Program Book and Abstracts - ISCD

Global
Assessment
of Skeletal
Health
WWW.ISCD.ORG
PROGRAM BOOK
— 2008 Annual Meeting 41

Dear Colleague,
On behalf of the International Society for Clinical Densitometry, we are pleased to
welcome you to the 14th Annual Meeting. The 2008 program will include sessions
of interest to all, including interactive sessions as well as numerous concurrent
sessions.
The ISCD Annual Meeting is the largest gathering of specialists in the field of bone
densitometry, bringing together many different medical disciplines. The Annual
Meeting plenary and concurrent sessions, specialty workshops, abstracts, poster
and challenging case presentations, discussion groups, and symposia will provide
multiple learning opportunities about new developments in the field of bone
densitometry. You will also have the opportunity to network with your colleagues
and leaders in the field.
The ISCD Annual Meeting Committee and the Board hope you enjoy the 14th
Annual Meeting!
Donald Bachman, MD, CCD Anita Colquhoun, MRT, CDT
Tamara Vokes, MD, CCD
2008 Annual Meeting Committee
We would like to thank and acknowledge the hard work and time our
committee volunteers have given over the past year.
Donald Bachman, MD, CCD, Co-Chair
Anita Colquhoun, MRT, CDT, Co-Chair
Tamara Vokes, MD, CCD, Co-Chair
Gerald Avery, RT, CDT
Joao Lindolfo C. Borges, MD, CCD
Didier Hans, PhD, CCD, CDT
Diane C. Krueger, BD, CDT
David C. Kendler, MD, CCD
E. Michael Lewiecki, MD, CCD
Christopher Shuhart, MD, CCD
S. Bobo Tanner, MD, CCD
Carol Zapalowski, PhD, CCD

Table of Contents
Page
Officers and Board of Directors .................................................................................................................. 1
Committee Meetings ...................................................................................................................................... 2
General Information ....................................................................................................................................... 3
ISCD Annual Meeting Education Evaluator................................................................................................ 4
Disclosures ....................................................................................................................................................... 5
2007 Annual Meeting Award Winners ........................................................................................................ 8
Scientific Exhibits ............................................................................................................................................. 9
ISCD Acknowledgment of Abstract Reviewers ...................................................................................... 10
Best Abstracts ................................................................................................................................................ 10
Poster Days and Hours ................................................................................................................................ 12
Poster Presentation Abstracts .................................................................................................................... 12
Challenging Cases ......................................................................................................................................... 40
Handouts ......................................................................................................................................................... 41

2008-2009 Officers and Board of Directors
PRESIDENT
Sanford Baim, MD, CCD – 2009
Glendale, WI
PRESIDENT-ELECT
Andrew J. Laster, MD, CCD – 2009
Charlotte, NC
VICE-PRESIDENT
Didier B. Hans, PhD, PD, CCD – 2009
Lausanne, VD, SWITZERLAND
TREASURER
S. Bobo Tanner, MD, CCD – 2009
Nashville, TN
SECRETARY
Bennié L. Leverich, RN, CDT – 2009
Bethlehem, PA
IMMEDIATE PAST-PRESIDENT
David L. Kendler, MD, CCD – 2008
Vancouver, BC, CANADA
BOARD OF DIRECTORS (2008-2009)
Gerald Avery, RT(R)(N), CNMT, CDT – 2009
Indianapolis, IN
Susan B. Broy, MD, CCD – 2011
Morton Grove, IL
Anita Colquhoun, MRT(N), CDT – 2010
Toronto, ON, CANADA
Kathryn M. Diemer, MD, CCD – 2011
St. Louis, MO
Akira Itabashi, MD, PhD, CCD – 2011
Kumagaya, Saitama, JAPAN
Lawrence G. Jankowski, CDT – 2011
Morton Grove, IL
Diane C. Krueger, BS, CDT – 2010
Madison, WI
Brian C. Lentle, MD, CCD – 2011
Vancouver, BC CANADA
William D. Leslie, MD, FRCPC, MSc, CCD – 2011
Winnipeg, MB CANADA
Roman S. Lorenc, MD, PhD, CCD – 2011
Warsaw, POLAND
Sergio Ragi-Eis, MD, CCD – 2011
Vitoria, ES, BRAZIL
Bradford J. Richmond, MD, CCD – 2009
Cleveland, OH
Joseph L. Shaker, MD, CCD – 2010
Boise, ID
James A. Simon, MD, CCD – 2009
Washington, D.C.
Christine Simonelli, MD, CCD – 2011
Woodbury, MN
Tamara J. Vokes, MD, CCD – 2009
Chicago, IL
Sunil J. Wimalawansa, MD, PhD, FRCP, DSc – 2011
New Brunswick, NJ
EX OFFICIO BOARD MEMBERS
Editor, Journal of Clinical Densitometry
Past President
Paul Miller, MD, CCD
Lakewood, CO
Chair, Education Council
Edward S. Leib, MD, CCD
Burlington, VT
Chair, Certification Council
Susan E. Williams, MD, MS, CCD
Xenia, OH
Chair, Publications Committee
Diane L. Schneider, MD, CCD
La Jolla, CA
Chair, Scientific Advisory Committee
Past President
E. Michael Lewiecki, MD, CCD
Albuquerque, NM
Past Presidents
John Bilezikian, MD, CCD
New York, NY
Neil Binkley, MD, CCD
Madison, WI
Steven Petak, MD, JD, CCD
Houston, TX
Nelson B. Watts, MD, CCD
Cincinnati, OH
— 2008 Annual Meeting 1

CONTACT INFORMATION
Address: 342 North Main Street
West Hartford, CT 06117-2507
USA
Phone: 860.586.7563
Fax: 860.586.7550
E-mail General: iscd@iscd.org
Certification: certification@iscd.org
recertification@iscd.org
Membership: membership@iscd.org
Web site: www.ISCD.org
STAFF
M. Suzanne C. Berry, MBA, CAE (Ext. 510)
Executive Director
E-mail: sberry@iscd.org
Priscilla T. Shisler (Ext. 549)
Director of Education
E-mail: pshisler@iscd.org
JoLynn Amsden (Ext. 585)
Education Project Manager
E-mail: jamsden@iscd.org
Beth Baddeley (Ext. 543)
Certification Administrator
E-mail: ebaddeley@iscd.org
Francesca Blanco (Ext. 204)
Meeting Planner
E-mail: fblanco@iscd.org
Jean Fazzino (Ext. 545)
Leadership Liaison
E-mail: jfazzino@iscd.org
Donna Fiorentino (Ext. 553)
Public Policy Affairs Manager
E-mail: dfiorentino@iscd.org
Jennifer Gentry (Ext. 529)
Publications/Web Site Coordinator
Email: jgentry@iscd.org
Anabela Gomes (Ext. 583)
Education Registrar
E-mail: agomes@iscd.org
Nancy Gianetti (Ext. 534)
Membership Services Administrator
E-mail: ngianetti@iscd.org
Amanda Neal (Ext. 515)
Education Project Manager
E-mail: aneal@iscd.org
Elizabeth Pillsworth (Ext. 566)
Director Meetings and Events
E-mail: epillsworth@iscd.org
Helene Weston (Ext. 539)
Education Project Manager
E-mail: hweston@iscd.org
Committee Meetings – Invitation Only
Thursday, March 13, 2008
7:00 a.m.-8:00 a.m.
Public Policy
Board Room A
12:30 p.m.-1:30 p.m.
Membership Committee
Board Room A
6:30 p.m.-8:00 p.m.
Annual Meeting Committee
Board Room A
Friday, March 14, 2008
6:30 a.m.-8:00 a.m.
IRC
Bayview AB
7:00 a.m.-9:00 a.m.
VFA Committee
Board Room A
11:30 a.m.-12:30 p.m.
JCD Editorial Board
Garden Room A
Saturday, March 15, 2008
2:30 p.m.-6:00 p.m.
Certification Council
Board Room A
2:30 p.m.-4:00 p.m.
CME Training
Bayview AB
2 — 2008 Annual Meeting

General Information
Purpose Statement
The incidence of osteoporotic fractures is increasing both in
North America and globally. Contributing to this is aging of the
population, suboptimal diet and exercise in children and
adolescents leading to low peak bone mass, more sedentary
lifestyles in many parts of the world, and an increase in the
prevalence of diseases and use of medications that lower bone
mass. The need for tailored screening, diagnosis and treatment
suitable for different cultures is therefore increasingly important.
To this end, new technologies and treatments should be
assessed and appropriate standards and guidelines developed
and implemented. Position statements arising from ISCD
conferences will be helpful in this regard. The ISCD Annual
Meeting will help as a forum to educate healthcare professionals
and assist them to successfully diagnose, prevent and treat
osteoporosis worldwide.
Learning Objectives
Upon completion of this activity, participants should be able to:
· Compare and contrast approaches to diagnosing, screening,
managing, and treating osteoporosis according to various
national guidelines
· Evaluate the utility of the technologies available for bone
health assessment in clinical practice
· Recognize the impact of certain disease states and
medications on skeletal health to initiate treatment earlier
than you did prior to the ISCD Annual Meeting or to make
changes to existing treatments
· Apply the recommendations made during the 2007 Adult
and Pediatric Position Development Conferences (PDC) in
adult and pediatric populations
Target Audience
The target audience for this educational activity is clinicians,
technologists, researchers, scientists, and healthcare providers
who wish to learn the skills and techniques of quality skeletal
assessment to implement in their practice.
Accreditation Statement
This activity has been planned and implemented in accordance
with the Essential Areas and policies of the Accreditation
Council for Continuing Medical Education through the joint
sponsorship of the University of Cincinnati and the International
Society for Clinincal Densitometry (ISCD). The University of
Cincinnati is accredited by the Accreditation Council for
Continuing Medical Education to provide continuing medical
education for physicians.
The University of Cincinnati College of Medicine is accredited
by the Accreditation Council for Continuing Medical Education
(ACCME) to sponsor continuing medical education for
physicians.
Credit Designation
The University of Cincinnati designates this educational activity
for a maximum of 25 AMA PRA Category 1 Credit(s).
Physicians should only claim credits commensurate with the
extent of their participation in the activity.
Disclosure Statement
The University of Cincinnati is committed to resolving all
conflicts of interest issues that could arise as a result of
prospective faculty members’ relevant relationships with drug or
device manufacturers. The University of Cincinnati is committed
to maintaining only those speakers with financial interest that
can be reconciled with the goals and educational integrity of the
CME program.
In accordance with ACCME Standards for Commercial Support,
the speaker(s) for this course have been asked to disclose to
participants the existence of any financial relationships in any
amount occurring within the past 12 months. Disclosures can
be found starting on page 5 of this Program Book.
University of Cincinnati Disclaimer Statement
The opinions expressed during this educational activity are
those of the faculty and do not necessarily represent the views
of the University of Cincinnati or ISCD. Participants have an
implied responsibility to use the newly acquired information to
enhance patient outcomes and their own professional
development.
CE Credit
This meeting qualifies for up to 25 category A credits through
the American Society of Radiologic Technologists (ASRT).
Policy on Commercial Support and Faculty Disclosure
The ISCD maintains a policy on the use of commercial support
which ensures that all educational activities supported by the
ISCD provide in-depth presentations that are fair, independent,
free of commercial bias and scientifically rigorous. To this end, all
speakers are required to complete a Conflict of Interest
Disclosure Form. All disclosures are included in this program
book starting on page 5.
Clinicians - CME Certificates
Full instructions for completing your evaluation of the 2008
Annual Meeting are on page 4 of this program book. A CME
certificate will be created during that process for you to print
for your records.
Technologists - CE Certificates
Full instructions for completing your evaluation of the 2008
Annual Meeting are on page 4 of this program book. If you
would like to receive Category A CE credit, you must sign in
and out of every session you attend. Once you complete the
online evaluation, ISCD staff will verify your certificate with the
sign-in sheets. After the number of credits is verified, your
certificate will be sent to you via email.
Acknowledgement
We gratefully acknowledge the following companies for their
educational grants in support of this activity: Eli Lilly and
Company, GE Healthcare, GTx, Hologic, Merck and Co.,
Medtronic, MicroMRI, Roche Diagnostics, Inc. and Wyeth
Pharmaceuticals
— 2008 Annual Meeting 3

ISCD Annual Meeting Education Evaluator
The International Society for Clinical Densitometry (ISCD)
Education Evaluator is the credit reporting and evaluation
system which will allow the ISCD staff to get your feedback on
the ISCD Annual Meeting and make it easy for you to process
your own CME/CE certificate.
Evaluations are very important to us. The planning and
execution of useful sound continuing medical education
programs are largely guided by input provided by program
participants. These evaluations are required for continuing
medical education accreditation. In addition, your response to
the following questions will help to ensure that future programs
are informative and meet participants’ educational needs. Your
evaluation must be completed online in order to process your
CME/CE certificate.
Information submitted through ISCD Education Evaluator will
only be shared in the aggregate and will not include any contact
reference or information. The only exception would be
information sent to the accrediting bodies, University of
Cincinnati and the ASRT for credit information only. Access to
course attendees is limited to the ISCD staff administrator and is
only used to assist the attendee with obtaining their attendance
certificate.
ISCD Education Evaluator Instructions
If you pre-registered for the Annual Meeting, you received an
e-mail with this instruction sheet and your ID Number and
Password. If you registered onsite, you will receive an e-mail
with your ID Number and Password about 2 weeks after the
meeting.
Below are the instructions for accessing the Education Evaluator
and frequently asked questions.
Steps for Accessing the ISCD Education Evaluator
1. Access the ISCD evaluator at wwwISCD.org under
HIGHLIGHTS section, from any computer that has internet
access for up to six weeks after the meeting.
2. Select Annual Meeting (if you attended the BDC and/or VFA
course, evaluation(s) will be done separately).
3. Enter your ID number and password. These can be found on
your acknowledgement and on your ISCD name badge.
4. Select Technologist or Clinician.
5. Select sessions attended and complete the individual session
evaluations using your notes from this booklet.
6. Complete the overall Annual Meeting evaluation.
7. Please verify all sessions attended have been selected before
selecting Yes or No.
8. Print your certificate.
9. Please NOTE: Use the back button on your browser and
then select Log Out from the upper right hand corner of the
page to complete the session. Logging Out must be
completed before evaluating a education course. (e.g. BDC or
VFA course)
Frequently Asked Questions
Where can I find my ID number and password?
If you pre-registered for the Annual Meeting, you received an
e-mail with this instruction sheet and your ID Number and
Password. If you registered onsite, you will receive an e-mail
with your ID Number and Password about 2 weeks after the
meeting.
When can I start entering my evaluation information?
As long as you are pre-registered for the ISCD Annual Meeting
you may start entering each day’s session evaluations at the end
of each day. The system will be available until six weeks after the
Annual Meeting (April 28, 2008).
Where can I access the ISCD evaluation system?
You can access the evaluation system from any computer that
has internet access at www.ISCD.org under the HIGHLIGHTS
section.
What is the paper evaluation for?
You will need to take notes for each lecture so you can enter
the information online later.
Can I enter part of my information now and finish
later?
Yes, you may enter partial information and return at a later time
to finish. The system will allow this until you indicate that you
are finished.
4 — 2008 Annual Meeting

Disclosures
Judith Adams, MBBS, FRCR, FRCP
No Financial Relationships to Disclose
Gerald Avery, RT(R)(N), CDT
No Financial Relationships to Disclose
Donald Bachman, MD, CCD
No Financial Relationships to Disclose
Laura Bachrach, MD
Consultant: Novartis, Takeda Global, Roche/GSK
Grant Recipient: Genentech
Sanford Baim, MD, CCD
No Financial Relationships to Disclose
John Bilezikian, MD, CCD
Advisory Board: Merck, Lilly, sanofi-aventis, Novartis,
P&G
Consultant: Merck, Lilly, sanofi-aventis, Novartis, P&G
Grant Recipient: P&G, sanofi-aventis
Neil Binkley, MD, CCD
Research Funding: Merck, Novartis, Roche/GSK,
sanofi-aventis, Deltanoid, Macroflux
Speaker: Merck, Roche/GSK, P&G, Novartis
Consultant: Merck, Novartis, Lilly
Sydney Lou Bonnick, MD, CCD
Advisory Board: Wyeth, Amgen, Merck
Consultant: Wyeth, Merck
Shareholder: P&G
Speaker: Wyeth, Roche/GSK, Merck, Novartis, Amgen
Other: Amgen
João Lindolfo C. Borges, MD, CCD
Advisory Board: Roche/GSK, Schering
Speaker: Roche, Schering
Susan Broy, MD, CCD
Research Funding: Merck P&G, Novartis, Lilly,
Roche/GSK
Speaker: Merck, P&G, Lilly, Novartis, sanofi-aventis
Consultant: Merck, P&G, Lilly, Novartis, sanofi-aventis,
Roche, Amgen
Advisory Board: Merck, P&G, Lilly, Novartis,
Roche/GSK, Amgen, Aventis
JoAnn Caudill, RT(R)(M), CDT
No Financial Relationships to Disclose
Anita Colquhoun, RT(M)(N), CDT
No Financial Relationships to Disclose
Gary Edelson, MD, CCD
Speaker: Merck, Alliance for Better Bone Health, Lilly,
Novartis
Ghada El-Hajj Fuleihan, MD, MPH
Advisory Board: Lilly SERM
Grant Recipient: sanofi-aventis, Lilly
Kenneth Faulkner, PhD
Employee: Synarc
Shareholder: Synarc
Harry Genant, MD, PhD
Advisory Board: GE, Hologic, Amgen, Lilly, Roche/GSK,
Merck, Servier, BMS
Consultant: GE, Hologic, Amgen, Lilly, Roche/GSK,
Merck, Servier, BMS
Officer: Synarc
Shareholder: Synarc
Deborah T. Gold, PhD
Advisory Board: Roche/GSK, Lilly, P&G, sanofi-aventis,
Sciele, Amgen
Consultant: Roche/GSK, Lilly, P&G, sanofi-aventis, Sciele,
Amgen
Speaker: Roche/GSK, Lilly, P&G, sanofi-aventis, Sciele,
Amgen
Bill N. Griffin, MD, CCD
No Financial Relationships to Disclose
David Hanley, MD, CCD
Advisory Board: Alliance for Better Bone Health (P&G,
sanofi-aventis), Amgen, Lilly, Novartis, Wyeth, NPS, Paladin
Consultant: Merck
Grant Recipient: Alliance for Better Bone Health (P&G,
sanofi-aventis), Amgen, Lilly, Novartis, Wyeth, NPS, Pfizer
Speaker: Alliance for Better Bone Health (P&G, sanofiaventis),
Amgen, Lilly, Novartis, Wyeth, NPS, Nycomed
Didier Hans, PhD, PD, CCD
Consultant: Medi Maps, Servier
Shareholder: Synarc, Inc.
Michele Heater, RT, CDT
No Financial Relationships to Disclose
Akira Itabashi, MD, PhD, CCD
No Financial Relationships to Disclose
Sophie Jamal, MD, PhD, FRCP
No Financial Relationships to Disclose
Larry G. Jankowski, CDT
Speaker: sanofi-aventis, P&G
Heidi Kalkwarf, PhD
Employee (spouse): P&G
Sue Kaste, DO
No Financial Relationships to Disclose
Tony Keaveny, PhD
Consultant: Biomimetic Therapeutics, Inc., Merck, Lilly,
Roche/GSK, Novartis, Amgen
Officer: O.N. Diagnostics, LLC
Shareholder: O.N. Diagnostics, LLC
Grant Recipient: Merck, Pfizer, Biomimetic Therapeutics,
Lilly, Amgen, Roche/GSK
— 2008 Annual Meeting 5

David Kendler, MD, CCD
Grant Recipient: Amgen, Lilly, Merck, Norvartis, Pfizer,
Wyeth, Takeda, Servier, Zelos
Advisory Board: Amgen, Lilly, Novartis, Servier, Wyeth
Speaker: Servier, Lilly, Novartis, Pfizer, Amgen
Consultant: Amgen, Lilly, Novartis, Servier, Wyeth
Aliya Khan, MD, CCD
Speaker: Merck, Lilly, Servier, Novartis, P&G, Amgen
Advisory Board: Merck, Lilly, Servier, Novartis, P&G,
Amgen
Grant Recipient: Merck, Lilly, Servier, Novartis, P&G,
Amgen
Consultant: Merck, Lilly, Servier, Novartis, P&G, Amgen
Michael Kleerekoper, MD, CCD
Consultant: Roche/GSK
Speaker: Roche/GSK
Advisory Board: Roche/GSK
Lynn Kohlmeier, MD
Grant Recipient: sanofi-aventis, P&G, Novartis, Amgen
Speaker: Merck, Lilly, Novartis, Aventis, Roche/GSK, P&G
Research: Merck, Lilly, Novartis, Amgen
Marc-Antoine Krieg, MD, CCD
No Financial Relationships to Disclose
Diane, Krueger, CDT
No Financial Relationships to Disclose
Annie, Kung, MD, FCRP, CCD
No Financial Relationships to Disclose
Nancy Lane, MD
Advisory Board: Wyeth, Beizdoxiphene
Grant Recipient: P&G, Zosano
Speaker: Lilly, Roche/GSK, Novartis, Genentech
Andrew Laster, MD, CCD
Speaker: Lilly, Merck, P&G, Roche/GSK, Abbott,
Genentech
Consultant: Lilly, Genentech, Hologic
Advisory Board: Lilly, Roche/GSK, Genentech, Abbott
Board member: ISCD
Mary Leonard, MD, MSCE
No Financial Relationships to Disclose
William Leslie, MD, CCD
Grant Recipient: Alliance for Better Bone Health, P&G,
sanofi-aventis, Novartis, Genzyme
Consultant: Genzyme
Bennié Leverich, RN, CDT
Consultant: Hologic
Michael Lewiecki, MD, CCD
Consultant: Merck, Lilly, Novartis, P&G, sanofi-aventis,
Roche/GSK, Wyeth, Servier, Amgen, Upsher-Smith
Grant Recipient: Merck, Eli Lilly, Novartis, P&G,
sanofi-aventis, Roche/GSK, Wyeth, Amgen, Pfizer
Speaker: Merck, Eli Lilly, Novartis, P&G, sanofi-aventis,
Roche/GlaxoSmithKline, Wyeth, Servier, Amgen,
Upsher-Smith
Ownership Interest: GE Healthcare, P&G
Advisory Board: Merck, Lilly, Novartis, P&G, sanofiaventis,
Roche/GSK, Wyeth, Servier, Amgen, Upsher-Smith
Board of Directors: ISCD
Roman Lorenc, MD, PhD, CCD
No Financial Relationships to Disclose
Marjorie Luckey, MD, CCD
Consultant: Lilly, Merck, Amgen
Grant Recipient: Roche/GSK, Amgen, P&G
Speaker: P&G, Lilly, Merck, sanofi-aventis, Novartis
Paul D. Miller, MD, CCD
Grant Recipient: P&G, sanofi-aventis, Roche/GSK, Lilly,
Merck, Novartis, Amgen
Speaker: P&G, sanofi-aventis, Merck, Lilly, Amgen, NPS,
Novartis, Roche/GSK
Consultant: P&G, sanofi-aventis, Merck, Lilly, Amgen,
NPS, Novartis, Roche/GSK
Advisory Board: P&G, sanofi-aventis, Merck, Lilly,
Amgen, NPS, Novartis, Roche/GSK
Sarah Morgan, MD, CCD
Advisory Board: Merck, P&G, Lilly, Amgen, Roche/GSK
Grant Recipient: P&G
Speaker: Merck, P&G, Amgen, Roche/GSK
Consultant: Merck, P&G, Lilly, Amgen, Roche/GSK
Orlando Ortiz, MD, MBA, FACR
Consultant: Kyphon Corporation
Eric Orwoll, MD
Research Funding: Amgen, Pfizer, Lilly, Zelos, Imaging
Therapeutics, Solvay, Novartis
Consulting: Lilly, Merck, Servier
Honoraria: Merck
Steven M. Petak, MD, CCD
Advisory Board: Lilly, Roche/GSK
Officer: AACE – Immediate Past President
Grant Recipient: sanofi-aventis/P&G
Speaker: Eli Lilly, Roche/GSK, Novartis, sanofi-aventis,
P&G, Merck
Sergio Ragi-Eis, MD, CCD
Speaker: sanofi-aventis Brazil, Roche/GSK Brazil, Merck
Sharp & Dohme Brazil, Merck & Co., Lilly Brazil
Brad Richmond, MD, CCD
No Financial Relationships to Disclose
6 — 2008 Annual Meeting

Harold Rosen, MD, CCD
Speaker: P&G, Novartis
Brian Sabowitz, MD, FACP, CCD
Speaker: P&G, sanofi-sventis, Lilly
John Schousboe, MD
Consultant: Merck
Grant Recipient: Hologic
Elliot N. Schwartz, MD, CCD
Advisory Board: Merck, Lilly, Novartis
Consultant: Merck, Lilly
Grant Recpient: Merck, Lilly, Novartis, Amgen, P&G
Speaker: Merck, Lilly, Novartis, Amgen, P&G, Roche/GSK
Other Relationships: Lilly, Novartis, Amgen, Roche/GSK
John Shepherd, PhD, CCD
No Financial Relationships to Disclose
Christopher Shuhart, MD, CCD
Consultant: Illumigen Bioscienes, Inc.
Shareholder: Illumigen Biosciences, Inc.
Grant Recipient: Hoffman-LaRoche, Inc.
S. Bobo Tanner, MD, CCD
Grant Recipient: Genentech, Lilly, Roche/GSK, Merck,
P&G
Speaker: Novartis, Merck, Roche/GSK, Lilly, P&G,
Amgen, Genentech
Rogene Tesar, PhD, CDT, CCD
Consultant: Advanced Health Education Center, P&G
Joyce Urban, RT(R)(M), CDT
Grant Recipient: Mindway Software
Fred Vernacchia, MD
Consultant: Bard Biopsy Systems
Speaker: GE
Tamara Vokes, MD, CCD
Grant Recipient: Merck, P&G
Speaker: Merck, P&G, Roche/GSK, Novartis
Sharon Wartenbee, RT, CDT
No Financial Relationships to Disclose
Nelson Watts, MD, CCD
Consultant: Lilly, Roche/GSK, Novartis, P&G,
sanofi-aventis, Kyphon, Amgen
Research Funding: Amgen, Lilly, Novartis, P&G,
sanofi-aventis, MicroMRI, Radius, Solvay
Honoraria: Amgen, sanofi-aventis, Novartis, P&G
Jean Weigert, MD, CCD
Grant Recipient: Dilon Technology, Inc.
Carol Zapalowski, MD, PhD, CCD
Consultant: P&G
Speaker: P&G, Lilly, Abbott, Novartis
Babette Zemel, PhD
No Financial Relationships to Disclose
— 2008 Annual Meeting 7

2008 Annual Meeting Award Winners
ISCD Dr. Paul D. Miller Service Award
Presented to
an ISCD Member for distinguished service
and dedication to ISCD
Neil C. Binkley, MD, CCD
ISCD Technologist Instructor of the Year
Lawrence G. Jankowski, CDT
ISCD Clinician Instructor of the Year
David Kendler, MD, FRCPC, CCD
ISCD Technologist of the Year Award
Presented to
an ISCD Technologist Member for distinguished
service and dedication to the field of bone densitometry
Laura Fairbanks, MS
ISCD Clinician of the Year Award
Presented to
an ISCD Clinician Member for distinguished service
and dedication to the field of bone densitometry
Elliott N. Schwartz, MD, CCD, CPD
ISCD Global Leadership Award
Presented to
an ISCD Member for distinguished service and
leadership in the global promotion of the field of bone
densitometry and ISCD
Sergio Ragi-Eis, MD, CCD, CDT
ISCD Super Tech Award
Presented to
an ISCD Technologist Member for exhibiting and
maintaining high standards as a densitometry technologist
Martha L. Manilla-McIntosh, BS, RT(R), CDT
ISCD VFA Instructor of the Year
Neil C. Binkley, MD, CCD
ISCD Best Poster – Clinician
Nelson B. Watts, MD, CCD
ISCD Best Poster – Technologist
Dessa Gemar, BA, CDT
ISCD Young Investigator Travel Award
These travel awards are made possible by a grant from
Merck & Co.
International Young Investigator Travel Awards:
Michael Roman Doschak, PhD
Sheerin Ansari Eyre, PhD
Alireza Moayyeri, MD, MPH
Jason D. Vescovi, PhD, CCD
Ali Ghasem-Zadeh, MS
United States Young Investigator Travel Awards:
Bjoern Buehring, MD
Jeffrey R. Curtis, MD
Mariam Khan, MD
Abey Mukkananchery, MS
Erik Dean Swenson, MD
Denise Angelica Teves, MD
Askin Uysal, MD
Sparkle Joy Williams, BS
Susan E. Williams, MD, MS, RD, CNSP, CCD
International Faculty Travel Awards:
Luis Miguel del Rio Barquero, MD
Manuel Diaz Curiel, MD
Bruno Muzzi Camargos, MD
Hans Mallmin, MD
Oscar Antunez Flores, MD
8 — 2008 Annual Meeting

Scientific Exhibits
AMGEN
Thursday, March 13, 2:00 p.m. – 6:00 p.m.
Marina Room
The Amgen Scientific Exhibit is an interactive poster session covering two topics: the RANK Ligand Pathway and bone biology and
Epidemiologic trends in bone health. The exhibit contains scientific posters and will be open on Thursday, March 13, from 2:00 p.m.
until 6:00 p.m. in the Hyatt Marina room. Amgen Medical staff will be in attendance.
(Acknowledgements to University of Alabama Birmingham and Duke University Medical Center)
ELI LILLY & COMPANY
Thursday, March 13, 8:00 a.m. – 12:00 p.m.
Marina Room
The Eli Lilly & Company Scientific Exhibit will feature high-resolution CT images of in vivochanges in vertebral microarchitecture
during teriparatide treatment in the Marina room on Thursday, March 13, from 8:00 a.m. to 12:00 p.m. Scientific poster
presentations include recent clinical findings on teriparatide use in patients with glucocorticoid-induced osteoporosis, and the
effects of switching versus adding teriparatide in patients who previously took antiresorptives.
THE ALLIANCE FOR BETTER BONE HEALTH
Friday March 14, 9:30 a.m. – 5:30 p.m.
Marina Room
The Alliance for Better Bone Health Scientific Exhibit is an interactive poster session on osteoporosis disease state, fracture risk,
health outcomes and treatment. The exhibit contains a 3D theater, other interactive stations, and scientific posters and will be
open on Friday, March 14, from 9:30 am to 5:30 pm in the Marina room. In addition to posters from the Alliance, we have invited
several independent investigators to staff their posters from 12:00 p.m. to 1:30 p.m.
— 2008 Annual Meeting 9

