalence of osteoporosis

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• Overestimate the prevalence of osteoporosis

• Not part of WHO Criteria

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• Hip– Total Hip– Femoral Neck

Some Patients• Forearm– If hip or spine cannot

be measured– Hyperparathyroidism– Very obese

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33% radius

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1/3 radius

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1392DIAGNOSTIC PITFALLS

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• Patient’s demographic data

• Patient’s positioning

• Scan analysis

• Artifact

• Calibration

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• Scan analysis

• Artifact

• Calibration

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• Scan analysis

• Artifact

• Calibration

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1392SPINE

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1392SPINERegion of Interest

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SPINE

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SPINE

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1392SPINE

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1392HIP

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1392HIP

Region of Interest

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1392HIP

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1392HIP

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1392HIP

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• Scan analysis

• Artifact

• Calibration

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1392ARTIFACT

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1392ARTIFACT

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1392ARTIFACT

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• Scan analysis

• Artifact

• Calibration

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1392Calibration

Phantom

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MONITORING

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1392MONITORING

– Lumbar Spine 2.8%

– Femoral Neck 5.6%

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1392MONITORING

– Lumbar Spine 2.8%

– Femoral Neck 5.6%

(change in BMD ÷ prior BMD ) x100=significant percentage change

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1392INDICATIONS

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1392INDICATIONS• Women ≥ 65

• Younger Women with ≥ 1 risk factors

• Postmenopausal women with fracture

• Estrogen Deficiency

• Long-Term steroid

• Monitoring of Therapy

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THANKS FOR

YOUR ATTENTION

Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi...

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