ISCD Acknowledgment of Abstract Reviewers
The ISCD thanks the following Scientific Advisory Committee members for their
review of the submitted abstracts.
E. Michael Lewiecki, MD, CCD, Chair
Anita Colquhoun, MRT(N), CDT
Brian Lentle, MD, CCD
Gary Edelson, MD
Ghada El-Hajj Fuleihan, MD, MPH, CCD
Paul Rochmis, MD
Joe Shaker, MD, CCD
Rogene Tesar, PhD, CCD, CDT
Best Abstracts
Best Abstract – Clinician
180 Nelson Watts, MD, CCD
VERTEBRAL FRACTURE RISK IS REDUCED FOR WOMEN WHO LOSE FEMORAL NECK BONE
MINERAL DENSITY DURING TERIPARATIDE TREATMENT
Best Abstract – Technologist
171 Dessa Gemar, BA, CDT
COMPARISON OF VITAMIN D SUPPLEMENTATION REGIMENS
10 — 2008 Annual Meeting

180 — VERTEBRAL FRACTURE RISK IS REDUCED FOR WOMEN WHO LOSE FEMORAL NECK BONE MINERAL DENSITY
DURING TERIPARATIDE TREATMENT
Nelson B. Watts, Director, University of Cincinnati Bone Health and Osteoporosis Center, Paul D. Miller, Colorado Center for Bone
Research, Robert Marcus, MD, Eli Lilly & Company, Peiqi Chen, PhD, Eli Lilly & Company, Jody Arsenault, PhD (Eli Lilly) Kelly Krohn, MD
(Eli Lilly)
Measuring bone mineral density (BMD) is a commonly-accepted way of monitoring response to therapy, and loss of BMD is sometimes viewed as a
therapeutic failure. In the Fracture Prevention Trial (FPT) most women treated with teriparatide (TPTD) showed a gain in lumber spine BMD at 1yr.
However, some women had no gain or loss in hip BMD at 1yr (Gallagher et al., 2006). The objective of this analysis was to test the hypothesis that
women who received TPTD and lost femoral neck (FN) BMD at 1yr would, nevertheless, benefit from treatment, compared with placebo (PL).
Using data from the FPT, we compared risk reductions of new vertebral fractures with various ranges of change in FN BMD at 1yr. At baseline
women were randomized to PL, TPTD 20 or 40¼g/day by injection. FN BMD was measured at baseline and 12 months. New vertebral fractures
were assessed by lateral spine radiographs at baseline and study endpoint. Significantly fewer women lost more than 4% FN BMD at 1yr in the
TPTD group (82/816=10%) compared to PL (61/400=15%). Women treated with TPTD who lost more than 4% FN BMD at 1yr had a vertebral
fracture risk reduction of 89% [RR 0.11(95 CI, 0.03 to 0.45)] compared to PL. Vertebral fracture risk reduction relative to PL was consistent across
a range of change in FN BMD at 1yr (interaction p value=0.40). Women who received TPTD and lost FN BMD at 1yr still benefit from a substantial
reduction in risk of vertebral fracture compared to placebo.
171 — COMPARISON OF VITAMIN D SUPPLEMENTATION REGIMENS
Dessa Gemar, University of Wisconsin Osteoporosis Clinical Research Program, Abbey Woods, University of Wisconsin Osteoporosis
Clinical Research Program, Jean Engelke, University of Wisconsin Osteoporosis Clinical Research Program, Diane Krueger, University of
Wisconsin Osteoporosis Clinical Research Program, Neil Binkley University of Wisconsin Osteoporosis Clinical Research Program
Ergocalciferol (D2) is assumed to be less effective than cholecalciferol (D3) in maintaining serum 25-hydroxyvitamin D [25(OH)D], however, data
supporting this are limited. Additionally, daily treatment adherence is often poor, prompting clinicians to prescribe once-monthly high-dose D. When
dosing monthly, it is logical that trough 25(OH)D measurement is appropriate, however this has not been investigated. As such, the purpose of this
year-long randomized, double-blind trial was to evaluate the effect of daily (1,600 IU) versus once-monthly (50,000 IU) D2 or D3 dosing on serum
25(OH)D in adults age 65+. Utility of obtaining trough 25(OH)D measurements and effect of weight and baseline 25(OH)D on response was
investigated. Preliminary data from 32 participants through six months are reported. Baseline mean age was 77 years and mean 25(OH)D was 25.2
± 3.3 ng/ml; 34% were

Wednesday, March 12, 2008 – Friday, March 14, 2008
Poster Days and Hours
Posters on display Wednesday through Friday
Wednesday, March 12, 2008..................................................... 5:00 p.m.-6:30 p.m.
Thursday, March 13, 2008......................................................9:30 a.m.-12:30 p.m.
...................................................................................................... 2:00 p.m.-6:00 p.m.
Authors Present (Odd Numbered Posters) ..................... 2:00 p.m.-3:00 p.m.
Friday, March 14, 2008 ........................................................... 9:30 a.m.-12:00 p.m.
...................................................................................................... 2:30 p.m.-6:00 p.m.
Authors Present (Even Numbered Posters) ..................... 2:30 p.m.-3:30 p.m.
Challenging Cases
Thursday, March 13, 2008................................................... 10:00 a.m.-10:30 a.m.
Challenging Cases 201, 202 and 203
Friday, March 14, 2008 ......................................................... 10:00 a.m.-10:30 a.m.
Challenging Cases 204, 205 and 206
Poster Presentations
Abstracts
12 — 2008 Annual Meeting

Poster Sections – Listing by Category
Page
Assessment of Bone Quality......................................... 15
100 ONCE-MONTHLY ORAL IBANDRONATE EFFECT ON HIP BONE
STRENGTH AND QUALITY ASSESSED BY VOLUMETRIC
QUANTITATIVE COMPUTED TOMOGRAPHY AND FINITE
ELEMENT ANALYSIS IN POSTMENOPAUSAL WOMEN WITH
OSTEOPOROSIS
102 EFFICACY OF STRONTIUM RANELATE AND RISEDRONATE
ON BONE MASS IN A RAT MODEL OF OSTEOPOROSIS USING
IN-VIVO MICRO-CT
103 EFFECTS OF ONCE-MONTHLY ORAL IBANDRONATE ON
LUMBAR SPINE BONE STRENGTH AND QUALITY ASSESSED BY
VOLUMETRIC QUANTITATIVE COMPUTED TOMOGRAPHY AND
FINITE ELEMENT ANALYSIS
104 DISSECTION OF RADIAL DXA BMD MEASUREMENTS USING
HIGH RESOLUTION-PERIPHERAL QUANTITATIVE COMPUTED
TOMOGRAPHY (HR-pQCT) PARAMETERS
105 MULTI-CENTER MRI REPRODUCIBILITY OF CANCELLOUS BONE
MICROSTRUCTURE AT THE DISTAL RADIUS
106 MULTI-CENTER MRI REPRODUCIBILITY OF CANCELLOUS BONE
MICROSTRUCTURE AT THE DISTAL RADIUS
107 DYNAMIC BONE QUALITY-A NON-INVASIVE MEASURE OF
BONE’S BIOMECHANICAL PROPERTY
Assessment of Fracture Risk ........................................ 16
108 COMPARISON OF BONE MINERAL DENSITY IN ELDERLY
PATIENTS ACCORDING TO PRESENCE OF INTERTROCHANTERIC
FRACTURE
109 LOW BONE MINERAL DENSITY DUE TO DELAYED PUBERTY IN
MAJOR BETATHALESSEMIC PATIENTS IS NOT ASSOCIATED TO
HIGH FRACTURE PREVALENCE
110 SOUTHERN CALIFORNIA HISPANIC WOMEN OSTEOPOROSIS
EDUCATION AND SCREENING PROJECT
Central DXA .................................................................. 17
111 OSTEOPOROSIS RESEARCH
112 SCIENTIFIC FLAWS OF THE WHO T-SCORE DEFINITION OF
OSTEOPOROSIS
113 HIP AXIS LENGTH (HAL) IN JAPANESE MEN AND WOMEN
114 HEALTHY BODY COMPOSITION WITH DXA
115 ULTRASOUND DENSITOMETRY EVALUATION IN
POSTMENOPAUSAL WOMEN WITH COLLES FRACTURE
116 RAPID INSPECTION OF LEAD APRONS AND OTHER PERSONAL
RADIATION SHIELDING USING A FAN-BEAM BONE
DENSITOMETER - VERIFICATION OF SYSTEM ABILITY TO
IDENTIFY SMALL SHIELDING DEFECTS
117 DOES T-SCORE AT ONE SCAN SITE REFLECT T-SCORE AT OTHER
SITES IN A CHINESE POPULATION?
118 THE LOSS OF FOLLOW UP AFTER HIP FRAGILITY FRACTURE
119 ENHANCED FRACTURE DETECTION WITH IDXA; EFFECT ON
MILD FRACTURE IDENTIFICATION
120 25-HYDROXYVITAMIN D STATUS AS MARKER OF VITAMIN D
NECESSARY IN OSTEOPOROTIC POSTMENOPAUSAL WOMEN
121 IS UNIVERSAL STANDARDIZATION EQUATION STILL VALID TO
USE?
122 NO SIGNIFICANT DIFFERENCE IN THE SEMI-QUANTITATIVE
ANALYSIS OF DIPHOSPHONATE UPTAKE IN THE JAW IN
SUBJECTS RECEIVING BISPHOSPHONATES
123 HETEROSCEDASTIC REGRESSION ANALYSIS OF FACTORS
AFFECTING BONE MINERAL DENSITY PRECISION AND
MONITORING
124 REFERRAL SOURCES FOR BONE DENSITOMETRY AT TWO
VETERANS’ ADMINISTRATION MEDICAL CENTERS
125 DIFFERENCE IN THE SPINAL BONE MINERAL DENSITY
MEASURED WITH AND WITHOUT HIPS FLEXION
126 REPRODUCIBILITY OF HIP GEOMETRIC PARAMETERS USING
DXA
127 AUTOMATED DXA INSTRUMENT QUALITY CONTROL:
EXPERIENCE IN FRANCE
128 CENTRAL DXA AND PERIPHERAL DXA SHOULD BE ROUTINE IN
THE EVALUATION OF MEN WITH PROSTATE CANCER DURING
ANDROGEN-DEPRIVATION THERAPY
129 THE EFFECT OF ACCURACY ERRORS ON THE CLINICAL
INTERPRETATION OF DXA SCANS
130 SHOULD DIALYSATE BE DRAINED PRIOR TO DUAL-ENERGY
X-RAY ABSORPTIOMETRY (DXA) SCANNING IN PERITONEAL
DIALYSIS (PD) PATIENTS?
131 EXTREME BMD INCREASES WITH VITAMIN D: AN
OVERLOOKED ANABOLIC THERAPY
132 SURPRISES IN CROSS CALIBRATION: A COMPARISON OF BODY
COMPOSITION VALUES BETWEEN DXA MANUFACTURERS
133 PREVALENCE OF HIGH BMD T-SCORES IN A COMMUNITY
POPULATION
134 HIGH BMD: HOW COMMON IS IT?
135 EFFECT OF RADIONUCLIDE BONE SCANS ON BMD
MEASUREMENTS USING A LUNAR DPX IQ DENSITOMETER
136 IN VIVO EVALUATION OF STUDIES DONE WITH THE
NORLAND XR-46 AND XR-800 SERIES EQUIPMENT
137 EVALUATION OF BONE MINERAL CONTENT AND AREA BY
THE NORLAND XR-46, XR-800 AND XR-600 SYSTEMS ON THE
BMIL PHANTOM
138 INTER- AND INTRA-READER VARIABILITY OF HOLOGIC HSA
AND COMPARISON TO BECK HSA
139 FREQUENCY OF CERTIFIED CLINICAL DENSITOMETRIST (CCD)
RECLASSIFICATION OF FRACTURE RISK BASED ON LOWEST T-
SCORE: A MULTI-SPECIALTY CLINIC S EXPERIENCE
140 LONGITUDINAL TRENDS IN USE OF BONE MASS MEASUREMENT
AMONG OLDER AMERICANS, 1999-2005
141 ANALYSIS OF HIP SCANS ON HOLOGIC DXA SYSTEMS
142 AUTOMATED SOFTWARE IN DXA QUALITY CONTROL:
RETROSPECTIVE ANALYSIS OF DAILY PHANTOM SCANS
Economic Issues in Osteoporosis Care........................ 39
207 IMPACT OF MEDICARE CUTBACKS IN DXA REIMBURSEMENT ON
CARE OF PATIENTS AT RISK FOR FRACTURE
Epidemiology .................................................................. 25
144 PSYCHOSOCIAL IMPACTS ON BONE TURNOVER IN ADULT MEN:
PRELIMINARY FINDINGS FROM THE MIDUS STUDY
145 THE DISTRIBUTION AND CORRELATES OF BONE MINERAL
DENSITY IN JAMAICAN YOUNG ADULTS
146 BONE MINERAL DENSITY IN SYSTEMIC LUPUS ERYTHEMATOSIS
147 THE RELATIONSHIP BETWEEN FREE TESTOSTERONE AND
LONGITUDINAL CHANGES IN BONE MINERAL DENSITY IN
ELDERLY MEN
148 PREVALENCE OF OSTEOPOROSIS IN AN OHIO MENNONITE
COMMUNITY
149 OSTEOPOROSIS AND HYPOVITAMINOSIS D IN THE LEBANESE
ELDERLY: A POPULATION BASED STUDY
Monitoring Therapy ....................................................... 27
150 PATIENT CHARACTERISTICS ASSOCIATED WITH BONE MINERAL
DENSITY (BMD) RESPONSES TO ALENDRONATE
Page
— 2008 Annual Meeting 13

Page
Page
151 IN VIVO LONGITUDINAL NON-INVASIVE MEASUREMENT OF
CROSS-SECTIONAL BENDING STIFFNESS — A PILOT STUDY OF
TERIPARATIDE THERAPY
152 QUANTIFICATION AND DESCRIPTION OF GASTROINTESTINAL
ADVERSE EVENTS (GI AES) IN PATIENTS SWITCHED FROM
BRANDED FOSAMAX® TO GENERIC ALENDRONATE
Other............................................................................... 27
153 WEB BASED TRAINING AND CERTIFICATION OF DXA
OPERATORS FOR CLINICAL DRUG TRIALS
154 A SPONTANEOUS METATARSAL FRACTURE LEADS TO THE
DIAGNOSIS OF CUSHINGS DISEASE
155 SEVERE METABOLIC BONE DISEASE IN A 76-YEAR-OLD WOMAN
THIRTY-THREE YEARS AFTER BARIATRIC SURGERY
156 TERIPARATIDE [(rh PTH (1-34)] (TPTD) STIMULATES
OSTEOBLAST FUNCTION
157 BIOCHEMICAL MARKERS AND BONE HISTOLOGY AMONG
CHRONIC KIDNEY DISEASE PATIENTS
158 LONG-TERM EFFECT OF LUMBAR EPIDURAL CORTICOSTEROID
INJECTIONS ON BONE MINERAL DENSITY OF THE LUMBAR
SPINE
159 IN VITRO AND IN VIVO DIFFERENCES BETWEEN BRANDED
AND GENERIC WEEKLY BISPHOSPHONATE TABLETS
160 TERIPARATIDE [(rh PTH (1-34)] (TPTD) SPEEDS FRACTURE
HEALING AND INITIATES HEALING OF NON-UNIONS IN
HUMANS
Patient Education .......................................................... 29
161 BENEFITS OF REPORTING BONE DENSITY RESULTS DIRECTLY TO
PATIENTS
162 BREAKING THE BARRIERS TO BETTER HEALTH IN OSTEOPOROSIS
PATIENTS
Peripheral DXA ............................................................. 30
163 UTILITY OF HEEL DXA IN DIAGNOSING OSTEOPOROSIS
Prevention and Treatment of Osteoporosis ................ 30
164 OSTEOPOROSIS RISK FACTORS AND PREVENTION AMONG
FEMALE PHYSICIANS IN NORTHERN CALIFORNIA
166 EFFICACY AND SAFETY OF MONTHLY ORAL IBANDRONATE IN
POSTMENOPAUSAL WOMEN WITH OSTEOPENIA
167 MONTHLY IBANDRONATE REDUCES SERUM CTX WITHIN THREE
DAYS OF TREATMENT INITIATION AND MAINTAINS A MONTHLY
PATTERN OF SERUM CTX SUPPRESSION
168 THE USE OF ANNUAL CUMULATIVE EXPOSURE TO EVALUATE THE
EFFICACY OF IBANDRONATE
169 FAILURE TO INITIATE TREATMENT IN PATIENTS WITH
OSTEOPOROSIS
170 FRACTURE RATES WITH MONTHLY ORAL IBANDRONATE AND
WEEKLY BISPHOSPHONATES: THE eVALUATION OF
IBANDRONATE EFFICACY (VIBE) DATABASE FRACTURE STUDY
171 COMPARISON OF VITAMIN D SUPPLEMENTATION REGIMENS
172 ORTHOPAEDIC MANAGEMENT IMPROVES THE EARLY RATE OF
OSTEOPOROSIS TREATMENT AFTER HIP FRACTURE: A
RANDOMIZED CLINICAL TRIAL
173 AN OBSERVATIONAL COHORT STUDY OF RISEDRONATE AND
ALENDRONATE WITH THE ADDITION OF IBANDRONATE:
EFFECTIVENESS OF BISPHOSPHONATE TREATMENT ON HIP
FRACTURES
174 RISEDRONATE DID NOT INCREASE GASTROINTESTINAL ADVERSE
EVENTS(AES) IN SUBJECTS TAKING NONSTEROIDAL ANTI-
INFLAMMATORY DRUGS (NSAIDS) OR ASPIRIN
175 AN OBSERVATIONAL COHORT STUDY OF RISEDRONATE AND
ALENDRONATE WITH THE ADDITION OF IBANDRONATE:
EFFECTIVENESS OF BISPHOSPHONATE TREATMENT ON
NONVERTEBRAL FRACTURES
176 BISPHOSPHONATE THERAPY AND HIP FRACTURES WITHIN
THE RISEDRONATE AND ALENDRONATE (REAL) COHORT
STUDY: SUBGROUP WITH PRIOR FRACTURE
177 A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
STUDY OF ODANACATIB (MK-822) IN THE TREATMENT OF
POSTMENOPAUSAL WOMEN WITH LOW BMD: 18-MONTH
RESULTS
178 BONE MINERAL DENSITY OF POSTMENOPAUSAL WOMEN
PARTICIPATING IN REGULAR YOGA ACTIVITY
179 USAGE OF THE INTERNET TO PROVIDE EVIDENCED BASED
EXERCISE PROGRAMS FOR THE PREVENTION AND
MANAGEMENT OF OSTEOPOROSIS
180 VERTEBRAL FRACTURE RISK IS REDUCED FOR WOMEN WHO
LOSE FEMORAL NECK BONE MINERAL DENSITY DURING
TERIPARATIDE TREATMENT
181 RISEDRONATE SHOWS CONSISTENT REDUCTION OF THE RISK
OF NEW VERTEBRAL FRACTURES OVER THREE YEARS IN PROTON
PUMP INHIBITOR (PPI) AND H2-RECEPTOR ANTAGONIST (H2RA)
USERS
QCT/Peripheral QCT .................................................... 34
182 NEW MEASURING ‘¡†”•”œ’ OF BMD
183 DIFFICULT TO DEAL WITH OSTEOPOROSIS
184 INTRA-OPERATOR PRECISION FOR IN VIVO HIGH RESOLUTION
PQCT SCANS
185 PHANTOMLESS QCT STUDIES POSSIBLE ADVANTAGES FOR
REDUCED PATIENT DOSE
186 PHANTOMLESS METHODS FOR CALIBRATION OF QCT FOR HIP
STUDIES
187 UNCERTAINTY IN INTERPRETATION OF T-SCORE AND Z-SCORE
IN BOTH QCT AND DXA WITH BONE MINERAL STUDIES
188 SHORT-TERM PRECISION OF PERIPHERAL QUANTITATIVE
COMPUTED TOMOGRAPHY FOR HARD AND SOFT TISSUE
MEASUREMENTS AT MID-SHAFT AND DISTAL REGIONS OF THE TIBIA
189 OVERWEIGHT CHILDREN HAVE INCREASED TIBIA BONE
DENSITY AND BONE STRENGTH ATTRIBUTABLE TO INCREASED
MUSCLE MASS
190 STRESS FRACTURES IN FEMALE ATHLETES: RELATIONSHIP WITH
SKELETAL HEALTH, BONE TURNOVER, ENERGY STATUS, AND
MENSTRUAL FUNCTION
191 PHYSICAL ACTIVITY RELATIONSHIPS WITH PQCT FAT & MUSCLE
PARAMETERS
192 FINITE ELEMENT ANALYSIS OF PROXIMAL FEMUR QCT SCANS
FOR THE ASSESSMENT OF HIP FRACTURE RISK IN OLDER MEN
193 THE EFFECT OF INCLUDING QUS ASSESSMENT IN FRACTURE
RISK PREDICTION MODELS FOR OLDER MEN AND WOMEN: THE
EPIC-NORFOLK COHORT STUDY
194 MICRO-STRUCTURAL BASIS OF BONE FRAGILITY IN WOMEN
AND MEN
Radiographic Absorptiometry ...................................... 38
195 EFFICACY OF GH-TREATMENT ON BMD CHANGES IN CHILDREN
WITH GH-DEFICIENCY, FOLLOWED FOUR YEARS BY DIGITAL X-
RAY RADIOGRAMMETRY vGROWTH
196 BONE MINERAL DENSITY IN UKRAINIAN WOMEN
197 TOWARDS AN UNDERSTANDING OF THE MECHANISM OF
FEMUR STRENGTH IMPROVEMENT BY ALENDRONATE IN
POSTMENOPAUSAL WOMEN
Ultrasonometry ............................................................. 38
198 AGE-DEPENDENT FEATURES OF BONE TISSUE STATE IN
UKRAINIAN MEN
199 STRUCTURAL-FUNCTIONAL STATE OF BONE LOSS OF THE
POSTMENOPAUSAL WOMEN WITH VERTEBRAL FRACTURES
200 OSTEOPOROSIS BELIEFS AMONG CHINESE IMMIGRANTS IN
CHINATOWN, CHICAGO
14 — 2008 Annual Meeting

100 — ONCE-MONTHLY ORAL IBANDRONATE EFFECT ON HIP BONE
STRENGTH AND QUALITY ASSESSED BY VOLUMETRIC QUANTITATIVE
COMPUTED TOMOGRAPHY AND FINITE ELEMENT ANALYSIS IN
POSTMENOPAUSAL WOMEN WITH OSTEOPOROSIS
Alan D. Kivitz, Altoona Arthritis & Osteoporosis Center, Duncansville, PA, TM Keaveny,
PhD, O.N. Diagnostics, Berkeley, CA, H.K. Genant, PhD, Synarc, Inc., San Francisco, CA,
T. Fuerst, PhD, Synarc, Inc., San Francisco, CA, MB Enslin, MBA, GlaxoSmithKline, King
of Prussia, PA, G Dasic, PhD, GlaxoSmithKline, King of Prussia, PA, R Davies, MS,
GlaxoSmithKline, King of Prussia, PA, EM Lewiecki, MD, FACP, New Mexico Clinical
Research & Osteoporosis Center, Albuquerque, NM
Bone strength and quality play an important role in fracture prevention. We examined
effects of once-monthly oral ibandronate on measures of bone strength and quality in
a 12-month randomized, double-blind, placebo-controlled study. Postmenopausal
women (n=97) aged 55-80 years with bone mineral density (BMD) T-scores -5.0) received oral ibandronate (150 mg/mo) or placebo. The primary endpoint was
assessment of integral (cortical plus trabecular compartments) total hip volumetric
BMD by quantitative computed tomography (QCT) after 12 months ibandronate or
placebo treatment in the intent-to-treat population; secondary analyses included other
proximal femur sites and finite element analysis (FEA). P-values were generated posthoc
for descriptive purposes only. Volumetric BMD results (Table) demonstrated
clinically meaningful differences between ibandronate and placebo recipients for
integral (combined cortical and trabecular) density, for the total hip, trochanter, and
femoral neck regions. Trabecular volumetric BMD for total hip and trochanter
increased more with ibandronate than with placebo, whereas cortical volumetric BMD
changes were similar between the groups. FEA results (Table) showed improvements in
the ibandronate group for strength of the whole proximal femur (under falling load)
and the individual cortical
and trabecular
compartments. Oncemonthly
oral ibandronate
for 12 months resulted in
volumetric BMD gains, as
expected from previous
BMD gains observed by
dual-energy x-ray
absorptiometry. The main
effect occurred in the
proximal femur,
predominantly in the
trabecular compartment,
and conferred
improvements in mechanical
strength as modeled by FEA.
102 — EFFICACY OF STRONTIUM RANELATE AND RISEDRONATE ON
BONE MASS IN A RAT MODEL OF OSTEOPOROSIS USING IN-VIVO
MICRO-CT
Michael Roman Doschak, Assistant Professor, Faculty of Pharmaceutical Sci, Michael D.
Jones, University of Alberta, Guang LI, University of Alberta, Jillian Foster, University of
Alberta, MJM Duke, University of Alberta
Micro-Computed Tomography (micro-CT) is a high resolution X-ray imaging modality to
assess bone microarchitecture, and BMD when calibrated against “phantoms”. We tested if
micro-CT bone quality assessments of antiresorptive therapy could be employed to
compensate for strontium biasing of BMD measurements by DXA. Ovariectomized (OVX)
rats were imaged using “in-vivo” micro-CT at baseline, one month and two months post-
OVX to assess the loss of bone mass. Antiresorptive drug interventions (either risedronate
or strontium ranelate) were then initiated and continued for a further three months to an
endpoint of 5 months post-OVX, and assessed with “in-vivo” micro-CT at monthly intervals.
At the experimental endpoint, rat tibiae were dissected free of soft tissues and both micro-
CT and DXA BMD measurements conducted “ex-vivo”. Bone samples were then tested for
mechanical strength to failure in 3-point flexural analyses, then incinerated in a muffle-furnace
and the ash used to assess calcium and strontium content by Instrumental Neutron
Activation Analysis (INAA). Results confirmed significant loss of bone mass in OVX rats as
measured with “in-vivo” micro-CT during the first 2 months. Both risedronate and strontium
ranelate slowed the further loss of bone mass, resulting in greater bone mass over untreated
OVX controls. Micro-CT based histomorphometric analyses of trabecular bone was
significantly correlated with bone strength measurements from mechanical testing. INAA
accurately measured bone strontium content, and the relationship with BMD positive bias
was explored. We conclude that assessment of antiresorptive drug efficacy (including
that of strontium) of bone mass may be readily determined using “in-vivo” micro-CT.
103 — EFFECTS OF ONCE-MONTHLY ORAL IBANDRONATE ON
LUMBAR SPINE BONE STRENGTH AND QUALITY ASSESSED BY
VOLUMETRIC QUANTITATIVE COMPUTED TOMOGRAPHY AND FINITE
ELEMENT ANALYSIS
E. Michael Lewiecki, New Mexico Clinical Research & Osteoporosis Center, TM
Keaveny, PhD, O.N. Diagnostics, H.K. Genant, PhD, Synarc, Inc., K. Engelke,Synarc, Inc.,
MB Enslin, MBA, GlaxoSmithKline, G Dasic, PhD, GlaxoSmithKline, R Davies, MS;
GlaxoSmithKline, AD Kivitz, MD; Altoona Arthritis & Osteoporosis Center
This 12-month randomized, double-blind, placebo-controlled study evaluated the
effect of once-monthly oral ibandronate on bone strength and quality in
postmenopausal women with osteoporosis as assessed by volumetric quantitative
computed tomography (QCT) and finite element analysis (FEA). Ninety-seven women
aged 55-80 years received oral ibandronate (150 mg/mo) or placebo. The primary
endpoint was mean percent change from baseline to 12 months in integral (cortical
plus trabecular compartments) total hip volumetric BMD assessed by QCT. Secondary
endpoints, reported here, assessed QCT and FEA changes in the lumbar spine (LS). P-
values were generated post-hoc for descriptive purposes only. Ibandronate induced
greater mean increases than placebo in BMD in integral vertebral density (3.09% vs -
1.08%, P=0.0013) and in the vertebral body midsection (2.36% vs -1.32%, P=0.0105)
(Table). Treatment differences were most pronounced for integral vertebral density
(4.37%), trabecular vertebral density (4.22%), and vertebral mid-section integral
density (3.98%) (Table). FEA results showed that after 12 months of treatment,
vertebral compressive strength, trabecular vertebral strength, cortical vertebral
strength, and vertebral anteroposterior bending stiffness declined in placebo recipients
but increased in ibandronate recipients (Table). Once-monthly oral ibandronate
markedly improved
volumetric vertebral
body BMD, consistent
with previous studies
findings of increased
areal BMD dual-energy
x-ray absorptiometry.
Ibandronate exerted
effects on both
trabecular and cortical
bone; these positive
effects, particularly in
the outer 2 mm of
bone, translated into
improved strength as
determined by FEA.
104 — DISSECTION OF RADIAL DXA BMD MEASUREMENTS USING
HIGH RESOLUTION-PERIPHERAL QUANTITATIVE COMPUTED
TOMOGRAPHY (HR-pQCT) PARAMETERS
Sharmila Majumdar, Professor in Residence, Departments of Radiology, Stephanie
Boutroy, INSERM U831 and University of Lyon, Lyon, France, Steven K. Boyd, Associate
Professor of Mechanical & Manufacturing Engineering, University of Calgary, Calgary,
AB, Canada, Cesar Bogado, Instituto de Investigaciones Metabólicas, Buenos Aires,
Argentina, Pierre D. Delmas, David A. Hanley, Deborah Sellmeyer, Angela M. Cheung,
Ego Seeman, Thierry Thomas, Elizabeth Shane, Ann Kearns, Gerald Crans, Cesar
Libanati, and Jose Zanchetta
Purpose: We investigated relationships between DXA BMD measurements and HRpQCT
parameters (BMD, bone geometry and microstructure) using baseline data
collected from an ongoing blinded phase 2 trial. Methods: Ambulatory postmenopausal
women aged 50-70 years with a lumbar spine or total hip T-score between -2.0 and -
3.0 were randomized 1:1:1 to denosumab, alendronate, or placebo. Statistical
modeling and t-tests were used to evaluate relationships between HR-pQCT and DXA
BMD parameters. Results: Subjects (n=247; mean age 60.6 years) had median T-scores
of -2.5 and -1.4 at the lumbar spine and total hip, respectively. HR-pQCT parameter
modeling showed slice area, cortical thickness, cortical density, and trabecular bone
volume/tissue volume (BV/TV) predicted radial DXA BMD, most notably at the
ultradistal site (r2=0.74). The t-tests comparing radial HR-pQCT parameters (BV/TV,
cortical thickness, and cortical density) between groups of subjects with T-scores higher
or lower than the median DXA T-score at the lumbar spine, total hip, or radius
showed no differences for groups stratified by lumbar spine BMD. However, mean BV/
TV and cortical thickness were significantly larger in the higher total hip BMD group
(Pd0.05). Mean HR-pQCT parameters were significantly larger (P

105 — MULTI-CENTER MRI REPRODUCIBILITY OF CANCELLOUS BONE
MICROSTRUCTURE AT THE DISTAL RADIUS
Bryon R Gomberg, MicroMRI Inc., Pamela Seaman, MicroMRI Inc., Michael Kleerekoper,
MicroMRI Inc.
Cancellous bone micro-architecture assessment by microscopic MRI (mMRI) has been
reported for single scanners[1, 2], yet osteoporosis studies typically require multiple medical
centers (MC). Here we report validation data across multiple MCs. We installed our mMRI
technology on 9 GE Signa 1.5T MRI scanners located mostly in the US. During each
typical installation 4 subjects are scanned 3 times at the right ultra-distal radius. Scans
of low quality or high subject motion were excluded, and the remaining scans
processed using a previously reported technique [2]. Across MC accuracy was
evaluated with data from 4 subjects scanned at all MCs (33 scans). Micro-architecture
parameters were derived for a 10-mm slab of the complete radius cross section. Root
mean square (RMS) of the coefficient of variation (RMS-CV) and RMS differences (RMSdiffs)
determined reproducibility and accuracy, respectively. Reproducibility showed all
endpoints having RMS-CV consistent with previously published values. Of a total of
117 scans, 107 from 25 subjects were of sufficient quality for analysis (90.7% yield).
Results for primary endpoints are provided in table 1. Figure 1 below shows typical
rescans. For comparison of accuracy we looked at the parameters from the same
subject at several MCs (table 2). There were no significant differences across MCs for
any parameter and for any subject (p< 0.05). This study demonstrates that the
reproducibility across multiple MCs is comparable to values published for a single MC.
Accuracy is within the range of the measurement error and there was no significant
difference across MCs for the same subject s parameters. We conclude that the
commercial mMRI method tested is suitable for multi-center clinical studies.
106 — MULTI-CENTER MRI REPRODUCIBILITY OF CANCELLOUS BONE
MICROSTRUCTURE AT THE DISTAL RADIUS
BR Gomberg, MicroMRI Inc., P Seaman, MicroMRI Inc., M Kleerekoper, MicroMRI Inc.
Cancellous bone micro-architecture assessment by microscopic MRI (mMRI) has been
documented on single scanners[1, 2], but studies of metabolic bone disease require more
patients than can be typically recruited at a single site, requiring multiple medical centers
(MC) for clinical trials. Here we report validation data across multiple MCs. We installed our
mMRI technology on 9 1.5T MRI scanners located in 7 MCs in the US, 1 in Argentina, and 1
in Israel. During each typical installation 4 subjects are scanned 3 times at the right distal
radius. Scans of low quality or high subject motion were excluded, and the remaining scans
processed using a previously reported technique [2]. Across MC accuracy comparisons were
done by scanning 4 subjects at all MCs for a total of 33 scans. Micro-architecture parameters
are derived for a 12-mm slab of the complete radius cross section. Root mean square of the
coefficient of variation (RMS-CV) was used to determine reproducibility and accuracy was
determined by root mean square differences (RMS-diffs). Reproducibility by ¼MRI showed all
parameters having equal or lower RMS-CV than the previously published values. Of a total of
117 scans 107 from 25 subjects were of sufficient quality for analysis (90.7% yield). Results
for 5 endpoints of the 15 mMRI parameters are provided in table 1. The amount of
cancellous bone is represented by BV/TV (volume of cancellous bone), trabecular thickness
(Tb.thk) and topological skeleton density (Skel Dens). Topological parameters are represented
by surface to curve ratio (Surf/Curv) and erosion index. Figure 1 below shows typical rescans.
For comparison of accuracy we looked at the parameters from the same subject at several
MCs (table 2). There were no significant differences across MCs for any parameter and
for any subject (p< 0.05). This study demonstrates that the reproducibility across
multiple MCs is comparable to values published for a single MC. Yield is very good, the
accuracy is within the range of the measurement error and there was no significant
difference across MCs for the same subject s endpoints. We conclude that the
commercial mMRI method tested is suitable for multi-center clinical studies.
107 — DYNAMIC BONE QUALITY-A NON-INVASIVE MEASURE OF
BONE’S BIOMECHANICAL PROPERTY
Amit Bhattacharya, Professor of Environmental Health & Bioengineering, Nelson B.
Watts, Professor of Medicine & Director of University of Cincinnati Bone Health and
Osteoporosis Center, Kermit Davis, Associate Professor of Environmental Health and
Rehabilitation Science, Susan Kotowski, PhD candidate Environmental Health, Rakesh
Shukla, Professor of Environmental Health
A new approach to non-invasively characterize bone quality is described and tested on
osteoporosis patients with and without fracture. Traditional non-invasive tools used for
characterizing bone quality determine biomechanical variables under unloaded or static
conditions; however, structural failure of human bone and/or any mechanical system rarely
occurs under static conditions. A better understanding of bone fracture and prevention
requires measurement of both static and dynamic biomechanical properties of bone when
exposed to realistic “real-world” in-vivo external loadings such as heel strike. Therefore, we
developed and tested a non-invasive technique that provides information about dynamic
bone quality. This technique deals with quantifying the weight bearing bone s natural shock
absorbing (BSA) capacity when exposed to external loading associated with heel strike. The
test protocol estimated BSA variable (bone s damping) from low mass miniature
accelerometers attached at load-bearing skeletal sites, long bones and spine, during heel
strike tasks performed by the patients. In 67 patients with postmenopausal
osteoporosis age 65 to 86 years, (28 with documented vertebral fractures, 39 without
fractures) the damping value was significantly lower (-64%) in the patients with
vertebral fractures and damping values for both groups were significantly lower (-42%
to -79%) than healthy subjects (p values between 0.04 and 0.0001). In conclusion, the
dynamic bone quality as measured by BSA was able to significantly discriminate
between the fractured and non-fractured patients.
108 — COMPARISON OF BONE MINERAL DENSITY IN ELDERLY
PATIENTS ACCORDING TO PRESENCE OF INTERTROCHANTERIC
FRACTURE
SangHo Moon, Chief of Orthopaedic Surgery, Handong University, GyuMin Kong,
Doctor of Orthopaedic Surgery, Handong University, Pohang, Korea, ByoungHo Suh,
Doctor of Orthopaedic Surgery, Handong University, Pohang, Korea, HyeonGuk Cho,
Doctor of Orthopaedic Surgery, Handong University, Pohang, Korea
Purpose of this study was to analyze difference in bone mineral density (BMD) between
intertrochanteric fracture and control group and to explore the predictive value of BMD for
intertrochanteric fracture. 57 patients who were over 60-year-old with intertrochanteric
fracture were examined. For control group, 110 patients who did not have any fracture were
selected. Dual energy X-ray absorptiometry was studied at 1, 2, 3, 4 lumbar vertebrae,
femoral neck, trochanter and Ward’s triangle. BMD was compared at each site between two
groups statistically. Fracture group consisted of 16 male, 41 female and was average 70.8 year
old. Control group consisted of 21 male, 89 female and was average 68.1 year old.
There was no differences in sex and age between two groups (p>0.05). BMD of L1, L2
and mean lumbar area were significantly less in fracture group than control group
(p0.05). BMD of L1, L2 and mean lumbar area in fracture group had lower value
significantly, but had no differences between two groups at another sites. BMD of L1,
L2 and mean lumbar area might be used as the most sensitive predictive indicator for
risk of osteoporotic fractures including intertrochanteric fracture in elderly patient.
16 — 2008 Annual Meeting

109 — LOW BONE MINERAL DENSITY DUE TO DELAYED PUBERTY IN
MAJOR BETATHALESSEMIC PATIENTS IS NOT ASSOCIATED TO HIGH
FRACTURE PREVALENCE
Carmen Barbu, MD, Assistant Professor of Endocrinology, Carol Davila, A. Roman,
Elias Hospital, A. Zarnea, Elias Hospital, C. Poiana, Associate Professor of Endocrinology,
Carol Davila University, CI Parhon Institute, S. Fica, Professor of Endocrinology, Carol
Davila University, Elias Hospital
Aim of the study was to assess the prevalence of low bone density in beta-thalassemic
patients and its relationship to delayed puberty and fracture risk. 27 patients (9 females and
18 male) with major betathalassemia (mean age 19.55±6.92) were evaluated clinically (height,
weight, Tanner pubertal status) and biologically (gonadal, thyroid, growth hormone status and
serum ferritin). BMD (bone mineral density) was measured by total body dual-energy x-ray
absorbtiometry (DXA); Z score was used for diagnostic and comparison. 18 patients (67%) in
our group had low BMD for age without any direct correlation between BMD and serum
hemoglobin levels. We found a significantly higher prevalence (16/22 patients) of low BMD in
post pubertal age compared to pre- and pubertal age patients (2/5) in spite of similar
characteristics in terms of serum ferritin, hemoglobin levels or prevalence of growth
hormone failure. 15 patients (55.5%) had delayed puberty with Z score significantly
lower comparing to the other subjects (prepubertal and post pubertal with normal
onset of puberty). There was no history of fracture in the study group. These results
suggests that delayed puberty has a significant contribution to low BMD in
betathalassemic patients in addition to chronic anemia and iron overloading,
underlining the need for early endocrine evaluation and therapy. In spite of very low
BMD for age, there were no osteoporotic fractures in our study group, suggesting that
delayed puberty could play also a protective role through the lack of puberty induced
peak of the bone turnover.
110 — SOUTHERN CALIFORNIA HISPANIC WOMEN OSTEOPOROSIS
EDUCATION AND SCREENING PROJECT
Augusto Focil, MD, MPH, CCD, Medical Director, FOCILMED
This study identified Hispanic women at risk for osteoporosis to determine 1) if
providing a fracture risk assessment in addition to osteoporosis education would
motivate them to seek medical help and 2) if acculturation of Hispanic women had an
impact on health seeking behavior. 318 postmenopausal Hispanic women of low
economic/education status were recruited at osteoporosis screening events in Ventura
County, CA. Osteoporosis education and written materials were provided in Spanish.
After obtaining written informed consent, all participants received 1) a risk factor
questionnaire; 2) an acculturation questionnaire; and 3) a heel peripheral bone
density report. The latter half of women screened also received an absolute fracture
risk report (AFR). A survey 6 months later (via telephone and in-home interviews)
assessed osteoporosis awareness, if medical intervention was sought and if osteoporosis
therapy was initiated. At screening, 14% of Hispanic women in this study were taking
estrogen (n = 45), 43% calcium (n = 137), and 21% vitamin D (n = 67). Overall, 38%
of the Hispanic women in the study had low bone mass (LBM)/osteopenia (n = 121),
13% were osteoporotic (n = 43), and 31% of women e 65 years old were
osteoporotic. Follow-up surveys were completed in 201 out of 318 screened women
(63%), 143 in the T-score only group (70%) and 58 from the T-score plus an AFR
group (50%). There was no difference detected in the response with “seeking medical
help” between women classified with LBM/osteopenia (40%) or osteoporosis (41%). The
number of risk factors and/or a T-score with AFR did not have an impact on this
parameter. Age, risk factors and a T-score plus AFR did not appear to influence
physician ordering an axial DXA and/or prescribing an osteoporosis treatment or the
likelihood of patients filling their prescriptions. There was a non-significant trend in the
osteoporosis patients to seek medical help, receive an axial DXA, receive a prescription
for osteoporosis threapy (30%), and fill the prescription (19%). The acculturation
questionnaire showed that 310 out of 318 (97%) participants did not consider
themselves as Americanized (75% viewed themselves as being “very Mexican”), reflecting
a fairly homogeneous group of Hispanic women. It was therefore not possible to
determine if acculturation of Hispanic women had an impact on health seeking
behavior. Providing an AFR did not appear to influence patient or physician behavior.
Future studies need to identify factors that will change Hispanic women’s and their
physicians behavior related to osteoporosis.
111 — OSTEOPOROSIS RESEARCH
Antonio Bazarra-Fernandez, ObGyn consultant, Juan Canalejo University Hospita
Aim: to mean a new osteoporosis research À±Á±´μ¯³¼±. Material and method: worldwide
bibliography review on our idea problem. Results: Osteoporosis is a big problem. So, to
measure strength bone involve a great deal to cope with. Dual energy X-ray absorptiometry
(DXA) has served as a fit surrogate for the measurement of bone strength. By reason of the
two-dimensional nature of DXA, assumptions must be made regarding the tridimensional
nature of the bones involving a great deal to cope with. Therefore it is deduced, that this
method seems to be very sensitive to error, and it is necessary to know how to deal with
these errors, especially with the systematic errors introduced by using a parameterized
model. Even though a high concordance between the densitometers was observed on a single
measurement occasion, a significant discordance in longitudinal changes in BMD was
observed. Conclusions: a mathematical, physical and physiological 5-dimensional model
must be developed in order to gauge bone properties including geometry(2-
dimensional DXA ), space, time, motion and stress with some portable-computerdevices
in base of mouse models for quantitative trait loci (QTL) analyses. In the field of
skeletal micro-structure, ¼CT has proven to be an invaluable imaging tool and the use
of high resolution peripheral quantitative computed tomography (HR-pQCT), in vivo
nanotomography and nanofractography, must be considered for studies of bone
disease and its treatment, and here must stay new university research methods for new
times and new pathologies. Principles of engineering, mathematics, robotics and
physical sciences must be used.
112 — SCIENTIFIC FLAWS OF THE WHO T-SCORE DEFINITION OF
OSTEOPOROSIS
Glen M Blake, PhD, Senior Lecturer, King’s College London, UK
Although the WHO T-score definition of osteoporosis has made an important contribution
to the widespread clinical acceptance of DXA scanning, as a scientific paradigm it has serious
flaws. Some of these are listed below: [1] It creates a disease out of what is really only a risk
factor. [2] In view of the size of BMD accuracy errors, it overstates the ability of DXA scans
to determine patients’ skeletal status. [3] It represents an unnecessary imposition between a
BMD measurement and the evaluation of the patientís risk of fracture. [4] By focussing
attention on the diagnosis of osteoporosis, it diverts attention from the pivotal role of
fracture studies in determining the clinical value of bone densitometry. [5] It creates the
illusion that patient care is improved by examining multiple BMD sites when in reality there is
negligible improvement in fracture discrimination from using more than one site. [6] It
has led to claims that half or more of fragility fractures occur in patients who do not
have osteoporosis. [7] It creates confusion that the WHO definition of osteoporosis
can be applied to any type of bone densitometry measurement. [8] It creates
confusion that alternative techniques such as pDXA and QUS are best used in an
attempt to emulate the results of central DXA. [9] By focussing attention on T-scores, it
overlooks the fact that the unique information about fracture risk provided by a BMD
examination is given by the Z-score. The speedy adoption of the new WHO fracture
risk algorithm will correct many of the misunderstandings engendered by T-scores and
provide a stronger scientific framework for the future applications of bone
densitometry.
— 2008 Annual Meeting 17

113 — HIP AXIS LENGTH (HAL) IN JAPANESE MEN AND WOMEN
M Takakuwa, Takakuwa Orthopedic Nagayama Clinic, Asahikawa Cit, M. Konishi, GE
Healthcare, Madison, WI, USA, Q. Zhou, GE Healthcare, Madison, WI, USA, L. Weynand, GE
Healthcare, Madison, WI, USA
Hip fracture is the most serious complication of osteoporosis and a major public health
concern in industrialized countries. Bone mineral density (BMD) is the strongest single
predictor of fracture risk, but the structural geometry of the proximal femur also influences
hip fracture risk. Hip axis length (HAL), one measure of structural geometry, has been shown
to be an independent predictor of hip fracture risk in elderly Caucasian females. Longer HAL
is associated with higher risk of hip fracture. We determined mean HAL for right and
left femurs in 363 Japanese men and 1608 Japanese women between ages 20 and 100
years assessed for osteoporosis risk at an orthopedic clinic between April 2005 and
November 2007. Hip axis length, defined as the length from the lateral edge of the
proximal femur through the neck axis to the medial bone edge of the inner pelvic
brim, was measured with a Lunar Prodigy dual-energy x-ray absorptiometry (DXA)
system. The average (SD) age, height, and weight were 65.3 (12.8) yrs, 150.2 (6.8) cm
and 53.8 (9.2) kg for women and 67.0 (12.8) yrs, 162.3 (6.8) cm and 62.1 (10.5) kg
for men, respectively. There was a small, but statistically significant (paired t-tests),
difference between mean (SD) right (101.3 mm (5.3)) and left HAL (100.99 mm (5.4))
in women, but the difference between right (115.1 (6.1)) and left HAL (115.0 (6.2))
in men was not statistically significant.
114 — HEALTHY BODY COMPOSITION WITH DXA
Mary K Oates, MD, CCD, Marian Medical Center, Santa Maria CA, David W Oates,
MD, CCD, Marian Medical Center, Santa Maria CA, Howard S Barden, PhD, GE
Healthcare, Madison WI
Adult reference data for body composition has not been widely reported in the literature.
Collection of healthy body composition reference data should use a protocol that restricts
participation to subjects with few, if any, medical conditions affecting general health and body
composition, but which encompasses a wide variety of body shapes and sizes. We are
collecting male and female reference data of healthy subjects following a protocol that
excludes subjects who have or have had medical conditions including but not restricted to:
coronary heart disease, diabetes, kidney disease, liver disease, HIV, cancer, eating disorders,
hypertension under 50 years of age, surgical procedures for obesity, BMI less than 18
and greater than 40, and surgical implants. In addition, we excluded subjects who
were dieting, did not exercise at least 3 times a week, consumed >2 alcohol drinks/day,
had smoked within the past 6 months, or were professional athletes. We are reporting
initial female body composition results (age 18-59 years) measured with dual-energy
X-ray absorptiometry (DXA) using Lunar iDXA or Lunar Prodigy (GE Healthcare).
Average age, height, weight, and BMI were 41.4 years, 165.4 cm, 65.0 kg, and 23.8 kg/
ht2, respectively. Seventy-five women were measured on the iDXA; 108 different
women in a separate study were measured on the Prodigy. Mean %fat values for iDXA
and Prodigy were not significantly different (Student t-tests), even though different
subjects were measured on each densitometer. BMI and total body %fat showed similar
correlations for different subjects collected on each densitometer (r=0.7 0.8).
115 — ULTRASOUND DENSITOMETRY EVALUATION IN
POSTMENOPAUSAL WOMEN WITH COLLES FRACTURE
Vladyslav Povoroznyuk, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-
Medical Centre for the Problems of Osteoporosis, Vladymyr Vayda, Institute of
Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre for the Problems of
Osteoporosis
This research was aimed at studying the bone tissue state among women with Colles
fracture with aid of the ultrasound densitometry method. The total of 34 healthy
postmenopausal women 42 74 years old (62,1±7,5) having Colles fracture in their anamnesis
(CF) were examined by ultrasound bone densitometer “Achilles+” (Lunar Corp., Madison,
WI). The control group included postmenopausal women without any osteoporotic fractures
in their anamnesis (WF), being standardized by age, BMI, etc. The speed of sound (SOS, m/s),
broadband ultrasound attenuation (BUA, dB/MHz) and a calculated “Stiffness” index (SI, %)
were measured. The main risk factors for the osteoporotic Colles fracture turned out to be a
menarche after 15 years, an early and late menopause. 29,3% of patients with Colles fractures
had a bone tissue stiffness index coinciding with the limit of fracture risk or under it.
There was no revealed relation between the age and the ultrasound densitometry
indices among women of posmenopausal age without fractures. Only 12,5% of patients
with Colles fractures were noticed to have a normal bone tissue. The ultrasound
parameters were veritably lower among postmenopausal women with CF than among
WF (SOS: CF 1524±28,4; WF 1543±24,3, p < 0,05; BUA: CF 102±17,8; WF 109±12,0,
p < 0,05; SI: CF 76±14,9; WF 85±13,5, p < 0,05; all values are the mean ± SD). It is
caused by the decrease of bone tissue mineral density, it s accelerated aging, and the
development of osteopaenia and osteoporosis. The most tangible differences in these
indices were noticed among the elderly patients. Colles fracture indicates osteopaenia
and osteoporosis in postmenopausal period. In summary, ultrasound densitometry is
an effective screening method to reveal the women of risk group having future
osteoporotic Colles fracture in postmenopausal period.
116 — RAPID INSPECTION OF LEAD APRONS AND OTHER PERSONAL
RADIATION SHIELDING USING A FAN-BEAM BONE DENSITOMETER -
VERIFICATION OF SYSTEM ABILITY TO IDENTIFY SMALL SHIELDING
DEFECTS
Lawrence G. Jankowski, CDT, Chief Densitometry Tecnologists, Illinois Bone and Joint
Institute, Susan B. Broy, MD, Director, Osteoporosis Center, Illinois Bone and Joint
Institute, Morton Grove, IL
We wished to determine whether a fan-beam densitometer operated in whole-body scan
mode could perform inspections of lead aprons and other personal radiation devices with
sufficient sensitivity to detect defects meeting published rejection criteria. We scanned a
phantom consisting of 0.5mm lead equivalent material containing pinhole and linear
defects of known sizes using a Hologic Discovery-A in standard whole-body and VFA
scan modes. Sensitivity of the scanner to detect small defects was done by simple visual
examination of the phantom images using the standard display software. In whole-body
scan mode, single pinholes of 1.5mm in diameter and linear defects of 1mm by 5 mm
were readily identified. In VFA mode, pinhole and linear defects as small as 0.3 mm
were identified. The Hologic Discovery-A is capable of providing rapid, full-sized images
of lead-aprons and other shielding devices without special software, no radiation
burden to the operator, and with resolution suitable for use in a radiation safety
testing program. It is not known if other Hologic whole-body scanners or those from
other manufacturers have similar or superior ability to detect such defects and should
be verified by further research before adopting their use for this purpose.
18 — 2008 Annual Meeting

117 — DOES T-SCORE AT ONE SCAN SITE REFLECT T-SCORE AT OTHER
SITES IN A CHINESE POPULATION?
JM Wang, Norland—a CooperSurgical Company, YY Zhen, Surgical Department of
Beijing Haidian Hospital, Beijing, PRC, WY Shi, Beijing Vigor Medical Equipment
Company, Beijing, PRC, TV Sanchez, CooperSurgical Company, Socorro, NM USA
From time to time the question of how well bone density at one scan site reflects bone
density at another scan site becomes an issue. To explore this we compared T-score results
from AP Spine, Femur and Forearm sites within a Chinese population. Bone density at the AP
Spine (L2-L4), Femur (Femur Neck, Trochanter and Ward s Triangle) and Forearm
(Distal R+U and Proximal R+U) was measured in 219 Chinese women between 22 and
85 years of age referred to densitometry at Beijing Haidian Hospital. Studies were
performed using standard procedures on a Norland XR-36 scanner. T-score results
were computed using published reference sets for the Chinese population developed
on Norland equipment at Ji Shui Tan (Beijing). Significant positive correlations (ranging
between 0.64 and 0.86) were found between T-scores at the different measured sites.
The weakest correlations (ranging from 0.64 to 0.69) were found between T-score
from the AP Spine sites at the Hip or Forearm. The best correlations (ranging from
0.81 to 0.86) were found between T-score from sites within the Hip scan. Regression
residuals, however, indicate that T-scores from one scan site do not effectively reflect
the T-score at another scan site. As such, we would suggest that at a minimum, scans
should be carried out at two sites when the desire is to assess T-score in a patient.
118 — THE LOSS OF FOLLOW UP AFTER HIP FRAGILITY FRACTURE
Tomas Hala, Clinical Research Manager, Sanarc/CCBR Czech Republic, F. Senk, MD,
Head of the Osteocentre, Hospital Havlickuv Brod, Czech Republic, P. Zivny, MD,
Associate Professor of Clinical Biochemistry, Charles University, Hradec Kralove, Czech
Republic
Purpose:fragility fracture is a major risk for osteoporosis and has been identified as the only
clinically relevant marker of bone quality. It is important to identify whether patients who
experienced fragility fractures are being assessed and treated for osteoporosis in order to
reduce the risk of future fracture. The patients with fractures should be managed in
accordance with evidence-based clinical guidelines for osteoporosis. Objective:the main
objective of this study was to establish the BMD testing rate in osteoporosis management for
people over 50 years of age who had already suffered a hip fracture. This is the first study in
Czech Republic conducted for this purpose. Methods:we conducted a retrospective cohort
study using data from 5 fracture clinics and bone disease centres. Study population consisted
of all individuals over 50 years of age who sustained hip fracture between January 1, 2004 and
December 31, 2005 from regional hospitals where one fracture clinic and one bone disease
centre are in house, for accurate data analysis. We used Czech classification system for
fractures: hip ( S 72.0), pertrochanteric fracture (S 72.1) and subtrochanteric fracture
(S 72.2). We included patients with osteoporotic fractures and with DXA
measurements of L1-L4 and hip. We excluded those with high-energy trauma fractures.
Results:we analyzed data from 1465 patients, 1054 (71.95%) women and 411
(28.05%) men with proximal femur fractures. We have documented that 99 patients
(6.75%) with fractures underwent densitometric evaluation. The number of women
and men was 86 (5.87%)and 13 (0.88%), respectively. Out of those 99 patients, 67.3%
were over 70 years of age. Conclusions:there is evidence of a care gap between the
occurence of fragility fractures and the diagnosis of osteoporosis in some regions in
Czech Republic. This study provides evidence that many Czechs who experienced
fragility fracture are not being diagnosed and treated for prevention of future
fractures. The prevalence of bone mass measurements or physician follow-up is
enormously low.
119 — ENHANCED FRACTURE DETECTION WITH IDXA; EFFECT ON
MILD FRACTURE IDENTIFICATION
Bjoern Buehring, University of Wisconsin Osteoporosis Clinical Rese, Diane Krueger,
University of Wisconsin Osteoporosis Clinical Research Program, Mary Checovich,
University of Wisconsin Osteoporosis Clinical Research Program, Dessa Gemar,
University of Wisconsin Osteoporosis Clinical Research Program, Nellie Vallarta-Ast,
Neil Binkley
Prior osteoporotic fracture markedly increases fracture risk. Thus, knowledge of fracture
status is necessary for therapeutic decisions, making densitometric vertebral fracture
assessment (VFA) valuable. However, VFA limitations include vertebral non-visualization and
difficulties in mild (grade 1) fracture identification; weaknesses that may be reduced by
imaging improvements. As such, this study evaluated vertebral visualization and fracture
identification using GE Healthcare Lunar Prodigy and iDXA densitometers. VFA was
performed on 103 individuals, mean age and lowest T-score 72.6 years and -1.5. An
experienced reader (ER) and a resident physician (RES) evaluated printed images twice
on separate dates applying the Genant VSQ system without morphometry. Main
outcome parameters were evaluable vertebrae from T4-L5, fracture number/grade and
intra- and inter-rater reproducibility. More vertebral bodies were visualized (ER, 95%
vs. 79%; RES, 96% vs. 84%), and more fractures identified (ER, 41 vs. 28; RES 64 vs. 40),
with iDXA than Prodigy. Both readers identified substantially more mild fractures with
iDXA (50% more for ER and 400% for RES); ER identified fewer than RES. ER intrarater
reproducibility was better (kappa .86 for iDXA and Prodigy) than RES (kappa
.56 and .54). In conclusion, iDXA identifies >95% of vertebral bodies, thereby allowing
additional fracture detection. Possible explanations for reader disparity in mild
fracture identification with iDXA include ER bias against mild fracture identification,
thereby not optimally utilizing enhanced image quality, or over-identification of
vertebral deformities as mild fractures by the RES. These fractures will be adjudicated.
Studies comparing iDXA images to radiographs are indicated.
120 — 25-HYDROXYVITAMIN D STATUS AS MARKER OF VITAMIN D
NECESSARY IN OSTEOPOROTIC POSTMENOPAUSAL WOMEN
Catalina Poiana, MD, PhD, CCD, Associate Professor of Endocrinology, Carol Davila,
Mara Carsote, CCD, Endocrinologyst C.I.Parhon Institute of Endocrinology, Bucharest,
Romania, Carmen Barbu, CCD, Assisstant Professor of Endocrinology, Carol Davila
University of Medicne and Pharmacy, Corina Chirita, Resident in Endocrinology,
C.I.Parhon Institute of Endocrinology
Vitamin D status, a major factor in maintaining bone health, is best evaluated by serum levels
of 25-hidroxyvitamin D (25-OH D). General recommendations refer to supplement vitamin
D at treatment of osteoporosis. However it is unclear if its level should be constantly
measured or up to a certain age, in order to increase the intake when necessary. The aim of
our study was to evaluate the 25-OH D level in postmenopausal women diagnosed with
osteoporosis by DXA (at lumbar spine and femoral neck, GE-Prodigy). We studied two
groups of postmenopausal women: 57 women with osteoporosis and a control group
of 15 postmenopausal women with T-score above 2.5. We evaluated the phospho-calcic
metabolism. The results were analyzed by student t test. The average age of the two
groups was 62.14 +/- 8.67 years (range between 46 and 79), respective 57+/-0.03
years (range between 44 and 75). The years since menopause were 16.09+/-8.9,
respective 10.86+/-7.86 (p=0.03). Average 25-OH D level was 18.56+/-9.32ng/ml,
respective 23.94+/-9.07ng/ml (p=0.05). In osteoporotic patients 31.57% showed 25-
OH D level>20ng/ml, 57.89% between 20 and 10 ng/ml, and 10.52% less than 10ng/
ml. In contrast, in the control group 78.8% showed 25-OH D level>20ng/ml. Bone
markers presented mild differences between the two groups (p=0.03 for osteocalcin
and p=0.1 for Beta CrossLaps). No statistical significance was found between levels of
serum ionic calcium, phosphorus, alkaline phosphatase and parathormone. The results
showed that vitamin D is significantly lower in postmenopausal osteoporotic patients,
thus it should be evaluated before therapy initiation.
— 2008 Annual Meeting 19

121 — IS UNIVERSAL STANDARDIZATION EQUATION STILL VALID TO
USE?
Bo Fan, University of California San Franicsco, Ying Lu, University of California San
Francisco, Harry K. Genant, University California San Francisco, John A. Shepherd,
University California San Francisco
Purpose: To validate the DXA “universal standardization equations”, derived in 1995
on pencil bean systems, on three pairs of state-of-the-art scanners DXA scanners.
Methods: 87 postmanopausal women spine and left and right femur were scanned on
both Hologic Delphi version 11.2 and GE-Lunar Prodigy version 7.6 DXA scanners
at three clinical centers. The scans were analyzed by a single technologist at each
center. The spine, total hip and neck BMD results were converted to sBMD using the
equations developed by Hui (1) and Lu (2). Linear regression analysis was used to
describe the correlation and linear relationship of two scanner BMD results after
pooling the data from all centers. Bland-Altman analysis was used to describe the
differences in measures. Results: The Delphi and Prodigy sBMD values were highly
correlated (r ranged from 0.92(left neck) to 0.98 (spine, left and right total hip)).
Spine and right total hip sBMD values had significant intercepts and slopes for Bland-
Altman regression, with mean differences of 3.2 mg/cm2 (3.1%) and 7.6 mg/cm2
(0.9%) respectively. Conclusions: The sBMD values were not shown to be equivalent for
spine and some hip regions between Delphi and Prodigy systems. This dataset may be
appropriate to derive new sBMD relationships for the current technology. Reference:
1. Hui SL, Gao, S, Zhou, XH, Johnston, CC, Jr., Lu, Y, Gluer, CC, Grampp, S, Genant, H
(1997) Universal standardization of bone density measurements: a method with
optimal properties for calibration among several instruments.
J Bone Miner Res 12:1463-1470. 2. Lu Y, Fuerst, T, Hui, S, Genant, HK (2001)
Standardization of bone mineral density at femoral neck, trochanter and Ward’s
triangle. Osteoporos Int 12:438-444.
122 — NO SIGNIFICANT DIFFERENCE IN THE SEMI-QUANTITATIVE
ANALYSIS OF DIPHOSPHONATE UPTAKE IN THE JAW IN SUBJECTS
RECEIVING BISPHOSPHONATES
Askin Uysal, Attending Hospitalist Physician at Veterans Administration, Moheb Boktor,
Louisiana State University, Shreveport, LA, Deepa Ghanta, Louisiana State University,
Shreveport, LA, Anil Ramachanran, Chief of Nuclear Medicine Department, Veterans
Administration Overton Brooks Medical Center, Subhashini Yaturu, MD Chief of
Endocrinology at Veterans Administration Overton Brooks Medical Center, Shreveport,
LA Associate Professor of Medicine at Louisiana State University, Shreveport, LA
Osteonecrosis of the jaw (ONJ), a condition that involves exposed bone of the maxilla
or mandible, is most often identified in patients with cancer who are receiving
intravenous bisphosphonate therapy but it has also been diagnosed in patients
receiving oral bisphosphonates for nonmalignant conditions. Bisphosphonates remain
an important option for management of metabolic bone disease and play a significant
role in the management of malignant disease. Diphosphonate radionuclide bone
scintigraphy (bone scan) is quite sensitive in detecting changes in osseous metabolism.
Diphosphonate uptake in the jaw is similar to soft tissue that is very low and increased
uptake in areas of infected teeth and gums indicating increased vascularity. Methods: In
a retrospective study we reviewed the bone scans done in 2007 to compare the
diphosphonate uptake in 19 subjects with bisphosphonate use to that of 136 control
subjects. Mean duration of the bisphosphonate use is 12months. The bisphosphonates
used were residronate, alendronate or parenteral zolendronic acid. Semi-quantitative
analysis of the bone scans was performed on the jaw area of all patients on
bisphosphonates and also in the control group. Images from bone scans were
considered to be either positive or negative. The images were considered positive
when increased activity in the jaw in comparison with the rest, or increased activity in
specific areas in comparison with adjacent structures. The semi-quantitative analysis
performed on the delayed images did not demonstrate significant difference in the
bone scan uptakes in jaw area in patients on bisphosphonates.
123 — HETEROSCEDASTIC REGRESSION ANALYSIS OF FACTORS
AFFECTING BONE MINERAL DENSITY PRECISION AND MONITORING
William D Leslie, MD, CCD, Professor of Medicine and Radiology, University of,
Mohsen Sadatsafavi, MD MHSc, Center for Clinical Epidemiology and Evaluation,
Vancouver Coastal Health Institute, Vancouver, British Columbia, Canada, Alireza
Moayyeri, MD MPhil, Department of Public Health and Primary Care, University of
Cambridge, Cambridge, UK, Liqun Wang, PhD, Professor of Statistics, University of
Manitoba, Winnipeg, Manitoba, Canada
Identifying factors affecting BMD precision and inter-individual heterogeneity in BMD
change can help clinicians optimize BMD monitoring. BMD change for the lumbar
spine (LS) and total hip (TH) for short-term reproducibility (n=328) and long-term
clinical monitoring (n=2,720) populations from the Manitoba Bone Density Program
were analyzed with a joint heteroscedastic regression model using linear prediction
for mean change of BMD (monitoring population only) and log-linear prediction for
standard deviation (SD) of BMD change (both populations). For clinical monitoring,
male gender, greater baseline weight and cumulative systemic corticosteroid dose were
associated with higher dispersion (i.e., greater SD) of BMD change. Weight gain was
positively associated with SD of change for the LS while height loss was negatively
associated with SD of change for the TH. Each additional year of monitoring increased
the SD by 9.3% for the LS and 6.5% for the TH. Osteoporosis treatment duration
positively affected mean BMD change but did not increase BMD dispersion. For shortterm
reproducibility, performing replicate scans on a different day increased the SD in
measurement error by 38% for the LS and by 43% for the TH. Baseline BMD,
difference in bone area, and a repeat scan performed by different technologists were
associated with higher measurement error only for the TH. For both samples,
heteroscedastic regression outperformed models that assumed homogeneous variance.
We conclude that heteroscedastic regression techniques are powerful yet
underutilized tools in
analyzing longitudinal
BMD data, and can
be used to generate
individualized
predictions of BMD
change and estimates
of measurement
error.
124 — REFERRAL SOURCES FOR BONE DENSITOMETRY AT TWO
VETERANS’ ADMINISTRATION MEDICAL CENTERS
Andrew T. Shields, MD, Clinical Assistant Professor of Radiology, University of
Washington
Aim: Osteoporosis is a greatly underdiagnosed condition. Knowledge of the pattern of
referral sources for dual-energy x-ray absorptiometry (DXA) may lead to a better
understanding of how to target efforts to improve rates of identification of patients at
risk for osteoporosis. Methods: Referral sources from two Veterans Administration (VA)
Medical Centers VA Puget Sound (Seattle WA) and the American Lake VA (Tacoma WA)
were prospectively recorded as stated in requisitions for DXA. Results: 977 DXA scans
were done at the two medical centers between April 2007 and January 2008. 335
(34.3%) originated from general medicine clinics, 100 (10.2%) from women s clinics.
The remainder (542/977, 55.5%) originated from one of twenty specialty services,
including renal (93/977, 9.5%); bone marrow transplant (80/977, 8.2%); arthritis (69/
977, 7.0%); osteoporosis clinic (55/977, 5.6%); endocrinology (46/977, 4.7%);
gastroenterology (45/977, 4.6%); neurology (19/977, 1.9%); addiction treatment (16/
977, 1.6%); geriatrics (16/977, 1.6%); pulmonology (14/977, 1.4%); mental health (13/
977, 1.3%); urology (13//977, 1.3%); nursing home (10/977, 1.0%); and less than 1%
for orthopedics, emergency department, hematology/oncology, radiology, diabetes
clinic, pharmacy clinic, cardiology, optometry, and vascular lab. 13/977 were not
specified. Conclusion: Within the VA system, primary care clinics are gatekeepers for
specialty referrals. The fact that less than half (44.5%) of referrals for DXA originated
from primary care clinics suggests that primary care physicians are often allowing
specialists to take the lead in assessing fracture risk as determined by DXA, and that
efforts to improve rates of DXA utilization should target specialty as well as primary
care services.
20 — 2008 Annual Meeting

125 — DIFFERENCE IN THE SPINAL BONE MINERAL DENSITY
MEASURED WITH AND WITHOUT HIPS FLEXION
Yi-Shi Hwua, PhD, CCT, Assistant Professor, Central Taiwan University of Science and
Technology, Bao-Yuan Huang, Assistant Professor, Department of Early Childhood Care
and Education, Central Taiwan University of Science and Technology, Taiwan ROC, Mu-Yi
Hua, Associate Professor, Department of Chemical and Materials Engineering, Chang
Gung University, Taiwan ROC, Hsiao-Wei Wen, Assistant Professor, Department of Food
Science and Biotechnology, National Chung Hsing University, Taiwan ROC
Notwithstanding the Lunar scanner manufacturer recommended that patients
unnecessarily keep their hips flexed by 90 degrees during the measurement of spinal
bone mineral density (BMD) by modern dual-energy X-ray absorptiometry (DXA)
scanners. Using a GE Lunar DPX-MD+ scanner to measure spinal BMD in 13 young
women, from L1 to L4 in posterior-anterior projection, first the scan was done with
their legs elevated as recommended by the manufacturer and then with their legs flat
on the scanning table. The mean (SD) age of the women was 20.4 yr (0.2 yr), height
was 162.53 cm (4.01), body weight was 54.31 kg (9.18), and the body mass index
(BMI) was 20.56 (3.56). Paired student s t-test showed all of the BMD, BMC, region of
interest (ROI), T-scores and Z-scores changed significantly between the 2 scans (p <
0.05). With spinal BMD measured in the legs-down position, the percentage change
(1.33 %) of BMD was higher than these measured in the legs-up position. Between the
2 measurements, BMD, BMC, the area of the ROI, T-scores and Z-scores showed high
correlations (r = 0.985, 0.997, 0.980, 0.982 and 0.980, respectively). Either spinal
BMD was measured with their legs elevated or down, 12 women were found to have
normal BMD but 1 woman was found to have low bone mass. In conclusion,
statistically enhanced in the total spinal BMD was found when the BMD in a group of
young women was measured with their legs positioned flat.
126 — REPRODUCIBILITY OF HIP GEOMETRIC PARAMETERS USING
DXA
Diane Krueger, University of Wisconsin Osteoporosis Clinical Research Program,
Nellie Vallarta-Ast, University of Wisconsin Osteoporosis Clinical Research Program,
Mary Checovich, University of Wisconsin Osteoporosis Clinical Research Program,
Neil Binkley, University of Wisconsin Osteoporosis Clinical Research Program
Assessment of hip geometric parameters using DXA may help identify those at
increased hip fracture risk. However, the reproducibility of this methodology with
current generation instrumentation is not well defined. This study evaluated the
precision of hip geometric parameters using GE Healthcare Lunar Prodigy and iDXA
densitometers in postmenopausal women. Additionally, the reproducibility of these
measurements when performed by different technologists is being investigated. Thirty
postmenopausal women, mean age and BMI of 69.8 years and 25.8 kg/m2 had two
bilateral hip scans performed on each instrument with repositioning between scans.
Geometric parameters were determined using the auto-analysis feature for all regions
of interest; software versions 11.4 and 11.2 were used for Prodigy and iDXA
respectively. HAL was the most reproducible parameter (%CV ~0.7%) with both
instruments. Hip geometric parameter measurements between the instruments were
highly correlated, R2 = .96 for HAL, CSA, and CSMI. As might be expected, a calculated
parameter (FSI) was less reproducible than measured parameters (Table). Substantial
differences (e 20%) in FSI were demonstrated between the right and left hip in 30% of
subjects. In conclusion, these instruments demonstrate comparable reproducibility and
generate similar measurements. The utility of geometric parameters in clinical settings
needs to be defined. Whether the “weaker” side as indicated by FSI is more predictive
of fracture should be determined.
127 — AUTOMATED DXA INSTRUMENT QUALITY CONTROL:
EXPERIENCE IN FRANCE
P. Carceller, Med-Imaps, Bordeaux, France, D. Kendler MD CCD, University of British
Columbia, Vancouver, Canada, D. Hans PhD CDT CCD, Lausanne University Hospital
Switzerland
DXA instrument QC is usually performed by phantom scanning on a regular basis. ISCD
Official Positions encourage daily phantom scans with plotting results and analysing them
with Cusum and Shewhart s rules. It is only by applying such rigorous protocols that
individual patient scans can have assured validity. Few DXA Centres diligently apply statistical
tests to their QC data; most rely on visual analysis. In France, out of 158 DXA devices
followed over 2 years period, 25% of them showed severe violations. We developed and
applied, at selected DXA facilities, Med-Imaps automatic QC software to monitor QC data.
The Windows and Web based software is applicable to both GE and Hologic densitometers.
It is installed on the DXA computer, automatically detecting whenever a QC
measurement is performed. Area, BMC, and BMD data are analyzed based on Shewhart
and Cusum rules with immediate notification on the DXA computer of any violations
of stability. The daily QC data are then automatically transmitted by internet to a QC
center for further analysis. A report is emailed and posted on a secured web site for
the facility to access. Over 9 months, there were 789 daily QC measurements at 5 sites
from which 90 days showed violations. However, according to french regulation rules,
none of them led to “out of service” status. We have demonstrated the value of
automated DXA QC software and its implementation in France. We see value in
exploring the application of this software in other DXA facilities, perhaps in
conjunction with a more comprehensive facility accreditation program.
128 — CENTRAL DXA AND PERIPHERAL DXA SHOULD BE ROUTINE IN
THE EVALUATION OF MEN WITH PROSTATE CANCER DURING
ANDROGEN-DEPRIVATION THERAPY
Paul R Sieber, MD, CCD, Urological Associates of Lancaster, Leanne Schimke CUNP,
Urological Associates of Lancaster, F Michael Rommel MD, Urological Associates of
Lancaster, Chris G Theodoran DO, Urological Associates of Lancaster, Robert d Hong,
Michael Del Terzo, Paul J Russinko, Christopher A Woodard
Objectives: to evaluate the significance of adding peripheral DXA(distal 33% radius) to
routine central DXA(lumbar spine plus hip) in routine screening of men receiving
androgen-deprivation therapy(ADT) for prostate cancer Methods; we began routinely
adding peripheral DXA to central DXA in all men undergoing bone mineral density
evaluation for bone loss associated with ADT. We reviewed the results of our first 138
patients. Results: using standard central DXA 23 patients(16.7%) were normal(Tscore>-1.0),
75(54.3%) were osteopenic(T-score -1.0 to -2.5), and 40(29.0%) were
osteoporotic(T-score < -2.5). Adding forearm DXA changed the diagnosis in 17
patients(12%) In the new central plus peripheral classification 19(13.8%) were normal,
66(47.8%) osteoporotic, and 53(38.4%) osteoporotic. In addition. central DXA showed
37 patients had nonevaluable spines and 5 patients with nonevaluable hips. Results:
bone loss associated with ADT is now a well recognized problem. However the
evaluation and treatment of these patients is less well understood. We have seen
significant problems in the interpretation of central DXA as noted by our high
number of nonevaluable sites. In addition, peripheral DXA identifies more patients
with significant bone loss suggesting its role in the evaluation of this particular group
of patients.
— 2008 Annual Meeting 21

129 — THE EFFECT OF ACCURACY ERRORS ON THE CLINICAL
INTERPRETATION OF DXA SCANS
Glen M Blake, PhD, Senior Lecturer, King’s College London, UK, Ignac Fogelman,
King’s College London, UK
Although the effect of precision errors on DXA scan interpretation is widely discussed, the
effect of accuracy errors is comparatively neglected. Accuracy errors arise from the
inhomgeneous distribution of adipose tissue in the human body and are an unavoidable
source of measurement error in DXA scanning. They can be quantified either through
cadaver studies in which the results of in situ measurements are compared with true values
found by bone ashing, or else through imaging studies using CT scans to delineate adipose
tissue external to bone and MRI scans to measure percentage fat in bone marrow. In the
present study we undertook a literature review to identify studies of soft tissue accuracy
errors affecting spine and hip DXA measurements. A cadaver study published by Svendsen et
al. (1) was identified that provided in situ and true BMD values for lumbar spine, total hip and
femoral neck DXA. Results for the random BMD measurement errors were 5.3% for lumbar
spine, 6.5% for total hip and 6.7% for the femoral neck site. When converted into T-score
errors these figures correspond to 95% confidence intervals of +/- 0.95, 0.99 and 0.99
population standard deviations respectively. Results from CT and MRI imaging are consistent
with these findings. It is clear that BMD accuracy errors have a clinically important effect on
DXA scan interpretation and may cause T-score values to significantly misrepresent patients’
true bone status. (1) Svendsen et al. J Bone Miner Res 1995;(10:868-873.
130 — SHOULD DIALYSATE BE DRAINED PRIOR TO DUAL-ENERGY X-
RAY ABSORPTIOMETRY (DXA) SCANNING IN PERITONEAL DIALYSIS
(PD) PATIENTS?
Merry Lynn Mann, Second Year Medical Student, The University of Alabama, Denyse
Thornley-Brown, M.D., Associate Professor of Medicine, School of Medicine, The
University of Alabama, Birmingham, AL, Ruth Campbell, M.D., Assistant Professor of
Medicine, School of Medicine, University of Alabama, Birmingham, Al, Emmy Bell, M.D.,
Assistant Professor of Medicine, School of Medicine, The University of Alabama,
Birmingham, AL, Leandria Burroughs, RT(R), CDT, Nancy Nunnally RT(R), CDT, Rui Feng,
PhD, Sarah L. Morgan, MD, RD, CCD
Determination of bone mineral density (BMD) in patients with end stage renal disease
(ESRD) treated with PD can be useful in evaluation of metabolic bone disease. A recent study
reported that there was a significant change in measured BMD among patients with ascites
studied prior to and following large volume paracentesis. Given this observation, it is not
known whether peritoneal dialysate should be drained prior to DXA scanning in patients
with ESRD on PD. We hypothesized that the presence of indwelling peritoneal dialysate as
compared to drained dialysate will not change BMD in the lumbar spine, femoral neck or hip.
Thirty patients were recruited and gave informed consent to have a DXA at the lumbar
spine, femoral neck, and total hip before and after draining peritoneal dialysate. Scanning was
completed on a Hologic Discovery W scanner in array mode by the same ISCD-certified
technologist. The population was 20% Caucasian, 80% African-American; 60% were females,
40% were males. The mean age was 48.60 ± 11.77 years (range 21-71 years). The mean
volume of dialysate drained was 1908.33 ± 508.22 ml (range 500 3000 ml). Thirty to 117
minutes elapsed between scans (mean 60.17 ± 20.15 minutes). There was not a
significant difference in BMD at the lumbar spine, the femoral neck, and the total hip
before and after draining peritoneal dialysate. We conclude that BMD is not
significantly affected by the presence of indwelling peritoneal dialysate up to 3000 ml.
131 — EXTREME BMD INCREASES WITH VITAMIN D: AN OVERLOOKED
ANABOLIC THERAPY
John Joseph Carey, Merlin Park University Hospital, Galway, Ireland, Miriam F Delaney,
Bradford Richmond, The Cleveland Clinic, Cleveland, Ohio, Angelo A Licata, The
Cleveland Clinic Foundation, Cleveland, Ohio
Vitamin D insufficiency and deficiency are common in adult populations. Profound
deficiencies can result in osteomalacia though milder forms are often recognized as
secondary causes of osteoporosis. Vitamin D replacement is recommended which usually
results in attenuation of bone loss or even modest gains in BMD. However massive increases
in BMD have rarely been reported. In this abstract we present a case series of subjects
referred for osteoporosis evaluation who had very low or undetectable 25-hydroxyvitamin D
levels. All patients had baseline central DXA T-scores below -2.5 at multiple sites. Following
treatment with vitamin D and calcium supplementation, all experienced extremely large
increases in BMD up to 97% - in a relatively short period of time (see table). Such large
increases have rarely been described. Osteomalacia may masquerade as osteoporosis and
thus the diagnosis should not be based on DXA alone. Serum 25-hydroxy vitamin D levels
should be checked in all persons being evaluated for osteoporosis. Aggressive vitamin D
replenishment is warranted in cases of vitamin D deficiency. The resulting remineralization of
the skeleton occurs rapidly with appropriate therapy and may be associated with
dramatic increases in BMD over a short time period.
132 — SURPRISES IN CROSS CALIBRATION: A COMPARISON OF BODY
COMPOSITION VALUES BETWEEN DXA MANUFACTURERS
Sparkle Joy Williams, Research Health Science Specialist, Dept. of Veterans
Administration Medical Center
A comparison of a Hologic QDR 1000/W (pencil beam) and a GE Lunar iDXA (fan
beam) was performed in order to establish the appropriate cross calibration methods.
There is an established history of differences in the quantitative values seen in region
specific bone density in both inter-manufacturer and inter-beam measurements.
Typically these values are off by no more than 5% and are due to differences in
calculating the region of interest. The bone density values seen at both the femoral
neck and total femur are approximately equal when existing cross calibration
methods, provided by GE Lunar, are used. One would expect that body composition
would either be maintained across machines, or would vary in a predictable manner.
In a comparison between the two machines, disparity was seen in composition
distribution. In a survey of 30 individuals scanned once on both instruments, the
overall value of the total body mass (in kg) was approximately equal on both
machines (an average disparity of less than 1% existed). However, the iDXA
consistently reported total fat mass 22% higher than the QDR 1000/W (although
there were some slight variations depending on gender and BMI). Although it has
always been accepted that differences in database and calculation methods create a
need for instrument cross-calibration when referencing bone density values, this
report indicates that appropriate total body cross calibration methods are necessary.
Additional studies should be completed to determine the extent of the discrepancies
in distinguishing between lean mass and fat mass in body composition measurements.
22 — 2008 Annual Meeting

133 — PREVALENCE OF HIGH BMD T-SCORES IN A COMMUNITY
POPULATION
C. Simonelli, MD, CCD, HealthEast Osteoporosis Care, MC Schoeller, HealthEast
Osteoporosis Care, PJ Sinner, HealthEast Department of Research
There is no designated upper limit of normal for bone mineral density (BMD) testing results
with DXA, although many disease states may be associated with high BMD and may
potentially increase fracture risk. The purpose of this study is to report the prevalence of
BMD T-scores and Z-scores > +2.5 in adults by gender, age, BMI, fracture history, and by site
of BMD measurement: lumbar spine (LS), femoral neck (FN) and total proximal femur (TF).
BMD testing using the GE Lunar Prodigy” densitometer was performed between November
1999 and January 2007 on 8891 patients. High BMD Z-scores and T-scores increased with age
at the LS, most notably for men. 4.4% of men aged 40-49 had a high BMD whereas 16.9% had
a high BMD at age 80+. Increased BMD T-scores with aging was not seen at the TF or FN
sites . Patients with high BMD Z-scores were more likely to be obese (42%) than those with
Z-scores -1.0 to 1.0 (27%), despite using the weight-correction function. Finally, patients with
high BMD T-scores reported fewer fractures at non-hip/non-spine sites compared to patients
with a normal T-score -1.0 to +1.0 (1.3% vs. 6.7%, p-value = 0.06). BMD T-scores > +2.5 at the
femur sites are rare, do not increase with aging, and are associated with a decrease in
fracture history at non-hip/non-spine sites. Weight-adjusted BMD Z-scores > +2.5 are
associated with obesity. Further study of the significance of potentially high BMD and
associated disease states is warranted.
134 — HIGH BMD: HOW COMMON IS IT?
Nellie Vallarta-Ast, University of Wisconsin Osteoporosis Clinical Research Program,
Cynthia Wrase, William S. Middleton VAMC, Diane Krueger, University of Wisconsin
Osteoporosis Clinical Research Program, Neil Binkley, University of Wisconsin
Osteoporosis Clinical Research Program
High DXA-measured BMD may reflect degenerative changes, but is also seen in conditions of
skeletal fragility. However, there is no current consensus regarding when a diagnosis of high
BMD is appropriate. Though addressed at the 2007 ISCD Position Development Conference,
existing data did not allow defining when high BMD should be reported. The purpose of this
report is to describe densitometric and clinical characteristics of men with “high” BMD using
various cutpoints. Additionally, as obesity is associated with higher BMD, the possible utility of
weight-adjusting Z-scores was investigated. Data from 2270 men age 22-97 years receiving
clinically-indicated DXA scans from 10/2003-7/2007 were reviewed. Applying potential T- and
Z-score based cutpoints identified 12 men (mean age 71 years) with a lowest spine and hip T-
score e 2.0 (Table). One-third radius BMD was also high in five of these 12. All 12 had
apparent spinal degenerative disease visible on the DXA image, none had historical fractures
or VFA deformities and only one had “osteopetrosis” by electronic medical record review. In
conclusion, “high” BMD at the spine is not rare in men and likely reflects degenerative
changes. Z-score weight-adjustment does not appear to improve identification of those with
high BMD. Using a T-score cutpoint of +2.0 identified only 0.5% of men as being “high” at
both the spine and hip. Use of a +2.0 or + 2.5 T-score cutpoint to define “high BMD” may be
appropriate, however, prospective evaluation to assess the prevalence of osteosclerotic
diseases in such men is needed.
135 — EFFECT OF RADIONUCLIDE BONE SCANS ON BMD
MEASUREMENTS USING A LUNAR DPX IQ DENSITOMETER
Sumaya Ismail, Department of Nuclear Medicine, Groote Schuur Hosp
Although manufacturers of dual X-ray absorptiometry (DEXA) machines recommend a delay
of a bone density scan after the administration of radionuclides they do not provide any
reason for it. Studies performed to investigate this phenomenon provide conflicting results. It
has been demonstrated that different results are obtained using different machines. The main
objective of this study was to determine whether the presence of an intravenous dose of
99mTc-methylene diphosphonate (99mTcMDP) had an effect on measured bone mineral
density (BMD) and whether the magnitude of this effect was clinically significant. Secondary
objectives were to determine potential associations between BMD, recorded weight and the
measured dose of 99mTcMDP administered. Twenty eight patients attending the clinic
scheduled for a radionuclide bone scan had BMD measurements done prior to the
administration of a diagnostic dose of 99mTc-MDP and 2 hours after the injection using a
Lunar DPX-IQ densitometer. BMD measurements were done at the lumbar spine at (L1-L4)
and both hips at the femoral neck, trochanter as well as the total hip. The mean changes in
BMD measurements for the lumbar spine were -0.136 g/cm2, the equivalent of a reduction of
12.36% (p=0.004). Although all measured sites for the hip showed a reduction in readings
these did not exceed the LSC for these regions. Correlations with weight showed that bigger
differences in readings correlated with increased weight. No likely correlations were found
with 99mTc MDP dose. Our study confirms the reports of a significant effect of 99mTcMDP
on lumbar BMD using a Lunar densitometer. These effects were not seen at femoral sites of
measurement. Lumbar BMD measurements following 99mTcMDP need to be
interpreted with caution and are probably unreliable.
136 — IN VIVO EVALUATION OF STUDIES DONE WITH THE NORLAND
XR-46 AND XR-800 SERIES EQUIPMENT
KM Dudzek, Norland—a CooperSurgical Company, S de P Snodgrass, MD, University
of Florida and Shands Hospital Women’s Breast Center, Jacksonville, FL, K Cowan, RT,
University of Florida and Shands Hospital Women’s Breast Center, Jacksonville, FL,
RD White, MD, University of Florida and Shands Hospital, Jacksonville, FL, KR Wehmeier,
MD, University of Florida, Jacksonville, FL, TV Sanchez, CooperSurgical Company,
Socorro, NM
When significant hardware changes are introduced to equipment the impact of those
changes to the measurement in vivo precision and accuracy should be validated. This
study compared in vivo precision and accuracy of scans done on the earlier Norland
XR-46 and newly developed Norland XR-800 series of DXA equipment. Five to fifteen
subjects underwent four repeated scans without repositioning on both the scanners.
AP Spine, Lateral Spine, Hip, Forearm, a Research Scan of the Hand and Whole Body
study were evaluated. All scans were done by experienced operators. Precision and
absolute values for studies obtained on both scanners were compared. The XR-46 and
XR-800 scanner studies, respectively, show precision for BMD of 0.92% and 1.00% for
AP Spine, 2.04% and 1.80% for Lateral Spine, 0.59% and 0.74% for Total Hip, 0.80%
and 0.68% for Distal Forearm, 0.64% and 0.77% for Proximal Forearm, 1.09% and
0.690% for the Research Scan and 1.11% and 0.91% for Whole Body. Values for BMD
obtained with the two scanners proved very similar. As a percent of the XR-46 results,
values for BMD obtained with the XR-800 were 100.47% for AP Spine, 105.46% for
Lateral Spine, 100.33% for Total Hip, 100.71% for Distal Forearm, 101.50% for
Proximal Forearm, 99.69% for Research and 99.72% for the Whole Body scan. The
studies show that scans done on the XR-46 Series and on the XR-800 Series of
scanners result in similar precision and absolute values supporting a conclusion that
studies on these systems are fully interchangeable.
— 2008 Annual Meeting 23

137 — EVALUATION OF BONE MINERAL CONTENT AND AREA BY THE
NORLAND XR-46, XR-800 AND XR-600 SYSTEMS ON THE BMIL
PHANTOM
TV Sanchez, CooperSurgical Companies, DK Buckingham, Norland a CooperSurgical
Company, Fort Atkinson, WI USA, DR Purvis, Norland a CooperSurgical Company, Fort
Atkinson, WI USA, CA Dudzek, Norland a CooperSurgical Company, Fort Atkinson, WI USA,
GJ Ekker, CooperSurgical Company, Fort Atkinson, WI USA
The development of new scanners justifies the evaluation of measurements. This study
evaluates the measurement of Bone Mineral Content and Bone Area in the BMIL Phantom on
the new Norland Model XR-800 and XR-600 Scanners and compares those measurements to
values obtained on the earlier generation of systems, the Norland XR-46. A series of 25 AP
Spine studies were done on each of the three scanners the Norland XR-46, the XR-800 and
the XR-600—using standard settings of resolution (1.5 x 1.5 mm) and scan speeds (130 mm/
s). Analysis was carried out of the scans to obtain the “bone mineral content” and “bone
area” of the four plates found in the BMIL Phantom. Precision of BMC measurements on the
XR-46, XR-800 and XR-600 were similar for plate 1 (2.65%, 2.82%, 3.10%), plate 2 (1.55%,
1.40%, 1.41%), plate 3 (1.30%, 0.89%, 1.19%) and plate 4 (0.98%, 1.13%, 1.06%). Precision of
Area measurements on the XR-46, XR-800 and XR-600 were also similar for plate 1 (3.80%,
2.65%, 4.07%), plate 2 (2.59%, 2.10%, 2.49%), plate 3 (2.94%, 1.77%, 1.78%) and plate 4 (2.32%,
1.90%, 1.87%). Regressions for BMC between the XR-46 and XR-800 (y = 1.0328x 0.3217; r
=0.9999) and the XR-46 and XR-600 (y = 1.0223x 0.2690; r =0.9999) were similar. Similar
findings were seen for Area between the XR-46 and XR-800 (y = 1.1339x 2.5246; r =0.9971)
and the XR-46 and XR-600 (y = 1.0433x 0.9305; r =0.9988). The data confirms that
when using standard AP Spine settings the new systems (XR-800 and XR-600)
produce absolute measurements with similar precision to those found on the XR-46.
138 — INTER- AND INTRA-READER VARIABILITY OF HOLOGIC HSA
AND COMPARISON TO BECK HSA
Abey Mukkananchery, Synarc, Inc., Elsa Griffith, Synarc, Inc., Lorna Cole, Synarc, Inc.,
Sandy Stange, Synarc, Inc., Cesar Libanati, MD Thomas Fuerst, PhD
Hip Structural Analysis (HSA) extends DXA by measuring geometrical parameters related to
bone strength. The HSA method developed by Beck was recently incorporated into the
Hologic APEX software. The purpose of this study was to investigate the inter- and intrareader
variability of Hologic HSA and its agreement with Beck HSA. Baseline scans of 30
postmenopausal women (mean age: 61.2±8.9, mean neck T-score: -1.5±0.6) were selected
from an osteoporosis clinical trial cohort. Four readers analyzed the scans with Hologic HSA
manually reproducing the Beck ROI locations. Results from the four readers were compared
for inter-reader variability. Three readers repeated the analysis to measure intra-reader
variability. Accuracy was assessed by comparison with Beck HSA results. Cross-sectional area
(CSA), cross-sectional moment of inertia (CSMI), section modulus (Z) and buckling ratio
(BR) were measured. Root mean square coefficient of variation (CV%) was computed to
measure variability. Paired t-test and linear regression were used to test the agreement
between the techniques. The inter-reader results are summarized below as mean CV%. The
intra-reader results are similar but smaller. Hologic results agreed relatively well with the
Beck HSA results. The relationships were highly linear with correlation coefficients above
0.95 for most parameters. However paired T-test showed that most parameters were
statistically different (mean percent difference ranged from -1.6% to +17%). HSA
measurements can be obtained using the Beck software in its original form or with the
commercially available Hologic APEX. There are small differences between the results
likely due to differences in edge detection and ROI location.
139 — FREQUENCY OF CERTIFIED CLINICAL DENSITOMETRIST (CCD)
RECLASSIFICATION OF FRACTURE RISK BASED ON LOWEST T-SCORE: A
MULTI-SPECIALTY CLINIC S EXPERIENCE
Jesse C Krakauer, MD, FACP, Middletown Medical, Nir Y Krakauer, PhD, Department
of Earth and Planetary Science, University of California - Berkeley, CA, Vivek Oberoi,
Information Services, Middletown Medical, Middletown, NY, Rajan Gulati, MD, Medical
Director, Middletown Medical, Middletown, NY
We report the frequency of CCD reclassification of recommendation for consultation/
referral based solely on fracture risk estimates derived from lowest T-score (L1-L4, Total hip,
Femur Neck, Femur Trochanter). Spine and hip DXA was performed by a certified radiology
technologist (RT) on a Hologic QDR-1000. The 10-year fracture risk was categorized as Low
or Moderate/High (>10%), Can Assoc Radiol J 2005; 56: 178-188. The CCD reviewed the scan
images, prior scan results, questionnaire, diagnosis and medication lists. We retrospectively
studied reports over 8 months of 566 consecutive patients referred for DXA. Each record
was scored for concordance of T-score generated and CCD recommendations and for
osteoporosis Rx, family history, fracture hx, thinness, smoking and corticosteroid use. 36/248
(15%) of patients low fracture risk by T-score were reclassified medium/high risk by the CCD,
while 36/218 (17%) of patients medium/high by T-score were reclassified low risk.
Demographics significantly associated with reclassification were age > 65 years, male gender,
and initial scan. Clinical factors significantly associated with CCD recommended referral
despite low fracture risk by T-score; osteoporosis Rx (relative risk [RR] of reclassification:
4.3, p = 0.002, two-sided probability from the Fisher exact test) and smoking (RR: 0.4, p =
0.02). Clinical factors associated with reclassification as usual care despite moderate/high
fracture risk from T-score; osteoporosis Rx (RR: 0.1, p = 0.003), thinness (RR: 0.1, p =
0.008) and family history (RR: 2.4, p = 0.02). The relatively high rate of reclassification
we found supports the value of specialist review of densitometry scan records.
140 — LONGITUDINAL TRENDS IN USE OF BONE MASS
MEASUREMENT AMONG OLDER AMERICANS, 1999-2005
Jeffrey R. Curtis, MD, Assistant Professor of Medicine, University of Alabama,
Laura Carbone, MD, MSc, Veterans Administration Medical Center, University of
Tennessee; Memphis, TN, Hong Cheng, PhD, Department of Epidemiology, University of
Alabama; Birmingham, AL, Burton Hayes, MD, Veterans Administration Medical Center,
University of Tennessee; Memphis, TN, Andrew Laster, MD, Arthritis & Osteoporosis
Consultants of the Carolinas, Charlotte, NC, Robert Matthews, MS, Department of
Epidemiology, University of Alabama, Birmingham, AL, Kenneth G Saag, MD, MSc,
Division of Clinical Immunology and Rheumatology
Bone mass measurement (BMM) is useful to identify persons with low bone mass who
are at increased risk for fracture. Given the increased emphasis on preventive services,
we evaluated BMM trends among Medicare beneficiaries. We studied a 5% sample of
Medicare beneficiaries ages e 65 years in 1999-2005. We identified claims for BMM
tests performed in both facility and non-facility settings, evaluated temporal trends in
use of these tests and described the proportion of tests attributable to each physician
specialty. We also assessed testing patterns for persons tested more than once. We
pooled claims data from all years to describe the proportion of persons in the
population ever tested. From 1999-2005, use of central dual energy x-ray
absorptiometry (DXA) increased by approximately 50%, and use of peripheral DXA
declined. Central DXA use increased greatest among internists, family practitioners
and gynecologists. In 1999, the proportion of women tested was 8.4%; this increased
to 12.9% in 2005. Corresponding proportions for men were 0.6 and 1.7%,
respectively. Between 40 and 73% of persons receiving DXA were re-tested, most at ~2
year intervals. Aggregating data across all years, 30.0% of women and 4.4% of men
underwent central DXA at least once. Although use of DXA steadily increased from
1999 to 2005, only about 30% of women and 4% of men aged e 65 years had a
central DXA study. Given the importance of central DXA to assess the risk of
osteoporotic fractures, strategies to increase central DXA use to test at-risk persons
are warranted.
24 — 2008 Annual Meeting

141 — ANALYSIS OF HIP SCANS ON HOLOGIC DXA SYSTEMS
Glen M Blake, PhD, Senior Lecturer, King’s College London, UK, Jacqueline Shipley,
Royal National Hospital for Rheumatic Diseases, Bath, UK, Ignac Fogelman, King’s
College London, UK
DXA scans are widely used to monitor response to treatment. We report two patients in
whom follow-up scans showed unexpectedly large decreases in hip BMD. Investigation
showed that in both cases the automatic analysis failed to correctly identify the bone edges
and the operator had painted in the missing bone area. The scans were reanalysed manually
by raising the upper border of the analysis box to include a larger area of soft tissue until the
software correctly found the bone edges. When this was done the hip BMD changes were
consistent with the spine. Case 1 was an 82-year-old woman treated with risedronate. Using
automatic analysis her total hip BMD decreased by 46.4% compared with her previous scan.
When the scan was reanalysed manually the decrease was 3.6% compared with a spine BMD
decrease of 3.4%. Case 2 was a 73-year-old woman treated with alendronate. Using automatic
analysis her total hip BMD decreased by 25.3% compared with her previous scan. When the
scan was reanalysed there was an increase of +2.7% compared with a spine BMD
decrease of 5.0%. With Hologic DXA systems, painting in areas of bone missed by the
automatic analysis does not remove the error in the soft tissue baseline that results
from including bone within the soft tissue area. As a consequence BMD is
underestimated. When this happens in the hip the missing bone should not be painted
in but the upper border of the analysis box raised 10-20 pixels until the software
finds the bone edges correctly for itself.
142 — AUTOMATED SOFTWARE IN DXA QUALITY CONTROL:
RETROSPECTIVE ANALYSIS OF DAILY PHANTOM SCANS
P. Carceller, Med-Imaps, Bordeaux, France, D. Kendler, MD, CCD, University of British
Columbia, Vancouver, Canada, D. Hans, PhD, CDT, CCD, Lausanne University Hospital
Switzerland, E.M. Leweicki, MD, CCD, Albuquerque, New Mexico, S. Baim, MD, CCD, Denver,
Colorado, N.C. Binkley, MD, CCD, Wisconsin
Quality of DXA testing is related in part to machine performance, to operator, to interpreter
competence. Operators are encouraged to scan phantoms daily, to plot the results graphically
for visual assessment, then to apply statistical tests such as Cusum s and Shewhart s rules,
mostly applied retrospectively. We studied 6 systems (3 GE and 3 Hologic) in the US, Canada,
and Switzerland. We applied Med-Imaps software to phantom data obtained from 1996 to
nowadays. The software analyzed phantom data and generated a report of all violations of
statistical rules. We estimated the length of time patients might have been exposed to an
unstable system using traditional QC. We assumed that the Med-Imaps QC, if used in an
automatic daily fashion, would result in restoration of system stability after one day. We then
compared the duration of system instability using traditional QC to the time of exposure
likely from automated software. We found violations 1015 days over 217 months for 2
systems yet analyzed. There was a large variability in system stability for example with
HOLOGIC1 having 0 unusable day and HOLOGIC2 having 3 majors periods of
unstabilities detected (Shewhart s rules). In aggregate, this may expose patients to a
system with suboptimal QC for 523 days; with semi-automated software this would
result in (estimated) 140 days of suboptimal QC testing. We conclude that instrument
QC using traditional methods is suboptimal. Live, daily, automated QC would provide
an opportunity to reduce the exposure of patients to DXA systems generating
unreliable test results.
144 — PSYCHOSOCIAL IMPACTS ON BONE TURNOVER IN ADULT MEN:
PRELIMINARY FINDINGS FROM THE MIDUS STUDY
Arun Karlamangla, UCLA, Division of Geriatrics, Neil Binkley, MD, University of
Wisconsin Institute on Aging, Gayle Love, University of Wisconsin Institute on Aging,
Diane Krueger, University of Wisconsin Institute on Aging, Gail Greendale, Carolyn
Crandall, Teresa Seeman, Carol Ryff
Recent work demonstrates that bone remodeling is, at least in part, regulated centrally
in the hypothalamus. As osteoporosis ultimately results from disordered bone
remodeling, it is plausible that psychosocial factors, both negative (e.g., depression) but
also positive (e.g., purpose in life), could impact skeletal health. This work investigates
correlations between psychosocial variables and serum bone turnover markers in
adult male participants in MIDUS (Midlife in the US), a nationally representative cohort
study of aging. In this preliminary analysis, serum turnover markers (BSAP, P1NP and
NTx) in 247 men were correlated with positive and negative psychosocial variables.
Additionally, a bone balance index (BBI), developed by deriving turnover marker T-
scores and defining bone balance as formation T-score minus resorption T-score, was
used to investigate associations between bone balance and psychosocial variables. A
negative BBI favors resorption. In men age e 66 years (n = 75) measures of positive
psychosocial status are negatively correlated with serum NTx while aspects of
psychological ill-being are positively linked with NTx. In this group, the BBI is
consistent, with negative psychological factors favoring resorption while positive
variables favor formation. In contrast, among younger men (age 35-49, n = 61) the
relationship between psychosocial factors and BBI is opposite to that in older men in
that positive psychosocial factors are associated with increased bone resorption and a
negative BBI. In conclusion, psychosocial factors may play an important role in
osteoporosis pathogenesis in men. Differential associations between bone turnover and
psychosocial status may exist at various ages.
145 — THE DISTRIBUTION AND CORRELATES OF BONE MINERAL
DENSITY IN JAMAICAN YOUNG ADULTS
Sheerin Ansari Eyre, Senior Lecturer, University of the West Indies, Kingston, Jamaica,
Dr Kenneth Vaughn, Dr Micheal Boyne, Dr Trevor Ferguson, Dr Novie Younger,
Dr Marshall Tulloch Reid, Dr Maria Jackson, Dr Maureen Samms Vaughn,
Professor Rainford Wilks
Objective: To describe the distribution of bone mineral density (BMD) among Jamaican
young adults and evaluate factors associated with low BMD. Methods: 902 participants
from a sub sample of the 1986 Jamaica Perinatal Mortality Survey were studied. BMD
was estimated by stiffness index (SI) using quantitative ultrasound (Lunar Achilles
Express®) of the right calcaneus in 701 participants, age 18-20 years. Questionnaires
were used to obtain data on tobacco, marijuana, alcohol use and history of bone
fracture. Anthropometry by standardized techniques used to calculate body mass
index (BMI). Data were analyzed using Stata 9.2; associations with risk factors for low
BMD were assessed using chi-square test, ANOVA and linear regression. Low BMD was
defined as z-score < -1 in the absence of normative values. Results: The mean stiffness
index (SI) was 113.8 ± 22.4, significantly higher in males (116.5 ± 24.1 vs. 111.4 ±
20.6; p

146 — BONE MINERAL DENSITY IN SYSTEMIC LUPUS ERYTHEMATOSIS
Mariam Khan, MD, Internal Medicine Resident, Section of Rheumatology, Rush
University Medical Center, Chicago, IL, Lisa Maskala Streff, BA, RT, CDT, Rush University
Medical Center, Chicago IL, Meenakshi Jolly, MD, Section of Rheumatology, Rush
University Medical Center, Chicago IL, Charlotte Harris, MD, Section of Rheumatology,
Rush University Medical Center, Chicago IL, Joel Block, MD, Section of Rheumatology,
Rush University Medical Center, Chicago IL
We evaluated BMD, osteoporosis (OP) screening, and osteoporosis among an ethnically
diverse group of patients with systemic lupus erythematosis (SLE). With IRB approval,
records of 106 female SLE patients at Rush University were reviewed for a history of OP
screening, presence of low BMD (T score of = -1.0) or osteoporosis based on DXA. SLE
features were recorded, and the data were stratified by demographics, disease features and
OP risk factors. Chi square & Student s t test were performed. Subjects were 42.5 ±
13.1years old (mean±SD), had SLE 9.2 ± 8.6 years, and were 54% African American, 27%
Caucasian, 19% of other ethnicity. 71% had previously received prednisone = 7.5 mg/day or
equivalent for = 3 months. 68% had been screened for OP. Screening for OP did not
vary by ethnicity, disease features or risk factors for OP. Older age (p=0.001), post
menopausal status (p=0.001), and greater disease duration (p=0.004) were associated
with OP screening. Of those screened, 47.6% had low BMD which included 9.5% with
OP. Patients with low BMD or OP did not differ from the others by ethnicity, disease
features or OP risk factors. Higher serum creatinine (p=0.02) and low BMI (p=0.05)
were associated with low BMD. We observed no racial disparities in OP screening. Low
BMD was associated with age, later menarche, BMI, SLE disease duration, and decreased
renal function, but not with ethnicity, disease activity or damage among patients with
SLE. OP screening is important in SLE, especially in older patients with longer disease
duration.
147 — THE RELATIONSHIP BETWEEN FREE TESTOSTERONE AND
LONGITUDINAL CHANGES IN BONE MINERAL DENSITY IN ELDERLY
MEN
Denise Angelica Teves, MD, Division of Endocrinology, Medical College of Wisconsin,
Edith Burns, MD, Geriatrics, Medical College of Wisconsin, Prakash Laud, PhD,
Biostatistics, Medical College of Wisconsin, Joan Neuner, MD, Internal Medicine, Medical
College of Wisconsin
We analyzed the male cohort of an existing database collected between 1993 and 1999 in
greater Milwaukee, to determine the relationship between Free Testosterone levels and Bone
mineral density. Methods: A secondary data analysis of the male cohort of the prospective
study: “Causes of Lean Body Mass Atrophy in Aging Men and Women” was performed. These
were community-dwelling men age 60 and older. Bone mineral density, hormonal
measurements, and dietary intake were measured at 6 month intervals. We studied simple
correlations between free testosterone(FT) and bone mineral density(BMD) at different
study points and we built a mixed model to assess the rate of change of FT and BMD
and determine if there was a relationship between them. Results: We found a decline in
femoral neck BMD, at a rate of 0.0037 grams/cm2/year. The true relationship between
femoral neck BMD and age fits a slightly quadratic model up to age 75. Free
testosterone levels remained stable over 54 months of study. Simple correlations did
not find any significance between FT and BMD at baseline or study end-point or
between the change in FT and change in BMD over the entire 54 months. FT at
baseline did not predict the decline in BMD at the femoral neck. The lag correlations
did not reveal any significance between any of the variable pairs that were studied.
Conclusions: Elderly men have a decline in femoral neck BMD over 54 months of
0.0037 gr/cm2/year (95 % confidence intervals: -0.0046, -0.0029). Free testosterone
does not decrease over time. Free testosterone is not correlated with femoral neck
BMD at baseline or at the study end-point.
148 — PREVALENCE OF OSTEOPOROSIS IN AN OHIO MENNONITE
COMMUNITY
Norman D.E. Raymond, D.O., Physician, Doctors Hospital/OhioHealth, Columbus,
Shalin E. Arnett, D.O., Resident, Doctors Hospital/OhioHealth, Columbus, OH,
Linda Biddle, R.T., R., M., CDT, Radiology Technician, CDT, Osteoporosis Diagnostics &
Treatment Center, Marysville, OH, Frank R. Raymond, D.O., Physician, Marysville OB/
Gyn, Inc., Marysville, OH, James J. Perez, D.O.
The purpose of this study was to evaluate the prevalence of osteoporosis/osteopenia in
postmenopausal Mennonite women. Volunteers within a Mennonite community in Northwest
Ohio were enrolled in this prospective descriptive pilot study. Approximately, 170
participants were weighed and completed a short survey. The survey included medical and
family history, calcium intake, and weight recorded as over or under 127 pounds, as well as
other risk factors. Heel scans were performed on the 170 participants using a Sahara
ultrasound unit. Participants with a T-score of 1.0 SD or less with no risk factors and
participants with two risk factors regardless of their T-scores were offered a Central
DXA on a Hologic Discovery unit. One hundred and seventy women were evaluated,
of which 73 failed the heel screen and 21 demonstrated at least two risk factors.
Ninety-four patients went on to complete the Central DXA evaluation. Sixty-six
percent (62 of the 94) were diagnosed with osteopenia or osteoporosis. Of these, (51
of the 62) had a positive family history (82%). Of the original 170 women studied,
36% (61) illustrated low bone mineral density (osteopenia or osteoporosis). Although
multiple etiologic factors were included in this study, the distinctives of a late
nineteenth century lifestyle combined with significant family history were most
prevalent. Further evaluation of this otherwise understudied subgroup of the
American population would be warranted in light of their extraordinary healthy way
of life.
149 — OSTEOPOROSIS AND HYPOVITAMINOSIS D IN THE LEBANESE
ELDERLY: A POPULATION BASED STUDY
Arabi Asma, Calcium Metabolism and Osteoporosis Program, Depar, Baddoura Rafic,
Department of Rheumatology, Saint Joseph University, Awada Hassan, Department of
Rheumatology, Saint Joseph University, El-Hajj Fuleihan Ghada, Calcium Metabolism and
Osteoporosis Program, Department of Internal Medicine, American University of Beirut
Medical Center
Osteoporosis is a worldwide problem of increasing social and economic importance.
BMD in the Lebanese young and elderly is lower than that of age and gender matched
Western subjects. Hypovitaminosis is also a growing problem, and vitamin D has been
shown to have a salutary effect on BMD and fractures. This study evaluates the
epidemiology of hypovitaminosis D and osteoporosis in the elderly Lebanese. Subjects
were selected from a cohort previously studied (Baddoura et al., 2007). To this date,
195 out of 460 subjects have returned, at 4.2 ± 0.4 yrs of follow up. The
characteristics of the study population are shown in Table 1. Mean serum calcium and
phosphate were normal. The mean average 25-OHD value was 18 ± 11.6 ng/ml in
women and 17 ± 6 ng/ml in men (Table 3). These levels are sub-optimal as defined by
recent criteria where a desirable level is projected at 25-30 ng/ml. Overall, 36.9% of
the women and 18.5% of the men in our study had osteoporosis by WHO BMD
criteria ( T-score d-2.5 SD at either the spine or the hip). The percentage bone loss
experienced by the elderly is 0.19 ± 2.3 %/yr at the lumbar spine; -1.0 ± 1.8 %/yr at
the total hip; -0.64 ± 2.0 at the femoral neck (Table 4). There was no significant
difference in bone loss between genders except at the femoral neck. These primary
data indicate that osteoporosis and hypovitaminosis D are common disorders in the
elderly in our community. Further studies are needed to help contain this epidemic in
the country and region.
26 — 2008 Annual Meeting

150 — PATIENT CHARACTERISTICS ASSOCIATED WITH BONE MINERAL
DENSITY (BMD) RESPONSES TO ALENDRONATE
Erik Dean Swenson, M.D., Rheumatology Fellow, University of Wisconsin, Madi, Mary
E. Elliott PharmD, PhD, RPh, Assistant Professor of Pharmacy, The University of
Wisconsin, Madison, WI, Brooke L. Baltz PharmD, Pharmacy Student, Univeristy of
Wisconsin, Madison, WI, Arthur A. Schuna, M.S. , F.A.S.H.P. , R.Ph., Clinical Professor of
Pharmacy, University of Wisconsin & William H Middleton VA Hospital, Madison, WI,
Karen Elizabeth Hansen, M.D., CCD, Assistant Professor of Medicine, University of
Wisconsin School of Medicine & Public Health, Madison, WI
Some patients experience a decline in BMD despite bisphosphonate therapy. We performed a
study to detect factors associated with decreased BMD despite alendronate therapy. In a
retrospective chart review study, we identified men receiving primary care through one
Veterans Affairs Medical Center who began alendronate between July 2000 and May
2004 for low bone mass. We excluded men receiving primary care elsewhere or taking
alendronate for other indications. Two researchers reviewed each chart and recorded
data using a standardized form. We analyzed data using Pearson s correlation
coefficient, chi-square or Fisher exact test, and t-tests or Wilcoxon tests as appropriate.
We identified 140 men for study inclusion. Their mean age was 70 ± 9 years; 90% were
Caucasian. Any decline in lumbar spine, hip or 33% radius BMD occurred in 41%, 20%
and 42% of men respectively. Using precision errors, significant declines in BMD
occurred in 1%, 9% and 8% of men at the lumbar spine, hip and 33% radius,
respectively. Patient age associated inversely with difference in BMD (D-BMD), with hip
D-BMD (r 0.22, p=0.008). Similarly, body weight associated inversely with spine D-
BMD (r 0.17, p=0.04). Adherence, defined as the medication possession ratio,
correlated positively with spine and hip D-BMD (r=0.22, p=0.01 and r=0.18, p=0.03
respectively). We conclude that certain patient characteristics associate with BMD
declines despite alendronate therapy. In this small study, BMD response showed a
positive association with medication adherence and negative associations with age and
body weight. Larger studies are needed to confirm and extend these findings.
151 — IN VIVO LONGITUDINAL NON-INVASIVE MEASUREMENT OF
CROSS-SECTIONAL BENDING STIFFNESS — A PILOT STUDY OF
TERIPARATIDE THERAPY
Angela M. Cheung, MD, PhD, FRCP(C), CCD, Associate Professor, University Health
Network, University of Toronto, Lianne Tile, University Health Network, University of
Toronto, Heather McDonald-Blumer, Mount Sinai Hospital, University of Toronto,
Moira Kapral, University Health Network, University of Toronto, Claudia Chan,
Farrah Ahmed, Hanxian Hu, Yuna Lee, Anna Sawka, Rowena Ridout
Mechanical Response Tissue Analyzer (MRTA) is a novel and emerging tool that
measures cross-sectional bending stiffness (EI) non-invasively in vivo. In animal studies,
cross-sectional bending stiffness is a strong indicator of whole bone strength. We
conducted a pilot study to prospectively evaluate the changes in EI of the nondominant
ulna before and after teriparatide treatment. These subjects also had routine
BMD measurements by DXA at the spine, hip and forearm on the non-dominant side.
All subjects signed informed consent and the study was approved by the institutional
research ethics board. Sixteen subjects (13 women and 3 men) participated in the
study. Mean age was 62.5 years (range: 43.7 to 83.5). Baseline BMD for lumbar spine,
total hip and 1/3 radius were 0.692 g/cm2 (T-score:-2.2), 0.622 g/cm2 (T-score: -2.5),
0.588 g/cm2 (T-score: -2.2), respectively. On average, these subjects have previously
taken one or more osteoporosis therapies (mostly bisphosphonates) for a mean of 4.4
years prior to starting teriparatide therapy. Mean duration of teriparatide therapy was
10.5 months (range: 5.7 to 18.8 months). Mean percent changes in BMD were 6.3% at
the lumbar spine (p=0.009), -0.6% at the total hip (p=0.65), and 3.5% at the 1/3
radius (p=0.08). Mean EI of the ulna was 16.1 N/mm (range: 2.5 to 30.7) at baseline
and 17.5 N/mm (range: 10.1 to 29.7) at the end of the study, with a mean increase of
45.7% (p =0.26). The intra-operator coefficient of variation for EI was 1.9%. Our study
showed that measuring cross-sectional bending stiffness non-invasively in the clinical
setting is potentially valuable in the assessment of the effect of drug therapy on bone
strength. Future studies that include a larger sample of patients are needed to explore
the clinical utility of this type of measurement.
152 — QUANTIFICATION AND DESCRIPTION OF GASTROINTESTINAL
ADVERSE EVENTS (GI AES) IN PATIENTS SWITCHED FROM BRANDED
FOSAMAX® TO GENERIC ALENDRONATE
Papaioannou Alexandra, Professor of Medicine, McMaster University, Ontario, Canada,
George Ioannidis, Scientist, McMaster University, Ontario, Canada, Daniel Grima,
Scientist, McMaster University, Ontario, Canada, Jonathan D. Adachi, Professor of
Medicine, McMaster University, Ontario, Canada
Generic alendronate has recently been introduced into Canada with increased GI AEs
noted. These occurred in those previously tolerant to branded alendronate (Fosamax).
Thus, this study examined the GI AE profile of patients who were switched from
Fosamax to generic alendronate. All postmenopausal women 50 years of age and older
who were on Fosamax prior to July 2005 and who were subsequently switched to
generic alendronate were included in the study. Patients on Fosamax were on stable
doses that were well tolerated. Generic alendronate was introduced into the health
care system and within 2 months the conversion from Fosamax to generic alendronate
was almost complete. Patients, for the most part, were unaware of the conversion and
believed that they were still on Fosamax. A total of 173 women who were selected
from a single clinic that specialized in treating patients with osteoporosis were
analyzed. The average age of the patients was 68.9 years (9.43) at the approximate
time of switching. Results indicated that following the switch, 16.5% (29/173) of
patients on generic alendronate had a total of 35 GI AEs. Of the 35 GI AEs, most
patients complained about stomach pain (20%; 7/35), nausea (11.4%; 4/35), reflux
(11.4%; 4/35) and GI upset (11.4%; 4/35). In conclusion, generic alendronate may not
be as well tolerated as Fosamax and should not be considered equivalent in all
individuals. This may have implications for treatment adherence and effectiveness.
153 — WEB BASED TRAINING AND CERTIFICATION OF DXA
OPERATORS FOR CLINICAL DRUG TRIALS
Mary E. Sherman, RT, CDT, Clinical Studies Manager, BBDG/UCSF, San Francisco, Eric
Lee, BS, Staff Research Associate, BBDG/UCSF, San Francisco, CA, Lorena Marquez, BS,
Staff Research Associate, BBDG/UCSF, San Francisco, CA, John Shepherd, PhD, Assist.
Professor, Radiology, UCSF, San Francisco, CA
To reduce the error source and variation in measurements acquired in clinical trials
involving multiple study sites, it is common practice to introduce the operators to the
procedures and protocol for the specific study prior to beginning the study. With the
expansion of clinical trials and research throughout the country and overseas
including developing countries, the ability to certify DXA operators for participation
in clinical trials, other than mass meetings or individual site visits which are time
consuming and expensive, has become increasingly difficult. Utilizing Power Point
presentations previously developed for group and individual training sessions, we
developed a secured web based presentation discussing protocols, scan acquisition, and
quality control procedures. Individual ID s and passwords are sent to operators, who
have been identified by the sponsor, to allow them access to the study specific training
website. The protocols are presented in sections followed with a short quiz for each
section which may be answered on line. On completion of the training presentation
and quizzes and a passing score of at least 80%, the QA center certifies the operators
as qualified to participate in the study. The initial application of this website training in
Mexico and countries in Asia has been very well accepted in spite of language
differences. The process has proven very effective, low cost, and manageable.
Consequently, in lieu of group meetings and multi individual site visits, the use of a web
based training module for initial and follow-up training for clinical and research trials
may be appropriate.
— 2008 Annual Meeting 27

154 — A SPONTANEOUS METATARSAL FRACTURE LEADS TO THE
DIAGNOSIS OF CUSHINGS DISEASE
Anne M. Rosenberg, MD, Endocrinologist, Healtheast Care System, St. Paul, MN,
MC Schoeller, Lead Bone Density Technologist, Healtheast Osteoporosis Care,
Woodbury, MN, C. Simonelli, Medical Director HealthEast Osteoporosis Care,
Woodbury, MN
The following case reinforces the importance of a thorough evaluation for metabolic bone
disease in some patients with osteoporosis. A previously healthy 47-year-old pre-menopausal
woman developed a fifth metatarsal fracture while at Tae Kwon Do practice. The fracture was
not precipitated by significant trauma or impact. Review of systems revealed a several year
history of easy bruisability, fatigue, mood swings and rounding of her face. Examination of old
family photographs documented the change in facial fullness but no significant weight gain. A
bone density study revealed low bone mass with Z- scores of -3.6 at the spine and -2.0 at
the total femur. An evaluation for secondary causes of bone loss revealed a 24-hour urine
free cortisol at four times the upper limits of normal. A 1 mg dexamethasone suppression
test failed to suppress her 8 am cortisol level. An adrenocorticotrophin (ACTH) level
of 51 pg/mL suggested ACTH- dependent disease and she was ultimately found to have
a 4 mm pituitary adenoma on MRI. Transsphenoidal resection of the adenoma resulted
in biochemical cure of her Cushing s disease. To improve her bone health, she is
slowing weaning off her glucocorticoid replacement, participating in weight-bearing
activity, and optimizing her calcium and vitamin D intake. Glucocorticoid-induced
osteoporosis was first reported by Harvey Cushing when he described osteoporosis in
patients with high levels of cortisol due to an ACTH-producing tumor of the pituitary
gland. Though pituitary-dependent Cushing s syndrome is quite rare, one must
consider the diagnosis in patients with osteoporosis.
155 — SEVERE METABOLIC BONE DISEASE IN A 76-YEAR-OLD WOMAN
THIRTY-THREE YEARS AFTER BARIATRIC SURGERY
Susan E. Williams, MD, MS, CCD, Director, Center for Nutrition and Metabolic
Medicine, Angelo A. Licata, MD, PhD, CCD, FACN, FACP, FACE, Metabolic Bone Center,
Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic Foundation,
Cleveland, Ohio
Our purpose is to report a case of severe secondary metabolic bone disease diagnosed
thirty-three years after jejuno-ileal bypass (JIB). We present biochemical and DXA
abnormalities in a 76 year-old woman presenting with steatorrhea, fragile bones, renal oxalate
stones, chronic pain, and loss of functional independence 33 years after JIB. A 76-year-old
nonambulatory woman who underwent JIB in 1974 presented to our metabolic bone center
after being found to have hypocalcemia, hypovitaminosis D, hyperparathyroidism, proximal
weakness, and debilitating bone pain. Prior to presentation, the patient had been prescribed
50,000 IU cholecalciferol twice weekly and 1800 mg calcium carbonate daily however the
calcium was discontinued due to dyspepsia. During her initial office visit we recommended
calcium citrate, and 50,000 IU cholecalciferol daily. The cholecalciferol was further
increased to 100,000 IU daily when little improvement in 25-hydroxyvitamin D was
seen after eight weeks. Lab data before and after supplementation are noted in Table 1.
DXA measurements are noted in Table 2. Statistically significant changes in bone
density included an 8.2% decline at the left femoral neck; and a 17.8% increase in the
distal radius attributed to the routine use of free weights. Clinically, the patient
reported decreased bone pain, an ability to ambulate short distances with assistance, a
weight gain of 6 Kg, and no further oxalate stones. We conclude that JIB patients
remain at risk for severe bone disease. Aggressive oral supplementation with calcium
citrate and vitamin D3 is required to restore and maintain normal serum levels and
to prevent further bone loss. References available on request.
156 — TERIPARATIDE [(rh PTH (1-34)] (TPTD) STIMULATES OSTEOBLAST
FUNCTION
Elliott N. Schwartz, MD, Institute Director, Northern California Institute, Dee
Steinberg, Institute Manager, Northern California Institute for Bone Health, Inc.,
Oakland, CA
Teriparatide (TPTD) stimulates osteoblast function. Osteoblast function is a key to
fracture healing and also may be a key to the development of adynamic bone disease
(ABD). Numerous studies have shown increased fracture healing with TPTD in a
variety of experimental models. In these studies, intermittent low dose TPTD increased
callus formation, increased production of bone matrix proteins and increased other
potential mechanisms of fracture healing. There is anecdotal information that TPTD
may enhance fracture healing in humans. We have previously reported (ASBMR 2007,
Poster #M242, Abstract #295) our experience with the use of TPTD in acute
traumatic fractures and in fracture non-unions. We now report our experience with
TPTD treatment in stress fractures and ABD. In the last several years, we have seen 7
patients with a spectrum of stress fractures, from “simple” to “complex.” In some, ORIF
was followed by TPTD; in others, healing occurred spontaneously or with bone growth
stimulation. We also have seen patients with “severely suppressed bone turnover” or
ABD on bone biopsy similar to the “Odvina type patients” (Odvina et al, JCEM, 90:
1294-1301, 2005). Two years of treatment with TPTD did not improve bone turnover
(BTO) or BMD. In another patient without CKD with ABD on biopsy, 13 months of
TPTD did not improve BTO or BMD. In a patient on dialysis with biopsy proven ABD,
prolonged treatment with TPTD did not improve bone status. TPTD may be helpful in
improving healing of stress fractures. Based on only a few cases, with and without CKD,
TPTD did not seem to improve bone status in patients with biopsy proven ABD.
157 — BIOCHEMICAL MARKERS AND BONE HISTOLOGY AMONG
CHRONIC KIDNEY DISEASE PATIENTS
S.S Khan, MD, CCD, Associate Professor, Tufts New England Medical Center, M.R.
Iraniha, Research Assist, Tufts New England Medical Center, Boston, MA, M. Rathore,
Student, Tufts New England Medical Center, Boston, MA
Bone biopsy remained a diagnostic gold standard for renal osteodystrophy (ROD)
among patients with chronic kidney disease (CKD), however, due to invasiveness,
diagnosis of ROD is based on parathyroid hormone level (PTH) alone, which is suboptimal.
In our systematic review we described the distribution of ROD and
correlation of laboratory markers with bone histology in CKD. The articles were
chosen from pub med, published between 1985 and 2007, where bone histology was
given in combination with biochemical markers in CKD. Of 41 we selected articles
which have at least four out of seven laboratory variables PTH, calcium (ca),
phosphorus (P), alkaline phosphatase (ALP), bone alkaline phosphatase (bALP),
osteocalcin (OC) and Vitamin D. We calculated weighted mean for each variable.
Among pre dialysis patients, of total 1316 bone biopsies, 34%, had hyperparathyroid,
19% osteomalacia, and 8% adynamic bone disease. Among dialysis patients, out of 1548
bone biopsies, 43% had hyperparathyroid, 5% osteomalacia and 31% adynamic bone
disease. Among dialysis patients with high turnover when compared with low turnover
serum P, ALP, bALP, OC, and PTH level were significantly higher. Similarly, among pre
dialysis patients serum P, ALP, bAPL, OC, and PTH level were significantly higher. There
was a significant individual variation in bone turnover markers. We concluded that use
of combination of more laboratory markers might be predictive of underlying bone
turnover than PTH or ALP alone. A predictive modeling can be developed to diagnose
underlying rate of bone turnover using laboratory markers. Future studies are
required to test this hypothesis
28 — 2008 Annual Meeting

158 — LONG-TERM EFFECT OF LUMBAR EPIDURAL CORTICOSTEROID
INJECTIONS ON BONE MINERAL DENSITY OF THE LUMBAR SPINE
Sam Suthan, Department of Medicine, Sister’s Hospital of Buffalo, Joseph M. Grisanti,
M.D., Medical Director, Buffalo Rheumatology Associates, Michael W. Grisanti, M.D.,
Buffalo Rheumatology Assoicates, Mary Brennan, Buffalo Rheumatology Associates,
Patricia Daul, R.N., CCRC, James E. Hatem, Kelly Schwab, RT, Fred MacAdam, M.D.
The purpose of this study was to determine the long-term effect of lumbar epidural
corticosteroid injections on bone mineral density (BMD) of the lumbar spine in a prospective
manner. This is a long-term extension analysis of lumbar spine (BMD) on 34 subjects who
received an epidural corticosteroid injection consisting of 80mg of repository
methylprednisolone for the treatment of lumbar spondylosis or lumbar canal stenosis.
All subjects received a baseline lumbar spine DXA before the epidural injection and
then again 6 weeks later. This extension study assesses BMD of the lumbar spine
approximately 3 years post epidural injection. The change of BMD in the study
population over time was compared to the change anticipated in the NHAINES III
database in age and sex matched controls. Twenty-one of the 34 subjects consented to
the follow-up DEXA scan at 3 years. The results indicate that the average decrease in
BMD at 3 years in our subjects was 1.79%. The anticipated decrease in BMD over 3
years in the NHAINES III database for age and sex matched controls was 2.36%.
Statistical analysis using a paired two-sided T-test demonstrates the decline in BMD at
the lumbar spine in subjects seen 3 years after receiving an epidural repository
corticosteroid injection is not statistically different than the anticipated decline seen
with normal aging. We conclude that, other than the anticipated loss of BMD due to
aging, the use of an epidural corticosteroid injection did not result in additional loss of
bone.
159 — IN VITRO AND IN VIVO DIFFERENCES BETWEEN BRANDED AND
GENERIC WEEKLY BISPHOSPHONATE TABLETS
A C Perkins, Academic Medical Physics Medical School University of Nottingham,
P E Blackshaw, Academic Medical Physics Medical School University of Nottingham, UK,
P D Hay, Academic Medical Physics Medical School University of Nottingham, UK,
S C Lawes, Academic Medical Physics Medical School University of Nottingham, UK,
C T Atherton, R J Dansereau
Variation in disintegration times have been reported for generic bisphosphonates. This
could be important for oral bisphosphonates where incomplete swallowing may cause
serious iatrogenic complications for patients on long-term treatment. The in vitro
disintegration of 26 generic alendronate tablets available in Canada, Germany,
Netherlands and the UK was evaluated and compared to the branded product
(Fosamax®). The swallowing of two of the generic alendronate formulations was
compared to risedronate (Actonel®) tablets in 20 subjects with a mean age 62yrs. Tc-
99m labeled tablets were swallowed while monitoring using a gamma camera with
subjects in both an erect and a supine (45o) position. Six of the generic alendronate
tablets had rapid in vitro disintegration times (

162 — BREAKING THE BARRIERS TO BETTER HEALTH IN
OSTEOPOROSIS PATIENTS
Debbie Zeldow, Deputy Director, Alliance for Aging Research
A survey was conducted in order to identify any gaps in communication between women age
50 to 80 and their physicians regarding osteoporosis treatment. This survey, conducted by
telephone in December and January of 2004, included 752 post-menopausal women between
the ages of 50 and 80 with osteoporosis, and 352 primary care and ob/gyn physicians. It
examined attitudes towards living with osteoporosis, prescription medication usage, and
perceptions; as well as gaps in communication between the physician and patient. A physician
and patient guide were created based upon the information received in the survey.
The Alliance found that many patients don t understand the significance of an
osteoporosis diagnosis. Because they often show no symptoms, there is generally a low
osteoporosis treatment compliance rate. 70% of physicians reported lack of
persistence as a problem with osteoporosis medications. For those that do pursue
treatment, most patients reported that their main reasons for taking prescription
medications was their desire to remain healthy and independent, while doctors
believed that fear of bone fracture was their main concern. To effectively treat
osteoporosis, lines of communication between doctors and their patients need to be
improved. Doctors need to talk openly with their patients about the risks of
osteoporosis, and help them find the medication and regimen that best fits their
lifestyle and will facilitate optimal treatment outcomes. By rethinking physician- patient
communication, the patient can better understand the need to follow their physician s
specified treatment, which will help physicians treat their patients to the best of their
ability.
163 — UTILITY OF HEEL DXA IN DIAGNOSING OSTEOPOROSIS
Tamara Vokes, MD, CCD, Associate Professor of Medicine, University of Chicago
The current study examined how well heel DXA (PIXI, GE Medical Systems) diagnosed
osteoporosis in 861 subjects (769 female) referred for central BMD measurement as part of
their medical care. Osteoporosis was defined as BMD T-score at or below -2.5 at central site
or presence of prevalent vertebral fractures on VFA. There was a significant (p-2.5. The primary endpoint was the relative change from baseline (%) in
mean LS BMD at 1 year (intent-to-treat population). Adverse events and safety
laboratory parameters were monitored continuously. All patient received calcium and
vitamin D supplements. A total of 77 women received monthly ibandronate and 83
women received placebo. The subjects who received ibandronate achieved larger
increases in LS BMD after 1 year compared with placebo. At 1 year, the relative mean
change in LS BMD from baseline was 3.6% for women receiving ibandronate and -
0.4% for women receiving placebo (see Figure). The mean relative change in total hip
BMD was 1.5% for women receiving ibandronate and -0.9% in women receiving
placebo. Monthly ibandronate was well tolerated and the incidence of adverse events
was similar between treatment groups. The most common treatment-related adverse
events in patients receiving ibandronate were dyspepsia (5.2%), myalgia (5.2%), and
influenza-like illness (5.2%). Treatment of appropriate patients with monthly
ibandronate therapy may prevent PMO.
30 — 2008 Annual Meeting

167 — MONTHLY IBANDRONATE REDUCES SERUM CTX WITHIN
THREE DAYS OF TREATMENT INITIATION AND MAINTAINS A
MONTHLY PATTERN OF SERUM CTX SUPPRESSION
Stuart S Silverman, Cedars-Sinai Medical Center/UCLA, C Simonelli, MD, Health East
Osteoporosis Care, Woodbury, MN, JA Sunyecz, MD, 3Laurel Highlands Ob/Gyn, Hopwood,
PA, N Santiago, MD, Ponce Gastroenterology Research, Ponce, PR, JD Kohles, PhD, Roche,
Nutley, NJ; G Dasic, PhD, GlaxoSmithKline, King of Prussia, PA; Neil C Binkley, MD, University
of Wisconsin, Madison, WI
The speed of onset and pattern of suppression of the bone resorption marker serum C-
terminal telopeptide of type 1 collagen (sCTX) was evaluated in women with
postmenopausal osteoporosis (PMO) who received once-monthly oral ibandronate. This
randomized, double-blind, placebo-controlled trial enrolled women diagnosed with PMO
within the past 12 months and with ?3 months exposure to daily or weekly
bisphosphonate therapy for 5 years before screening. Patients received once-monthly
ibandronate (150 mg) or placebo for 6 months. sCTX levels were measured at baseline
and after study dose administration on Day 3 (Month 1 only) and Days 7, 14, 21, and
28 (Months 1-6). Participants fasted overnight and blood was sampled at the same
time of day throughout the study. Adverse events were monitored continuously. All
patients were provided calcium and vitamin D supplements. Sixty-seven women were
enrolled in this study; 49 received monthly ibandronate, 17 received placebo, and 1
did not take the study drug. At Day 3, median relative reduction in sCTX from
baseline was 70.2% with ibandronate and 6.0% with placebo (difference equal to
?64.2% [95% CI: ?80.8%, ?46.1%; p

171 — COMPARISON OF VITAMIN D SUPPLEMENTATION REGIMENS
Dessa Gemar, University of Wisconsin Osteoporosis Clinical Research Program,
Abbey Woods, University of Wisconsin Osteoporosis Clinical Research Program,
Jean Engelke, University of Wisconsin Osteoporosis Clinical Research Program,
Diane Krueger, University of Wisconsin Osteoporosis Clinical Research Program,
Neil Binkley University of Wisconsin Osteoporosis Clinical Research Program
Ergocalciferol (D2) is assumed to be less effective than cholecalciferol (D3) in
maintaining serum 25-hydroxyvitamin D [25(OH)D], however, data supporting this
are limited. Additionally, daily treatment adherence is often poor, prompting clinicians
to prescribe once-monthly high-dose D. When dosing monthly, it is logical that trough
25(OH)D measurement is appropriate, however this has not been investigated. As
such, the purpose of this year-long randomized, double-blind trial was to evaluate the
effect of daily (1,600 IU) versus once-monthly (50,000 IU) D2 or D3 dosing on serum
25(OH)D in adults age 65+. Utility of obtaining trough 25(OH)D measurements and
effect of weight and baseline 25(OH)D on response was investigated. Preliminary data
from 32 participants through six months are reported. Baseline mean age was 77
years and mean 25(OH)D was 25.2 ± 3.3 ng/ml; 34% were

175 — AN OBSERVATIONAL COHORT STUDY OF RISEDRONATE AND
ALENDRONATE WITH THE ADDITION OF IBANDRONATE:
EFFECTIVENESS OF BISPHOSPHONATE TREATMENT ON
NONVERTEBRAL FRACTURES
Deborah T. Gold, PhD, Duke University Medical Center, Duke Universtiy, D, Jeff Lange,
Procter & Gamble Pharmceuticals, Mason, OH, Johann D. Ringe, Medical Dept. IV,
Hospital Leverkusen, University of Cologne, Leverkusen, Germany, Abby G. Ableson,
Cleveland Clinic, Cleveland, OH
In a prior observational study of 33,830 women aged 65+ who initiated weekly
bisphosphonate dosing, patients on risedronate had a lower incidence of nonvertebral
fracture during the first year of therapy than patients on alendronate(REAL)1.
Monthly dosing of bisphosphonate became available in 2005. In this study we
compared nonvertebral fracture incidence during the first year of therapy among
patients on monthly ibandronate to patients in the REAL study. The study population
of REAL was identified from health services utilization records between 2002-2004
and included new users of risedronate or alendronate. The current study includes new
users of ibandronate from the same data source. Cox proportional modeling was used
to compare fracture incidence among the 3 patient groups, adjusting for baseline
fracture risk. All 3 patient groups, mean age 75, had similar prevalent fracture status. In
REAL, the nonvertebral fracture incidence in year one of therapy was 1.99% for
risedronate patients and 2.30% for alendronate patients. In comparison, nonvertebral
fracture incidence was 2.79% for ibandronate patients. Relative to ibandronate, the
adjusted relative rate of nonvertebral fracture for risedronate patients was 0.76
(95%CI 0.60-0.96) and for alendronate patients was 0.92 (95%CI 0.74-1.13). These
results do not appear to be explained by baseline differences in fracture risk between
cohorts. As with all cohort studies, interpretation of results is limited by the
nonrandomized study design. In this study, patients on risedronate had a lower
incidence of nonvertebral fractures during their first year of therapy than patients on
ibandronate. 1Silverman OI 2007 18:25
176 — BISPHOSPHONATE THERAPY AND HIP FRACTURES WITHIN THE
RISEDRONATE AND ALENDRONATE (REAL) COHORT STUDY: SUBGROUP
WITH PRIOR FRACTURE
Robert Lindsay, MD, PhD, Helen Hayes Hospital, West Haverstraw, NY, Stuart L.
Silverman, Cedars-Sinai Medical Center, Beverly Hills, CA, Nelson B. Watts, Bone Health
and Osteoporosis Center, Cincinnati, OH, Pierre D Delmas, INSERM Unit 403, Lyon,
France, Jeff L. Lange
In a prior obserservational study of 33,830 women (ages 65 and over) initiating oncea-week
dosing of bisphosphonate, the incidence of hip fracture during the first year of
therapy for patients on risedronate (0.37%) was lower (adjusted rate ratio = 0.57)
than patients on alendronate (0.58%).1 To further assess the homogeneity of this
observation across patients at different levels of fracture risk, we utilized a subgroup
within this study who had a diagnosed fracture in the one year prior to initiating
bisphosphonate therapy. The original study population was identified within records of
health services utilization and included new users of once-a-week dosing of risedronate
or alendronate. In the one year prior to initiating therapy for this population, 6.0%
had a diagnosed nonvertebral fracture, 3.1% had a diagnosed vertebral fracture, and
8.4% (n = 2845) had either fracture - which defined the subgroup for analyses. Cox
proportional hazard modeling was used to compare the incidence of hip fractures
during the first year of therapy. Compared to the original study population, the
subgroup with a fracture prior to initiating therapy was older and had more risk
factors for fracture (table). Within this subgroup, during the first year of therapy, the
incidence of hip fracture for patients on risedronate (0.73%) was lower (adjusted rate
ratio 0.34, 95% confidence interval 0.13 0.92) than patients on alendronate (1.93%).
Regardless of fracture history, patients receiving risedronate had lower rates of hip
fractures during their first year of therapy than patients receiving
alendronate.1Silverman et al. OI 2007
177 — A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
STUDY OF ODANACATIB (MK-822) IN THE TREATMENT OF
POSTMENOPAUSAL WOMEN WITH LOW BMD: 18-MONTH RESULTS
Felicia Cosman, MD, Helen Hayes Hospital, West Haverstraw, NY, Michael McClung,
Oregon Osteoporosis Center, Henry Bone, Michigan Bone and Mineral Center, Nadia
Verbruggen, Merck & Co., Inc., Andrea Rybak-Feiglin, Carolyn daSilva, Arthur Santora,
Avery Ince
Objectives: Cathepsin K, a cysteine protease expressed in osteoclasts, is necessary for
bone collagen degradation. Odanacatib, a selective inhibitor of cathepsin K, has been
shown to rapidly and reversibly decrease bone resorption in both preclinical and
Phase I clinical studies. Materials and Methods: A 1+1 year dose-ranging trial is ongoing
in postmenopausal women with low BMD to evaluate the safety and efficacy of weekly
doses of placebo, 3, 10, 25 or 50 mg of odanacatib on BMD and biochemical indices of
bone turnover. The primary hypothesis for the 1-year extension study was that
odanacatib would increase lumbar spine BMD compared with placebo over 24
months. An interim analysis comparing BMD at 18 months of treatment with that at
baseline was performed. Patients and investigators remain blinded to treatment
allocation. Postmenopausal women (N=399) with BMD T-scores d-2.0 and e-3.5 at
lumbar spine (LS), femoral neck (FN), trochanter, or total proximal femur were
randomized to receive placebo or 1 of 4 doses of odanacatib. Mean age was 64.2 ±
7.8 years. Three hundred twenty women completed the 12-month base study and
entered the 1-year extension. Results: Eighteen months of treatment produced doserelated
increases in BMD from baseline. The 50-mg dose of odanacatib resulted in a
4.8% increase from baseline in lumber spine BMD vs. 0.15% for placebo and a 2.4%
increase from baseline in total hip BMD vs. a 1.2% decrease for placebo. The 50-mg
dose resulted in a 49% reduction in uNTx/Cr vs. 2.3% for placebo and a 9%
reduction in BSAP vs. a 4% increase for placebo. The safety profile of odanacatib was
generally favorable. There were no dose-related trends in any adverse experiences
(AEs). The number of patients who discontinued the study due to AEs was the same
for the placebo and 50-mg groups (9 patients), as was the number who discontinued
due to AEs considered drug-related (4 patients). Rash was reported in 3.8% of those
in the 50-mg arm and in 8.4% of those in the placebo arm. Conclusions: Eighteen
months of odanacatib treatment was generally well-tolerated and increased lumbar
spine and total hip BMD in postmenopausal women with low BMD.
178 — BONE MINERAL DENSITY OF POSTMENOPAUSAL WOMEN
PARTICIPATING IN REGULAR YOGA ACTIVITY
Millie Sweesy-Barger, Department of Kinesiology, CSU Long Beach, Ralph Rozenek,
Ph.D., Department of Kinesiology, CSU Long Beach, CA, Albert C. Russo, Ph.D.,
Department of Physical Therapy, CSU Long Beach, CA, Susan E. Sklar, M.D., Department
of Kinesiology, CSU Long Beach, CA, Alison Wrynn, Ph.D. Department of Kinesiology,
CSU Long Beach, CA
Yoga is a popular form of activity that incorporates various body postures and poses.
Many people who participate believe that yoga will have beneficial effects on bone
mineral density (BMD). However, there is little scientific evidence to substantiate this.
The purpose of this cross-sectional study was to compare measures of BMD in a group
of post-menopausal women who regularly participated in yoga for a minimum of 3
years (Y; n=31) to a group of age-matched non-yoga participants (NY; n=31). Sites
measured for BMD included the AP spine, dual femur, non-dominant wrist, and whole
body. All subjects completed health and activity questionnaires. Data were analyzed
using MANCOVA (p < 0.05). Results showed that body mass (mean +/- sd) in Y (65.4
+/- 10.4 kg) was significantly lower than NY (72.9 +/- 14.3 kg). Percent body fat and
fat mass were also lower in Y (34.3 +/- 7.0%; 22.1 +/- 7.3 kg) than in NY (42.3 +/-
6.6%; 30.3 +/- 10.4 kg). However there were no differences in lean body mass (Y =
40.9 +/- 4.7 kg; NY = 39.4 +/- 4.8 kg). No differences were found in BMD at the spine,
femur, or whole body. Initial analysis indicated that wrist BMD was significantly higher
in NY (0.68 +/- 0.07 g/cm^2) compared to Y (0.64 +/- 0.07 g/cm^2). When covariates
were included in the analysis, no difference in wrist BMD was observed. These
preliminary results suggest that yoga activity may not provide an adequate stimulus to
produce positive effects on BMD.
— 2008 Annual Meeting 33

179 — USAGE OF THE INTERNET TO PROVIDE EVIDENCED BASED
EXERCISE PROGRAMS FOR THE PREVENTION AND MANAGEMENT OF
OSTEOPOROSIS
Adrian Rawlinson, MD, California Pacific Orthopaedics & Sports Medicine, Margaret
Martin, Physical Therapist, Function to Fitness
The purpose of the Program was to design a web site to make Exercise Programs for the
prevention and management of osteoporosis widely available. Targeted users include 1) the
general public and 2) Physicians and Physical Therapists responsible for the prevention and
treatment of osteoporosis. An online fracture risk and exercise/activity assessment
software tool assigns the appropriate Exercise Program based on information
provided by user. The Authors designed and developed nine separate Exercise
Programs based on risk fracture and current exercise/activity level. Each of the nine
Programs contain exercises for posture, balance, strength, cardiovascular, and flexibility.
In addition to the Exercise Programs, additional information on recommended ways
to perform daily activities, fall prevention strategies, fracture risk reduction strategies,
proper nutrition for bone health, and medical treatments for osteoporosis is also
provided. In May 2007, the Authors launched the web site. Results include: 1) Patients,
Physicians, Physical Therapists and other health care clinicians have been actively using
the site. 2) Persons concerned with their bone health now have easy-to-use, anytime
online access to evidence-based Exercise Programs for the prevention and
management of osteoporosis. 3) Persons receive assessment of fracture risk. 4)
Clinicians receive access to comprehensive Exercise Programs and current practices,
nutritional guidelines and medical treatments in the area of osteoporosis. Conclusion:
The site is the only internet resource with comprehensive Exercise Programs
specifically for the prevention and treatment of osteoporosis and has been used
extensively by both clinicians and patients.
180 — VERTEBRAL FRACTURE RISK IS REDUCED FOR WOMEN WHO
LOSE FEMORAL NECK BONE MINERAL DENSITY DURING
TERIPARATIDE TREATMENT
Nelson B. Watts, MD, CCD, Director, University of Cincinnati Bone Health and
Osteoporosis Center, Paul D. Miller, MD, Colorado Center for Bone Research,
Robert Marcus, MD, Eli Lilly & Company, Peiqi Chen, PhD, Eli Lilly & Company,
Jody Arsenault, PhD (Eli Lilly) Kelly Krohn, MD (Eli Lilly)
Measuring bone mineral density (BMD) is a commonly-accepted way of monitoring
response to therapy, and loss of BMD is sometimes viewed as a therapeutic failure. In
the Fracture Prevention Trial (FPT) most women treated with teriparatide (TPTD)
showed a gain in lumber spine BMD at 1yr. However, some women had no gain or loss
in hip BMD at 1yr (Gallagher et al., 2006). The objective of this analysis was to test the
hypothesis that women who received TPTD and lost femoral neck (FN) BMD at 1yr
would, nevertheless, benefit from treatment, compared with placebo (PL). Using data
from the FPT, we compared risk reductions of new vertebral fractures with various
ranges of change in FN BMD at 1yr. At baseline women were randomized to PL, TPTD
20 or 40¼g/day by injection. FN BMD was measured at baseline and 12 months. New
vertebral fractures were assessed by lateral spine radiographs at baseline and study
endpoint. Significantly fewer women lost more than 4% FN BMD at 1yr in the TPTD
group (82/816=10%) compared to PL (61/400=15%). Women treated with TPTD who
lost more than 4% FN BMD at 1yr had a vertebral fracture risk reduction of 89% [RR
0.11(95 CI, 0.03 to 0.45)] compared to PL. Vertebral fracture risk reduction relative
to PL was consistent across a range of change in FN BMD at 1yr (interaction p
value=0.40). Women who received TPTD and lost FN BMD at 1yr still benefit from a
substantial reduction in risk of vertebral fracture compared to placebo.
181 — RISEDRONATE SHOWS CONSISTENT REDUCTION OF THE RISK
OF NEW VERTEBRAL FRACTURES OVER THREE YEARS IN PROTON
PUMP INHIBITOR (PPI) AND H2-RECEPTOR ANTAGONIST (H2RA) USERS
Robert Lindsay, MD, PhD, Helen Hayes Hospital, West Haverstraw, NY, Jay L.
Goldstein, Department of Medicine, University of Illinois at Chicago, Illinois, Xiaojie
Zhou, Procter & Gamble Pharmaceuticals, Mason, OH, Christian Roux, Hospital
Cochin, Dept. Rheumatology, Paris, France, Andreas Grauer
Recently, the question was raised whether use of PPIs or H2RAs could interfere with
efficacy of bisphosphonates. In this retrospective analysis, we investigated whether
concomitant use of PPIs or H2RAs affected the efficacy of risedronate in reducing the
risk of new vertebral (Vert)-fractures. Intent-to-treat subjects (w/paired evaluable
spinal-radiographs) from 3 phase-III risedronate fracture trials were included. Subjects
were classified as PPI or H2RA users if they used either at any time during the trial.
Endpoint was time to 1st Vert-fracture; time-to-event methodology was used (Kaplan-
Meier and Cox regression) stratified by trial, adjusting for the number of prevalent
Vert-fractures. Of 5454 subjects, 1276 (23%) used PPIs or H2RAs. At baseline, PPI or
H2RA users and non-users were similar in age, BMD, BMI and prevalent Vert-fracture
history. However, PPI or H2RA users had a higher incidence of upper-gastrointestinal
(UGI) disease and more significant comorbidities. Regardless of PPI or H2RA use,
compared to placebo, risedronate significantly (p 0.698). In PPI and
H2RA users we observed higher incidence of UGI-AEs compared to non-users (257%
increased risk 95% CI 225-293%, p0.562). It has been hypothesized that PPIs or H2RAs may decrease the absorption
of calcium or bisphosphonates. Within the limits of these clinical trials, this study did
not demonstrate an influence of PPI or H2RA use on risedronate efficacy.
182 — NEW MEASURING ‘¡†”•”œ’ OF BMD
Antonio Bazarra-Fernandez, Juan Canalejo University Hospital Trust
Bone is a structure having an irregular shape at all scales of measurement and with
trabecular anisotropy. Cortical bone properties constitute another bone system with
microsystems, isotropy and anisotropy and variety of cross-section. DXA has served as
a fit surrogate for measuring bone strength. By reason of the two-dimensional nature
of DXA, assumptions must be made regarding the tridimensional nature of the bones,
dealing with an inference problem. The main limitation for a proper inference is that
only 2d information is got from detectors, and therefore all 3d information is lost, as
it is integrated out due to the nature of detector. It is necessary to be very carefull
when using models for data inference, because we obviously will never know the
underlying truth contained in the data. Therefore, it is tried to regain some
information about the third dimension by building a model of the bone, which
assumes axial symmetry and asymmetry. By using a model, to be arranged the
parameter of this model in such a way that they best fit the data, so it is only gained
information about how good the model can explain the data, but it is not gotten any
information of how good this model actually is, and maybe there is a much better
model. It is very difficult to make good inference of the bone strength. So, a
mathematical, physical and physiological 5-dimensional model must be developed in
order to gauge bone properties and to create a new measuring À±Á¬´μ¹³¼± of BMD.
34 — 2008 Annual Meeting

183 — DIFFICULT TO DEAL WITH OSTEOPOROSIS
Antonio Bazarra-Fernández, Juan Canalejo University Hospital Trust,ObGyn cons
Issues: There is a problem of osteoporosis in positive HIV persons. Bone disorders have
emerged as complication for adults and children, offsetting any quality-of-life advantages
gained by current use of antiretroviral. There is conflicting evidence on which specific
drug classes are more likely to. But the problem is measurement of BMD. Description:
So, to measure strength bone involve a great deal to cope with. DXA has served as a
fit surrogate for. By reason of the two-dimensional nature of DXA, assumptions must
be made regarding the tridimensional nature of the bones involving a great deal to
cope with. Lessons learned: Therefore it is deduced, that this method seem to be very
sensitive to error, and it is necessary to know how to deal with these errors, especially
with the systematic errors introduced by using a parameterized model. Significant
discordance in longitudinal changes in BMD was observed. Next steps and conclusions:
So, a mathematical, physical and physiological 5-dimensional model must be developed
in order to gauge bone properties including geometry (2-dimensional DXA) , space,
time, motion and stress with some portable-computer-devices in base of mouse models
for quantitative trait loci (QTL) analyses. In the field of skeletal micro-structure, ¼CT
has proven to be an invaluable imaging tool and the use of high resolution peripheral
quantitative computed tomography (HR-pQCT), in vivo nanotomography and
nanofractography, must be considered for studies of bone disease and its treatment,
and here must stay new university research methods for new times and new
pathologies.
184 — INTRA-OPERATOR PRECISION FOR IN VIVO HIGH RESOLUTION
PQCT SCANS
Angela M. Cheung, MD, PhD, FRCP(C), Associate Professor, University Health
Network, Claudia Chan, Osteoporosis and Women’s Health Programs, University Health
Network, Farrah Ahmed, Osteoporosis and Women’s Health Programs, University
Health Network, Hanxian Hu, Osteoporosis and Women’s Health Programs, University
Health Network, Alice Demaras, Irene Polidoulis, Lianne Tile
High resolution peripheral quantitative computed tomography (HR-pQCT) is a novel
and emerging technique for assessing bone geometry and microarchitecture noninvasively,
however, little is known about its intra-operator reliability. We prospectively
recruited 31 subjects for scanning of the radius and tibia on the Xtreme CT (Scanco,
Sweden) according to standard protocol by one operator. These subjects were repositioned
and re-scanned by the same operator on the same day. Informed consent
was obtained prior to any study procedures, and the study was approved by our
institutional research ethics board. Twenty-five women and six men participated in the
study. Two of them only had one site scanned. Mean age was 42.4 years (range: 20-69).
The root-mean-square coefficients of variation (and least significant change) for the
radius and the tibia were: total volumetric BMD 0.52% (4.9 mg/cm3) and 0.23% (2.1
mg/cm3), cortical volumetric BMD 0.46% (10.9 mg/cm3) and 0.19% (4.8 mg/cm3),
trabecular volumetric BMD 0.70% (2.8 mg/cm3) and 0.40% (1.9 mg/cm3), outer
trabecular volumetric BMD 0.63% (3.9 mg/cm3) and 0.44% (3.0 mg/cm3), inner
trabecular volumetric BMD 0.84.% (2.3 mg/cm3) and 0.35% (1.2 mg/cm3), cortical
thickness 1.33% (0.029 mm) and 0.50% (0.017 mm), trabecular thickness 4.55%
(0.009 mm) and 3.73% (0.008 mm), trabecular number 4.78 % (0.252 mm-1) and
4.08% (0.196 mm-1), trabecular separation 4.83% (0.063 mm) and 4.08% (0.062 mm-
1); BV/TV 0.71% (0.002) and 0.37% (0.001); and Tb. 1/N. SD 4.90% (0.023 mm) and
3.34% (0.020 mm). In summary, volumetric BMD parameters have excellent precision,
similar to those for areal BMD measurements by dual energy X-ray absorptiometry,
whereas geometric parameters have higher variation. Observed changes in geometric
parameters over time will need to be interpreted with this in mind.
185 — PHANTOMLESS QCT STUDIES POSSIBLE ADVANTAGES FOR
REDUCED PATIENT DOSE
David J. Goodenough, Professor of Radiology, The George Washington University,
William S Bonde
Purpose: This paper will study potential dose reduction by using phantomless
approaches compared to phantom based approaches for bone mineral density (BMD)
determination when used in conjunction with CT dose modulation techniques.
Method/Material: Dose modulation techniques react to the net signal reaching the
detector, therefore any object, such as an external bone mineral density phantom
placed the x-ray source and the detector may result in extra radiation on the
phantom side of the scan. BMD studies can, however, be performed with phantomless
techniques (utilizing in vivo reference samples of muscle and fat), whereby no external
phantom is necessary. The dose levels from the phantomless technique for bone
mineral determination are compared to dose levels from phantom based techniques.
Anthropomorphic phantoms were scanned at the same nominal various techniques
suggested for bone mineral density studies, with and without bone mineral phantoms.
Surface dose measurements were made with TLD s calibrated for the energy used in
the bone mineral study protocols. Other dose changing techniques were studies
including partial scans and alternate kVp s. Relative dose data is shown comparing
phantomless and phantom based methods. Results: The data show a significant surface
dose increase requirement for BMD phantom based techniques compared to
phantomless techniques for BMD studies, when used in conjunction with dose
modulation techniques. The dose increase will depend on the body shape and size. This
increase is most likely due to the increased mA required by the extra attenuation of
the x-ray beam by the external phantom. Conclusions: Dose increases may be
required by the use of external phantoms compared to phantomless techniques. This
increase may be important in screening approaches where dose levels are of particular
concern in CT based bone mineral studies.
186 — PHANTOMLESS METHODS FOR CALIBRATION OF QCT FOR HIP
STUDIES
David J. Goodenough, Professor of Radiology, The George Washington University,
William Bonde
Purpose: This paper will investigate the use of phantomless calibration techniques in
bone mineral density (BMD) for hip QCT studies. Method/Material: Currently
phantomless techniques using internal reference tissues are used to calibrate CT values
derived in bone mineral density (BMD) studies of the spine. These approaches use
internal reference tissue such as muscle and fat instead of systematic samples of a
known reference material (e.g. hydroxyapatite (HA) and other water equivalent
materials) placed external to the body. The complexity and size of the human hip and
surrounding scan area (bone, muscle, tissue, and air) particularly impose significant x-
ray spectral changes depending on the location within the CT scan of the femur. This
may be quite different than in the location of externally imposed phantoms. This
causes a potential problem in using calibration data from external phantom to
calibrate values such as BMD reading located in the femur. This spectral mismatch
paper shows the extension of the internal reference tissue technique to BMD by using
tissues such as muscle and fat. Differences in results are compared and contrasted by
internal and external reference techniques for BMD hip studies. Results: Significant
changes in derived BMD scoring data result from using internal vs. external calibration
phantoms. The spectral mismatch associated with the use of external phantoms may be
a problem for BMD by minimizing location dependent spectral mismatches near the
measurement area. Conclusions: Use of internal references for calibration may provide
significant improvements in BMD studies of the hip.
— 2008 Annual Meeting 35

187 — UNCERTAINTY IN INTERPRETATION OF T-SCORE AND Z-SCORE
IN BOTH QCT AND DXA WITH BONE MINERAL STUDIES
David J. Goodenough, Professor of Radiology, The George Washington University,
William S Bonde
Purpose: This paper will reinforce caution in interpreting bone mineral density (BMD) T-score
(the number of standard deviations (SD) above or below the average value in young adults)
and Z-scores (the comparative data for age matched results) in both spine and hip scanning.
Problems of portability will also be reexamined. Method/Materials: Z-scores and T-scores
have great practical appeal especially for the referring physician. WHO has defined
osteoporosis in terms of BMD values where a normal bone mass is designated as a T-score
no lower than -1, and osteoporosis is defined as a BMD value lower than -2.5 (i.e. a
value more than 2.5 standard deviations (SD) below the young age bone mass). Z-
score and T-score are influenced by the choice of normative data base which includes
the SD of the reference population. Also T-score is influenced by the reference age of
the “young age” normal. There is also a lack of portability between QCT scores and
methods, and DXA scores and methods. The reasons for this range from the
measurement of trabecular bone values of QCT compared to the integrated cortical
and trabecular bone of DXA. Several different normative data bases will be examined
from the U.S.A., Europe, and Iceland which show difference in resulting T-Score and Z-
score. Changes with an evolving database (such as UCSF) overtime, will be discussed
along with changes in derived Z & T-Scores. Various databases and selection of
reference “young age” is reviewed, and resulting Z & T-scores compared. Cross
comparisons with DXA is also examined. Results: T & Z-scores are shown to be
dependent on the selection of QCT vs. DXA, location (spine, hip, etc), normative
database and reference age. Typical variations are on the order of ± one unit of T-
score, and can range even higher. Conclusions: Although T & Z-scores from different
databases have the same general trends, but absolute values differ. The important
variable to monitor when assessing interval change is the difference between
measurements, rather than the absolute T or Z-score.
188 — SHORT-TERM PRECISION OF PERIPHERAL QUANTITATIVE
COMPUTED TOMOGRAPHY FOR HARD AND SOFT TISSUE
MEASUREMENTS AT MID-SHAFT AND DISTAL REGIONS OF THE TIBIA
Kyle W. Creamer, BS, CCD, Graduate Student, Rradiology Ttechnician, Virginia Tech,
Katrina L. Butner, Graduate Student, Radiology Technician, Virginia Tech, Blacksburg, VA,
William G. Herbert, Professor, Radiology Technician, Virginia Tech, Blacksburg, VA
The pQCT is a novel instrument used for determining volumetric bone density and
exploring other parameters of hard and soft tissues of the limbs. The purpose of this
study was to determine the coefficient of variation (CV) within our lab for various
regions of interest (ROI) for the Stratec XCT3000 pQCT scanner. The non-dominant
lower leg of 22 pre-menopausal women with widely varying physical activity habits
(Mean age ± SD 39.8 ± 4.6 yr, BMI = 25.4 ± 6.6 kg/m2) were scanned on 3 nonconsecutive
days using the system s TIBIA4S mask to obtain data at the 4 and 66% loci,
from the distal end of the bone. Analyses were made using the TIBIA4S macro, supplied
by the manufacturer, and the CALCBD and CORTBD functions. CVs were calculated
with the ISCD Advanced Precision Calculating Tool obtained from their website (http:/
/www.iscd.org/visitors/members/securefile.cfm?fileID=30). CVs for area and density
measures of cortical tissue ranged from 0.5 to 2.7% and for trabecular tissue from 1.8
to 8.0%. CVs for areal and density measures of soft tissues (marrow, muscle, fat) ranged
from 1.7 to 13.1%. With the exception of the marrow density from the TIBIA4S macro
at 66%, acceptable precision with the pQCT was achieved in our setting for the
conditions specified. These findings suggest potential for use of the pQCT in crosssectional
or short-term serial studies of humans in which hard and soft tissue features
of the leg may be of special interest.
189 — OVERWEIGHT CHILDREN HAVE INCREASED TIBIA BONE
DENSITY AND BONE STRENGTH ATTRIBUTABLE TO INCREASED
MUSCLE MASS
Donna Paulhamus, MS, RD, CDT, Program Coordinator, Gastoenterology,
Hepatology and Nutrition, Mary Leonard, MD, MSCE, Associate Professor of Pediatrics
and Epidemiology, Division of Nephrology, The Children’s Hospital of Philadelphia,
Philadelphia, PA, Nicolas Stettler, MD, MSCE, Assistant Professor of Pediatrics and
Epidemiology, Division of Gastroenterology, Hepatology and Nutrition, The Children’s
Hospital of Philadelphia, Philadelphia, PA, Babette Zemel, PhD, Research Associate
Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The
Children’s Hospital of Philadelphia, Philadelphia, PA
Pediatric DXA studies report conflicting results regarding the effect of obesity on
bone density. However, greater fracture rates among obese children have been
reported. We used peripheral quantitative computed tomography (pQCT) to
determine the effect of obesity on bone density and strength of the tibia. 610 children,
ages 5 to 18 years were enrolled. Trabecular and total volumetric BMD (3% site), and
cortical thickness (crt_thk), section modulus (sect_mod) at the 38% site were
measured. Muscle and fat area were assessed at the 66% site. pQCT measures were
converted to gender and race-specific Z-scores. Subjects were classified as healthy
weight (BMI95th%, n=62) groups. Regression analysis was used to evaluate the effects of
obesity on pQCT Z-scores, adjusting for height Z-score, puberty status, and body
composition (muscle and fat area Z-scores). Overweight and obese groups had
significantly increased values for all pQCT outcomes compared to the healthy weight
group (p

191 — PHYSICAL ACTIVITY RELATIONSHIPS WITH PQCT FAT &
MUSCLE PARAMETERS
Katrina Butner, Graduate Student, Radiology Technician, Virginia Tech, Kyle Creamer,
Graduate Student, Radiology Technician, Virginia Tech, Blacksburg, VA, William Herbert,
Professor, Radiology Technician, Virginia Tech, Blacksburg, VA
Peripheral quantitative computed tomography (pQCT) is a novel technology for
exploring soft tissues of the limbs, while planar DXA is a conventional means for
evaluating total and central body fat. We examined variation in fat depots and muscle
area of the non-dominant foreleg, using pQCT, and total and central fat, using DXA, in
relation to ambulatory activity by pedometer step count (PA) in 22 pre-menopausal
women with widely varying physical activity habits (Mean age ± SD 39.8 ± 4.6 yr, BMI
= 25.4 ± 6.6 kg/m2). For the pQCT measurements, muscle and fat cross-sectional areas
were assessed at a point 66 percent from the tibial distal end. Inter-correlations were
performed between fat and muscle scores, after normalization for BMI, and also with
PA (see Table). Both total body fat and central fat had moderate-high associations with
all other measures of interest, with the exception of subcutaneous and total fat at 66%,
which were unrelated to central fat. PA related significantly to muscle area (r=0.58,
p65)
followed on average for 5.5 years after a baseline hip QCT scan. FE analyses of the
QCT scans were performed (n=250 total, 40 with fractures), blinded to fracture status,
to simulate a sideways fall and in vivo loads were estimated from mass and height data.
Cox proportional hazards regression models were used to compute the hazard ratio
(HR) per standard deviation (SD) change in FE outcome after controlling for age,
study site, body mass index (BMI), and areal BMD (by DXA). The HR per SD change in
FE-strength, load-to-strength ratio, and BMD were highly significant before and after
adjusting for age (Table). When additionally adjusted for BMD (and study site and BMI,
which had little effect), the HR for the load-to-strength ratio remained statistically
significant. These results provide unique insight into hip fracture etiology and
demonstrate the clinical potential of such a biomechanical approach to the assessment
of hip fracture risk.
193 — THE EFFECT OF INCLUDING QUS ASSESSMENT IN FRACTURE
RISK PREDICTION MODELS FOR OLDER MEN AND WOMEN: THE EPIC-
NORFOLK COHORT STUDY
Alireza Moayyeri, PhD student in Epidemiology, Department of Public Health and
Primary Care, Stephan Kaptoge, Department of Public Health and Primary Care,
University of Cambridge, Robert N Luben, Department of Public Health and Primary
Care, University of Cambridge, Sheila Bingham, Department of Public Health and
Primary Care, University of Cambridge, Nicholas J Wareham, Jonathan Reeve,
Kay-Tee Khaw
The role of quantitative ultrasound (QUS) in clinical practice is still debatable.
Although QUS is correlated with BMD and bone structure, whether QUS predicts
fractures independently of BMD is unclear. We examined this in a sample of men and
women in the European Prospective Investigation into Cancer (EPIC)-Norfolk who
had both heel QUS and hip DXA between 1995 and 1997 and were followed for any
incident fracture up to March 2007. From 1,454 participants (701 men) aged 65-76
years at baseline, 79 developed a fracture over 15,567 person-years of follow-up. In
sex-stratified Cox proportional-hazard model including age, total hip BMD, height,
weight, history of fracture, smoking, and alcohol intake, BMD was significantly associated
with fracture risk (RR=0.44 per SD; 95%CI=0.33-0.58). After inclusion of heel
broadband ultrasound attenuation (BUA) into the model, both BMD (RR=0.52 per
SD; 95%CI=0.39-0.70) and BUA (RR=0.64 per SD; 95%CI=0.48-0.86) had significant
association with fractures. Global measures of model fit, area under ROC curve, and
Hosmer-Lemeshow statistic showed superiority of the model including BUA. We further
calculated exact 10-year absolute fracture risk for all participants and categorized
them in groups of

195 — EFFICACY OF GH-TREATMENT ON BMD CHANGES IN
CHILDREN WITH GH-DEFICIENCY, FOLLOWED FOUR YEARS BY
DIGITAL X-RAY RADIOGRAMMETRY vGROWTH
Corina Galesanu, Professor of Endocrinology, University of Medicine, Mihail Romeo
Galesanu, Centre of Radiology and Imaging Diagnosos, Iasi, Romania
Growth hormone (GH) has an essential role in bone mass accumulation and reaching
a normal peak bone mass. Digital X-ray Radiogrammetry (DXR-BMD) is an efficient
clinical method of estimating BMD. We purposed to follow the BMD in children with
isolated GHD under GH replacement therapy using DXR-BMD. Twenty-seven GHD
children: 7 girls and 20 boys vs 10 normal children were evaluated. The mean age at
the initiation therapy was 8.4 years for girls and 10.7 years for boys. No puberty on
set when therapy was initiated. The treatment was found in 0.03 mg/kg body weight/
day Somatropin. For the girls, growth delay was SD: -3.0±0.2, bone age retardation: -
2.4±0.4 years, mean GH level 1.32μUI/ml, GH after insulin stimulation: 5.08μUI/ml,
IGF1 basal level: 70ng/ml. After the treatment the mean height gain was 29.84 cm. The
mean of bone mass accumulation determined DXR-BMD was 0.032±0.2g/cm2/year vs
control group 0.054±0.8g/cm2/year. Mean level of IGF1 was 685.5 mg/ml. For the
boys growth delay was SD: -3.5±0.2, bone age retardation: -3.2±0.4 years, mean GH
basal level 0.6μUI/ml. GH after stimulation: 3.4 μUI/ml, mean level of IGF1 67.02 ng/ml.
After the treatment the mean level of IGF1 was 600.7 ng/ml, the height mean gain was
28.5 cm. The mean of bone mass accumulation was 0.034±0.2 g/cm2/year vs control
group 0.047±0.2 g/cm2/year. At two boys with without treatment the DXR-BMD
rested unmodified after one year. In our series of children the bone mass increases
significantly during rhGH-therapy. The treatment should be continued after the end of
linear growth for attain peak bone mass during adulthood.
196 — BONE MINERAL DENSITY IN UKRAINIAN WOMEN
Vladyslav Povoroznyuk, Institute of Gerontology AMS Ukraine, Ukrainian Sc, Nataliya
Dzerovych, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre
for the Problems of Osteoporosis, Tatyna Karasevskaya, Institute of Gerontology AMS
Ukraine, Ukrainian Scientific-Medical Centre for the Problems of Osteoporosis
Objective.The aim of this study were: to determine spine, femoral and radial BMD for
a representative sample of healthy women of Ukrainian female descent, to determine
the effect of age, height and weight on BMD, and to compare these results with those
from a large USA/Northern Europe and US/European reference sample. Materials and
methods.The research was conducted at the Ukrainian Scientific-Medical Centre for
the Problems of Osteoporosis, and included 353 women aged 20-79 years.
Conventional BMD measurements of the spine (L1-L4 in the anterior-posterior
position), proximal femur (neck, Ward’s triangle and trochanter regions) and radial
shaft (33% site) were determined by DXA using a densitometer Prodigy (GE Medical
systems). Results. Age-related changes in BMD were similar in form to those of USA/
Northern Europe and US/European reference data. However, BMD of spine for
subjects of 50-59 years in our sample were lower than published values. Regression
analyses showed that weight was a significant predictor of female spine and femur
BMD for both the premenopausal and postmenopausal decades. Age was a significant
predictor of female spine BMD in the 50-79 year age. The prevalence of osteoporosis
and osteopenia for female subjects was 11% at the femur neck, and 20% and 24% at
the spine and radial shaft respectively. Substantially lower prevalence of osteoporosis of
lumbar spine in Ukrainian population, based on the WHO criteria, was established in
comparison with US/European reference values. Conclusion.Thus, standardizing of
BMD measurements by DXA through the appropriate use of population-specific
reference values is recommended to improve the quality of medical care provided in
relation to the prevention and treatment of female subjects who are at risk as for
osteoporosis or are already osteoporotic.
197 — TOWARDS AN UNDERSTANDING OF THE MECHANISM OF
FEMUR STRENGTH IMPROVEMENT BY ALENDRONATE IN
POSTMENOPAUSAL WOMEN
Thomas J. Beck, Associate Professor, Radiology, Johns Hopkins Univ, J. Cauley,
Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, H. Wang,
Merck Research Laboratories, Rahway, NJ, A. DePapp, Merck Research Laboratories,
Rahway, NJ, K. Ensrud, Endocrinology, Minneapolis VA Medical Center, Minneapolis, MN,
Purpose: Examine the effect of Alendronate(ALN) on bone geometry parameters
separate from its mineralization effects. Methods: Compared differences in changes in
geometric parameters with ALN treatment as defined by 2 methods in 803
postmenopausal women with low bone mass (400 on placebo (PBO) and 403 treated
with ALN 5-10 mg/d) in the FIT trial. Method 1 derived from Hip Structure Analysis
(HSA) assumed a fixed mineralization and Method 2 utilized cortical margin
dimensions reliable in only thick cortex regions, but did not require a mineralization
assumption. Results: Annual rates of change after 36 months in bone cross section
analysis (CSA), section modulus, mean cortical thickness and buckling ratio for the two
treatment groups by both methods are shown in the Figure. With PBO, mean rates of
change in section modulus, cortical thickness and buckling ratio as defined by both
methods were similar, although the increase in CSA was greater using method 2. With
ALN, average rates of change in CSA were similar using both methods, but rates of
change in section modulus, cortical thickness, and buckling ratio were smaller in
magnitude using method 2. Except for Method 2 CSA, differences in rates of change in
parameters between ALN and PBO reached significance, irrespective of method (p<
0.05). Conclusions: ALN treatment appears to improve femur shaft geometry
independent of tissue mineralization effects, but geometric improvement is
overestimated by 50-75% if mineralization effects are not considered. Bone strength
improvement by ALN appears to combine geometric changes with greater tissue stress
resistance.
198 — AGE-DEPENDENT FEATURES OF BONE TISSUE STATE IN
UKRAINIAN MEN
Vladyslav Povoroznyuk, Institute of Gerontology AMS Ukraine, Ukrainian Sc, Vladymyr
Vayda, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre for
the Problems of Osteoporosis, Tatyna Orlyk, Institute of Gerontology AMS Ukraine,
Ukrainian Scientific-Medical Centre for the Problems of Osteoporosis, Nataliya
Dzerovych, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre
for the Problems of Osteoporosis, Yugen Kreslov, Institute of Gerontology AMS
Ukraine, Ukrainian Scientific-Medical Centre for the Problems of Osteoporosis
This research was aimed to studying the age-dependent peculiarities structuralfunctional
state of bone mass in Ukrainian men. Object. 1200 men are inspected in age
from 20 to 88 years ((“±m): age - 54,1±0,5 years; height - 1,74±0,003 m; weight -
81,6±0,4 kg) were examined and divided into the following age-dependent groups: 20-
29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89 years old. Methods. The structuralfunctional
state of bone mass was determined using ultrasound densitometry with use
of “Achilles+”. Results. Mineral density of bone in dependence on age are presented in
table. Notes: results are represented as “ ± m, BMI - body mass index, SOS speed of
sound, BUA broadbound ultrasound attenuation, SI stiffness index. With age the
gradual diminishing of indexes of the structurally-functional state of bone fabric is set
at men. The reliable decline of indexes of SOS and SI is observed at men after 50 years,
and reliable decline of BUA - at men more senior 70 years. Age had a rather weak
negative impact on SI described by a linear model (SI=108.7-0.26*Age; r= -0.25. t=8.9.
p

199 — STRUCTURAL-FUNCTIONAL STATE OF BONE LOSS OF THE
POSTMENOPAUSAL WOMEN WITH VERTEBRAL FRACTURES
Vladyslav Povoroznyuk, Institute of Gerontology AMS Ukraine, Ukrainian Sc, Nataliya
Grygoryeva, Institute of Gerontology AMS Ukraine, Ukrainian Scientific-Medical Centre for
the Problems of Osteoporosis
This research was aimed at studying the bone tissue state among women with vertebral
fracture with aid of the ultrasound densitometry method. The total of 71 postmenopausal
women 50 74 years old having vertebral fracture in their anamnesis (VF) were examined by
ultrasound bone densitometer (“Achilles+”) and X-ray absorptiometry (“Osteolog”). The
control group included postmenopausal women without any osteoporotic fractures in their
anamnesis (CG), being standardized by age, BMI, etc. The speed of sound (SOS, m/s),
broadband ultrasound attenuation (BUA, dB/MHz) and a calculated “Stiffness” index
(SI, %), T and Z-range were measured. Results. The main risk factors for the
osteoporotic vertebral fracture turned out to be a menarche after 15 years, an early
and late menopause. All indexes of ultrasound densitometry in postmenopausal women
were significant lower compared the data of healthy patients during all
postmenopausal period (Tabl.1). The ultrasound parameters were veritably lower
among of all postmenopausal women with vertebral fracture than among control
group (SOS: 1525,5±2,0 and 1498,0±4,0 m/s, p < 0,05; BUA: 107,3±0,7 and 99,5±1,4
dB/MG, p < 0,05; SI: 78,6±0,9 and 65,9±1,9 %, p < 0,05; all values are the mean ±
standard error). Tab. 1. Structural-functional state of bone mass in postmenopausal
women in depend of duration of postmenopausal period and vertebral fractures. In
summary, ultrasound densitometry is an effective screening method to reveal the
women of risk group having future osteoporotic vertebral fracture in postmenopausal
period.
200 — OSTEOPOROSIS BELIEFS AMONG CHINESE IMMIGRANTS IN
CHINATOWN, CHICAGO
Susanna Tan, Medical Student, Bone Health and Osteoporosis Center, Jessica Eng, BA,
Medical Student, Feinberg School of Medicine, Northwestern University, Han-Jo Ko, MS,
Medical Student, Feinberg School of Medicine, Northwestern University, Amy Yau, BS,
Medical Student, Feinberg School of Medicine, Northwestern University, Beatrice
Edwards, MD, Associate Professor, Bone Health and Osteoporosis, Feinberg School of
Medicine, Northwestern University
Background: Little is known about Chinese women s osteoporosis health beliefs. Purpose: To
assess osteoporosis health beliefs among Chinese women. Methods: Calcaneal ultrasound
(QUS-2 Quidel) and surveys conducted at a Health Fair in Chinatown. We explored prior
fractures, perceived likelihood of developing osteoporosis, stroke, heart disease and breast
cancer (Likert 1-5 scale) and the Osteoporosis Health Belief Scale (OHBS). OHBS evaluates
susceptibility, and seriousness of osteoporosis, benefits and barriers to calcium and exercise,
and general health motivation. Surveys were administered in Chinese. Analysis was conducted
with SPSS 15.0. Results: Mean age 59.65 ± 10.3 years. Mean BUA 73.6 ± 16.6. There was a
correlation between age and BMD (Pearson R 0.451; p 65
was obtained from IMS Health. We surveyed meetings in which osteoporosis 2 and
DXA 3 were a principal focus for years 2005 to 2007.
In 2007, there was a 44% increase in the number of osteoporosis prescriptions
compared to 2005 and 7% compared to 2006. In 2007, attendance at osteoporosis
meetings 2 declined 7% compared to 2005 and 3% compared to 2006. In 2007,
attendance at meetings in which DXA was a central component 3 decreased by 9%
compared to 2005 and 15% compared to 2006. Attendance at VFA courses declined
44% compared to 2005 and 30% from 2006.
In this first year of changes in Medicare reimbursement for DXA, compared to years
2005 and 2006, the number of osteoporosis prescriptions continued to increase.
However, there were declines in attendance at osteoporosis meetings, especially those
for VFA. We conclude that Medicare fee schedule changes may have an impact on the
care of patients with osteoporosis.
1
Excluding estrogen and hormone replacement therapy
2
American Society for Bone and Mineral Research (ASBMR), International Society for Clinical
Densitometry (ISCD) ISCD Position Development Conference (not held in 2006), Southern
Medical Association Osteoporosis Course, National Osteoporosis Foundation (not held in
2006), Santa Fe Bone Symposium, Metabolic Bone Disease Society of Colorado, Regional
ISCD Courses in Bone Densitometry or Vertebral Fracture Analysis (VFA)
3
International Society for Clinical Densitometry (ISCD), Southern Medical Association
Osteoporosis Course, Santa Fe Bone Symposium, Metabolic Bone Disease Society of
Colorado, Regional ISCD Courses in Bone Densitometry or Vertebral Fracture Analysis
(VFA)
Grant Support provided by the International Society of Clinical Densitometry (ISCD)
and the Alliance for Better Bone Health
— 2008 Annual Meeting 39

Challenging Cases
Poster Number: 201
VALIDITY OF DXA READINGS IN PRESENCE OF SOFT TISSUE ARTIFACT
Eric Lee, BS, University of California at San Francisco
Poster Number: 202
DO THE IMAGE ARTIFACTS VOID THE PEDIATRIC BMC RESULTS?
Li Wang, MD, University of California at San Francisco
Poster Number: 203
APPARENT “CURE” OF OSTEOPOROSIS
Elliot Schwartz, MD, CCD, CPD, Northern California Institute for Bone Health, Inc.
Poster Number: 204
ANATOMICAL VARIATION ON DXA
Lorena Marquez, BS, University of California at San Francisco
Poster Number: 205
AN INTERESTING BONE ABNORMALITY CASE STUDY BY DXA
Diana Yau, MRT(NM), Osteoporosis and Women Health Research Centre, Toronto, Canada
Poster Number: 206
ARTIFACT IN THE INTERTROCHANTERIC REGION OF A FEMUR DXA SCAN
David Kendler, MD, CCD, Osteoporosis Centre of British Columbia
40 — 2008 Annual Meeting

HANDOUTS
Thursday, March 13, 2008
The following sessions do not have slides included in this handout:
Peripheral Measurements Debate, Marc-Antoine Krieg
Peripheral Measurements Debase, John Shepherd
Non-Compliance with Medication: Issues in Osteoporosis Care, Michael Kleerekoper
Osteoporosis Care Around the Globe, David Hanley (Canada)
Slides were not available at time of printing.

2/25/2008
pQCT DEBATE
pQCT – Radius
Dean Inglis, Chris Gordon, Jonathan Adachi, Ontario, Canada
XCT 2000 at 250x250x2500 micron
HARRY K GENANT, MD, FACR, FRCR
PROFESSOR EMERITUS, UCSF
pQCT – Radius Sites
Comparative Demo
• Thickness mapping
[0.60, 2.21] , Mean: 1.41 mm [ 0.20, 1.79] , Mean: 0.96 mm
Cross-sectional sectional Change of BMD from
distal to proximal radius pQCT
pQCT - Radius Predicting Strength
500
400
300
200
100
0
-100
trabecular BMD
10 20 30 40 50 60 70 80 90
data 1
data 2
data 3
data 4
data 5
data 6
data 7
data 8
data 9
data 1
data 9
total BMD
1000
800
600
data 9
400
200
data 1
0
10 20 30 40 50 60 70 80 90
Age(years)
• Strong association of geometry-based parameters with bone failure
loads has been demonstrated.
• Moment of inertia, section modulus, and SSI (density weighted section
modulus) demonstrated the strongest correlations with failure load.
• Unclear that geometry-based parameters perform significantly better
than measurement of bone mass (BMC) alone.
• Combing multiple pQCT parameters improved prediction of failure
loads vs single variables, although not significantly better than by DXA
alone.
Masako Ito, M.D.
1 9
K Engelke - ISCD PDC
1

2/25/2008
pQCT - Radius Predicting Strength
pQCT – Distal Radius Normative Data
• Scan location (diaphysis vs metaphysis) having the strongest
prediction of mechanical competence has not been agreed upon.
• Compression tests of the ultra-distal region reveal highest
correlations between
ultimate strength and BMC.
•Loads to produce distal radius fractures by simulating a fall have
been accurately predicted by density measurements and geometric
measurements.
•Most accurate predictors of fracture strength are BMC at ultra-distal
site, area of cortical bone at shaft site, and combinations of BMD with
moments of inertia.
K Engelke - ISCD PDC
Published Single-slice pQCT of the forearm
• Swiss Female 20-80 Radius: trab, BMD Laboratory scanner
• German Male/female 20-80 Radius trab and int BMD Stratec XCT 900
• European Male/female 20-80 Radius: trab BMD Stratec XCT 960 and Densican
• Japanese Female 20-80 Radius: trab, cort and int BMD Stratec XCT 960
• German Male/female 20-80 Radius: trab and int BMD Stratec XCT 960?
• Japanese Female 20-80 Radius: trab, cort and int BMD Stratec XCT 960
• Italian Female 20-80 Radius: trab and tot BMD Stratec XCT 960
• Japanese Female 20-90 Radius: trab, cort and int BMD, cort and int BMC, SSI,
CSA, Stratec XCT 960
K Engelke - ISCD PDC
Quantitative computed tomography (QCT) of the forearm using clinical CT scanners
K. Engelke 1,2 , W. Timm 1 , B. Stampa 1 , T. Fuerst 1 , E. Paris 1 , C. Libanati 3 , H.K. Genant 1,4
1 Synarc Inc, San Francisco, CA, USA, and Hamburg, Germany; 2 Inst. of Medical Physics, Univ. of Erlangen, Germany;
3 Amgen Inc, Thousand Oaks, CA, USA; 4 Univ. of California, San Francisco, CA, USA
INTRODUCTION
METHODS
RESULTS
Multislice-CT of Trabecular Bone
We evaluated the performance of widely available clinical whole body
spiral CT scanners, as opposed to dedicated pQCT scanners to
assess BMD at the distal forearm. As pQCT scanners use low power
x-ray tubes an evaluation of a larger volume requires long (several
minutes) scanning time, increasing the likelihood of motion artifacts.
In contrast, clinical whole body spiral CT scanners allow scanning of a
10 - 20 cm forearm section in seconds improving patient comfort and
data acquisition quality .
METHODS
QCT acquisition
120 kV, 1 mm slice thickness, pitch 1, scan range: 10 cm of the
forearm starting 0.5 cm distally of the radial styloid
QCT analysis
BMD, cortical thickness and derived geometrical parameters from
single CT slices were determined using Geanie software (Commit Inc.
Finland) at ultradistal, distal and mid locations.
Custom software allowed extracting an arbitrary number of slices
perpendicular to the radial axis at preconfigured distances from the
styloid process (see Fig. 1).
A dedicated phantom developed in cooperation with QRM GmbH,
Germany, was used for simultaneous calibration of the CT values to
BMD.
Population
254 postmenopausal women; forearm scanned with QCT and DXA
Extracted 2D CT slices
Ultradistal, distal and mid locations for QCT slices are shown in Fig. 2
in relation to a DXA image.
Variables measured at each slice location
• udQCT: total BMD; Geanie cannot separate the thin cortex.
• dQCT: total, cortical and trabecular BMD and cortical thickness
• midQCT: total and cortical BMD and cortical thickness
For separation of bone from outer soft tissue a global threshold of 100
mg/cm 3 was used. For separation of cortical and trabecular bone a
global threshold of 500 mg/cm 3 was used for the determination of the
cortical ROI and a 70% periosteal peeling was used for the
determination of the trabecular ROI.
20 mm
10 mm
10 mm
• Accuracy of trabecular BMD as assessed from 110 scans of a
European Forearm Phantom (EFP) was 3.0 ± 3.6%.
• In-vivo QCT precision was determined from two scans obtained 1
month apart in all 254 subjects. Results (mean %CV ± SD) are
given in the table.
QCT in-vivo precision Ultra distal Distal Mid
Total BMD 0.8 ± 1.5 2.1 ± 1.9 0.8 ± 0.9
Total area 1.2 ± 1.0 1.8 ± 1.6 0.6 ± 0.7
Cortical BMD 1.2 ± 1.3 0.6 ± 0.7
Cortical thickness 2.6 ± 3.1 0.8 ± 0.7
• Along the radial axis, total radial BMD by QCT significantly
augmented from udQCT to dQCT by +108±33% and from dQCT to
midQCT by +66±25%.
• The corresponding BMD change for DXA from udDXA to midDXA
was +48±13%.
• Cortical thickness sign. increased from distal to mid by +61±40%
• Correlations (r 2 ) between QCT and DXA were: udQCT – udDXA:
0.45, average (udQCT and dQCT) – udDXA: 0.5 (see Fig. 3),
midQCT – midDXA: 0.47.
MS-CT
Distal Radius
X-ray
ultra distal
(udQCT)
Distal
(dQCT)
Mid
(midQCT)
r 2 =0.5
Fig. 1: slices to be analyzed by Geanie are extracted
perpendicular to the axis of the radius at preconfigurable distances
from the styloid process. The QRM calibration phantom, with two
circular inserts of 0 and 200 mg/cm 3 hydroxyapatite, is located
below the forearm and is scanned with each patient.
Fig. 2: 2D slices extracted from CT dataset, their positions relative
to the corresponding DXA scan (upper part) and analysis ROIs
(lower part).
Top row in lower part: CT image (left: ultradistal, center: distal, right:
mid); center and bottom rows: Geanie analyses ROIs; center row:
total ROI for udQCT and cortical ROIs (grey) for dQCT and
midQCT; bottom row: trabecular ROI (blue) for dQCT.
Fig. 3: Correlation of ultradistal BMD between DXA and QCT. For
QCT the average BMD of udQCT and dQCT is shown.
CONCLUSIONS
Forearm QCT, using clinical CT scanners, allows for an accurate,
precise and differential analysis of BMD along the axis of the radius.
In addition QCT allows for separate cortical and trabecular
measurements, as well as the provision of radial geometric
parameters. Forearm QCT presents valuable information beyond
that provided from simple projectional DXA measurements.
300x300 micron
10x10 micron
Thomas Link et al., Eur Radiol, 2003
HIGH RESOLUTION THIN SLICE
COMPUTED TOMOGRAPHY
Good Example
Poor Example
2

2/25/2008
ISCD Fourth
Position Development Conference
July 20-22, 2007
Presented by Sanford Baim and Neil Binkley
ISCD Fourth
Position Development Conference
Organization
• Steering Committee
– Sanford Baim, MD (Chair)
– Neil Binkley, MD
– Didier Hans, MD
– David Kendler, MD
– Micheal Lewiecki, MD
• Moderators
– John Bilezikian
– Stuart Silverman
• Marty Rotblatt – CAE, Associate Director ISCD
ISCD Fourth
Position Development Conference
Expert Panel
Sue Broy
Harry Genant (IBMS)
Claus Gluer
Akira Itabashi
Larry Jankowski
Michael Kleerkoper (NOF)
William Leslie
Marjorie Luckey
Paul Miller
Sergio Ortolani
Steven Petak
Sergio Ragi-Eis
Lawrence G. Raisz
(ASBMR)
Diane Schneider
Technical issues
Task Force Chair – Christine Simonelli
• What are the guidelines for BMD assessment in
men?
• How should we classify BMD in perimenopausal
women (and how is perimenopause defined in
clinical practice)?
• How do we define and interpret high BMD?
Task Force Members: JoAnn P. Caudill (USA), Aliya Khan (Canada), Edward S. Leib
(USA), Glenn Blake (UK), Mike Maricic (USA), Sergio Ragi Eis (Brazil)
VFA
Task Force Chair – John T. Schousboe
• Re-examine all indications for VFA and stress their
importance?
• What is the most appropriate method for defining a
vertebral fracture and excluding non-fracture
deformities and confounding factors?
• Is the accuracy of VFA alone sufficient to diagnose
vertebral fracture(s) and initiate treatment?
• What are the medical legal responsibilities of
interpreting VFA scans?
Task Force Members: Susan Broy (USA), Lynne Ferrar (UK),
Tamara Vokes (USA), Fergus McKiernan (USA)
QCT and pQCT
Task Force Chair – Klaus Engelke
• Can QCT/pQCT be used for:
– Fracture risk assessment?
– Diagnosis of osteoporosis?
– Initiate treatment?
– Monitor treatment?
t t?
• How should QCT/pQCT be interpreted and
reported?
• What are the quality control criteria for QCT/pQCT?
Task Force Members: Judith E. Adams (UK), Cesar E. Bogado (ARG),
Mary L. Bouxsein (USA), Felix Eckstein (GER), Dieter Felsenberg (Austria),
Masako Ito (JP), Sven Prevrhal (USA)
1

2/25/2008
QUS
Task Force Chair – Marc-Antoine Krieg
• Can QUS be used for:
– Fracture risk assessment?
– Diagnosis of osteoporosis?
– Initiate treatment?
– Monitor treatment?
t t?
• How should QUS be interpreted and reported?
• What are the quality control criteria for QUS?
Task Force Members: Alison Stewart (UK), Christian Roux (FR), Paul D. Miller (USA),
Reinhart Barkmann (GER),
Wojciech P. Olszynski (CAN),
Stefano Gonnelli (IT),
Saeko Fujiwara (JP),
Ethel S. Siris (USA), Peyman Hadji (GER), Douglas C Bauer
(USA), Robert S. Siffert (USA), Jonathan Kaufman (USA), Roman Lorenc (POL),
J. Huopio, Kuopio (FIN), Kaoru Yamazaki (JP),
Anne-Marie Schott (FR),
Luis Del Rio Barquero (SP)
Peripheral DXA
Task Force Chair – David Reid / Elliott Schwartz
• Can pDXA be used for:
– Fracture risk assessment?
– Diagnosis of osteoporosis?
– Initiate treatment?
– Monitor treatment?
• How should pDXA be interpreted and reported?
• What are the quality control criteria for pDXA?
Task Force Members: John Fordham (UK), Gen Blake (UK), Thomas Fuerst (USA),
Ethel Siris (USA), Dr Michael Jergas (GER), Prof Peyman Hadji (GER), Akira
Itabashi (JP), Elliot Shwartz (USA), John Shepherd (USA)
Case TIP
Case Presentations
• 48 year old Caucasian female 66 cm. tall
weighing 105 lbs
• Irregular menses for three years (last menses 3
months ago)
• Fractured right wrist one year ago
• Long term smoker
• History of rheumatoid arthritis (active)
• Methotrexate 12.5 mg/week
• Enbrel 50 mg/week
• Prednisone 4 mg/d
• Is patient at increased risk for future fractures?
• Should a DXA be performed?
Case TIMa
• 66 year old Caucasian male office clerk 68
inches tall weighing 144 lbs.
• Sustained a rib fracture after tripping over
telephone cord 6 months ago
• Should a DXA be performed?
• How should BMD interpreted?
Case TIMb
• 48 year old Caucasian male
• Cigarette smoker 1½ ppd for 20 years
• Consumed 3 beers a day for 20 years
• Loss of libido for past 3 years
• Tripped over a parking space concrete curb
while running after his girlfriend fracturing 3
ribs
• Should a DXA be performed?
• How should BMD interpreted?
2

2/25/2008
Case VF
• 77 year old female with COPD
• Historical height loss of 5 cm
• BMD total hip T –1.8
• Should a VFA be performed to exclude
prevalent vertebral fractures?
• What technique should be used for
identification of vertebral fractures?
• When should a VFA be repeated?
• What should the VFA report comment on?
Case QC
• 69 year old woman from Germany visiting her
daughter in the US asks you (son-in-law
physician) whether her QCT report from
Heidelberg is cause for concern?
– Lumbar Spine T –3.4
• Can BMD be used to predict her fracture risk,
diagnose osteoporosis, initiate therapy and
monitor treatment?
3

Questions to ponder about monitoring
efficacy of osteoporosis treatment with BTM
• Does the magnitude of change of BTM with Rx herald
the magnitude of BMD benefit? YES!
• Does the magnitude of change of BTM with Rx herald
a greater reduction in fracture risk? YES!
• Absent a baseline BTM, is there utility of post-Rx level
to monitor treatment? YES!
1
Questions to ponder about monitoring
efficacy of osteoporosis treatment with BTM
• Is there a threshold change in BTM, or post-Rx level, that
proves either
– Adequacy of dose
– No further benefit from further suppression
YES, 50% suppression, or T-score around 0
• What is the consequence of not reaching the BTM threshold?
VARIABLE
• If the BTM response to Rx is suboptimal, what can be done
for the pt? CAN CONSIDER INCREASING THE DOSE.
2
OR (95% CI) of fx risk with Aln Rx, per SD
increase in BMD, or decrease in BMT
• Variable spine fx non-vert fx hip fx
• BSAP 0.74(0.63-0.87) 0.89(0.78-1.00) 0.61(0.46-0.80)
• PINP 0.77(0.66-0.90) 0.90(0.80-1.03) 0.78(0.51-1.19)
• sCTX 0.77(0.58-1.03) 1.02(0.75-1.37) ----------------
• BMD
– Spine 0.92(0.76-1.11) 1.05(0.92-1.20) 0.94(0.56-1.58)
– Hip 0.74(0.61-0.89) 1.03(0.90-1.17) 0.74(0.47-1.17)
Bauer et al, JBMR 2004;19:1250
3
4
Urine NTX predicts response of BMD to HRT
Chestnut et al AJM 1997;102:29
JBMR 2007;22:1656 Eastell et al, fig 2
5
6
1

Greatest utility for BTM in the
individual patient on Rx
• BTM suppression on Rx can reassure us in a
patient losing BMD on Rx
• BTM suppression on Rx can be used to
provide positive feedback to patients on Rx
to encourage compliance.
Risk of vertebral fractures on raloxifene
according to ∆BMD and ∆turnover
PERCENT CHANGE IN FN BMD
-1% +1.5% +3.9%
• % ∆ OSTEOCALCIN
– -5% 11.8% 10.3% 9.0%
– -25% 9.6% 8.8% 8.1%
– -41% 8.2% 7.8% 7.5%
Sarkar et al, JBMR 2004;19:394
7
8
BMD vs BTM in providing feedback to
pts on RIS
• Spine BMD stable to increasing on RIS allows us
to give 89% of pts a positive message (FACT)
• Message of urine NTX decline of more than 30%
could only be delivered to 66% of pts (Delmas et al,
JCEM 2007;92:1296).
• Argues to me that BMD feedback would be more
supportive of pts on RIS.
9
Conclusions
• 50% decrease in BTM, or nadir BTM at the mean
for menstruating women, predicts improvement in
BMD and fx risk with Rx
• Many pts without the 50% decrease in BTM, will
have stable to increasing BMD.
• Poor precision of BTM makes them hard to use in
decision-making or feedback for individuals
• In patients on Rx with bone loss and suppressed
BTM, maybe there is no need to change Rx.
10
2

BONE TURNOVER MARKERS
BONE TURNOVER MARKES
Nelson B. Watts MD
Bone Health and Osteoporosis Center
Metabolic Bone Diseases and Mineral Disorders
• What are bone turnover markers (BTM)?
• How do they behave in healthy people?
• What can they tell us in patients with
osteoporosis?
• How can we use them for monitoring
therapy?
www.ucosteoporosis.com
www.ucosteoporosis.com
BONE REMODELING CYCLE
NORMAL BONE REMODELING
Resting / quiescent
Resorption: Formation:
osteoclasts osteoblasts
Activation
7-10 days Deficit 10-12 weeks;
mineralization
Resorption:
osteoclasts
Formation
osteoblasts
Adapted from Watts NB. Clin Chem 1999;45:1359-1368
www.ucosteoporosis.com
Activation Resorption Reversal Formation
www.ucosteoporosis.com
BIOCHEMICAL MARKERS OF BONE TURNOVER
FACTORS THAT AFFECT REMODELING
Formation
• Osteocalcin (OC)
• Bone-specific alkaline
phosphatase (BAP)
• Amino terminal
propeptide of type I
collagen (PINP)
• Carboxy terminal
propeptide of type I
collagen (PICP)
Resorption
• Pyridinoline (Pyr)
• Deoxypyridinoline (dPyr)
• Amino terminal telopeptide
of type I collagen (NTX)
• Carboxy terminal
telopeptide of type I
collagen (CTX)
• Diet
• Activity
• Season
• Pregnancy/menstrual cycle
• Time of day
• Age, gender, race
• Fracture
• Diseases
• Medications
Intra-individual variation is 20%-30%
www.ucosteoporosis.com
www.ucosteoporosis.com
1

SAMPLING FOR
BONE TURNOVER MARKERS
• Because of the diurnal variation (higher in the
morning than in the evening) and the decrease
after eating, bone turnover markers should be
measured on
– A second-morning fasting urine
– A fasting blood sample
RELEVANCE OF IMPRECISION
(SIGNAL : NOISE RATIO)
Measurement Variability Expected Change Ratio
Spine BMD ~1% ~4% ~4.0
Hip BMD ~2% ~3% ~1.5
Urine NTX ~30% ~60% ~2.0
Serum CTX ~15% ~30% ~2.0
www.ucosteoporosis.com
www.ucosteoporosis.com
NOT EVERYONE WITH OSTEOPOROSIS
HAS HIGH BONE TURNOVER
DECREASE IN BTM CORRELATES WITH
DECREASE IN FRACTURE RISK
100
80
60
89 Elderly Women with Osteoporosis
30
300
25
250
20
200
15
150
2.5
2.0
1.5
1.0
12 months
P=NS
2.5
2.0
1.5
1.0
6 months
P=0.036
40
10
100
0.5
0.5
20
0
5
50
0
0
Pyr Dpd NTx
0.0
Most Middle Least
Femoral Neck BMD
0.0
Most Middle Least
Bone-Specific Alkaline Phosphatase
Garnero P et al, J Clin Endocrinol Metab 1994;79:1693
Bjarnason NH et al. Osteoporos Int 2001;12:922-930
www.ucosteoporosis.com
www.ucosteoporosis.com
RELATIONSHIP BETWEEN CHANGE IN BONE
TURNOVER MARKER AND FRACTURE INCIDENCE
BONE TURNOVER MARKERS
20
10
0
New Vertebral Fractures over 3 Years
vs. 3 to 6 Month Marker Change from Baseline
Control
Risedronate 5mg 20
-60 -50 -40 -30 -20 -10 0
NTX % Change from Baseline
10
0
-70 -60 -50 -40 -30 -20 -10 0
CTX % Change from Baseline
• Bone turnover markers…
– Predict bone loss and fracture risk in untreated patients
• With treatment…
– Change sooner than BMD
– Identify more “responders” than BMD
– Explain a greater proportion of fracture reduction than
change in BMD
• Can be useful in monitoring the response to treatment
Eastell R et al, J Bone Miner Res 2003;18:1051-1056
www.ucosteoporosis.com
www.ucosteoporosis.com
2

2/25/2008
GE Healthcare Software
Review
• Hip scanning
• Advanced Hip Analysis
(AHA)
• Pediatric Hip
• Dual-femur
(revisited)
• Spine -“One Scan”
• Supine Forearm
• LVA
• Morphometry wizard
• Reverse LVA
• Quality Control
• Composer Wizard
Hologic Software Review
• Apex 2.2 (V12.7)
• Increased hip and spine precision
•Updated analysis engine
• HSA® (Beck)
• Baseline scans on-screen
• Auto-positioning hip
• New Spine Phantom
Image Quality Affects DXA
and VFA
• Accuracy
• Precision : matching positioning and ROI’s
• Trueness : Artifacts, increasing DJD
• Diagnostic sensitivity and specificity
• True positives and true negatives
• False false positives and false negatives
Image Quality - Historical Perspective
• 1980 - FDA
approves first
DPA device and
requires the
disclaimer:
“Image not for
diagnosis” to
appear on all
image printouts.
Image not for diagnosis
VFA Image Quality Assurance
Lacking
• Daily phantom and calibration blocks
inadequate for image resolution/contrast
• Manufacturers do not provide end-user tools
to test or monitor imaging performance
• No imaging resolution testing standards
• Scanner designs preclude use of “off-the-
shelf” radiography phantoms
VFA Image Resolution in Phantoms
Digital XR Discovery-IHD Discovery-IVA Prodigy iDXA
1

2/25/2008
Image Resolution Varies with
Table Height (Magnification)
1 lp
Hologic : Lateral Motion/Positioning
Affected by Magnification
1 lp
Focal Plane
Tabletop
Overlap Image Reconstruction Error?
• Limit of two
slightly offset
projections
• Rare event?
• Effect on BMD
is unknown,
probably
negligible.
Post-processing and Artifact
Detection
Baseline
Follow-up
Where We Need To Go:
• Better system QA
• Image resolution
• Standardization of
positioning, ROI
placement, etc.
• Better identification of
errors/artifacts
• Auditing trail
• Scan operator
• Analysis operator
• Physician approval
• Better training of
operators and
physicians (e.g.
CBDT)
• Better performance
standards (e.g. facility
accreditation)
• More science, less
marketing from
industry
“Ecce Machina!”
“Programming today is a race between software
engineers striving to build bigger and better
idiot-proof programs, and the universe trying to
produce bigger and better idiots. So far, the
universe is winning.”
- Rich Cook
2

Compliance and Persistence
With Osteoporosis Therapies
Deborah T. Gold, Ph.D.
Duke University it Medical Center
Durham, NC
International Society for Clinical Densitometry
Annual Meeting 2008
San Francisco
March 13, 2008
Definitions of Compliance and Persistence
COMPLIANCE: The extent to which a patient acts
in accordance with the prescribed interval and dose
of and dosing regimen.
PERSISTENCE: The duration of time from initiation
to discontinuation of therapy.
ADHERENCE is a synonym for COMPLIANCE
www.ispor.org/sigs/MCP_accomplishments.asp#definition
Bisphosphonate Compliance Poor
Multiple studies have now shown that
compliance and persistence with these drugs
are poor, regardless of dosing interval.
(Kamatari et al., 2007; Cramer et al., 2007; Payer et al., 2007; Cramer et al., 2006)
Although weekly dosing improves compliance
over daily dosing, this does not guarantee
that longer dosing intervals will continue to
improve compliance. (Gold et al., 2006; Keen et al., 2006;
Cramer et al., 2006; Carr et al., 2006)
More OP Medicines
In addition to the medications previously mentioned,
two other medications are approved for the prevention
and/or treatment of osteoporosis:
•Raloxifene (selective estrogen receptor modulator)
•Compliance with raloxifene higher than with bisphosphonates
(Turbi et al., 2004; Pasion et al., 2007)
•Teriparatide (parathyroid hormone)
•Patients who reported concerns about injection had rates of compliance that
were 91% (3 mo), 89% (1 yr), & 82% (18 mos) (Adachi et al., 2007)
•Teriparatide persistence very high at 12-18 months and likely higher than that
with oral medications. (Arden et al., 2006)
Five Dimensions Affecting OP Medication
Compliance and Persistence
1. Social and economic factors
Medication cost
Low health literacy
Lack of social support network/positive
reinforcement
2. Health care system factors
• Poor education about meds
• Restricted formularies
• Lack of positive reinforcement from HCP
• Patient ed materials too sophisticated
Five Dimensions Affecting OP Medication
Compliance and Persistence
3. Condition-related factors
Lack of symptoms
Chronicity of condition
Depression
4. Therapy-related factors
• Complexity of medication regimen
• Duration of therapy
• Lack of immediate benefit of therapy
• Actual or perceived side effects
• Treatment requires significant lifestyle changes
1

Five Dimensions Affecting OP Medication
Compliance and Persistence
5. Patient-related factors
Cognitive, visual, or hearing impairment
Poor understanding of need for medication
Perceived risk (or lack of risk) of fractures
Perceived benefit of treatment
Stigmatized by disease
Poor confidence in ability to follow regimen
Fear of dependence
s (%)
Patients
Persistence With Bisphosphonate Therapy Decreases the
Risk of Fracture
5
4.5 26%
Persistent
(n=2,029)
4
3.5
Non-persistent
3
(n=2,740)
2.5
2
1.5
HR=.739, P=.047
1
0.5
0
HR=hazard ratio.
Fracture Rate
Retrospective analysis of claims data from a large healthcare plan examining relationship between persistence
with alendronate therapy and fracture risk. Patients with 24 months of follow-up were stratified into persistent
(>6 months therapy) and non-persistent cohorts (30-day
gap in medication supply.
Gold D et al. CMRO 2007
Improving Compliance:
Overall Strategies
Emphasize the value of the treatment regimen
Provide simple, clear instructions repeatedly!
Listen to patient and respond to patient
preferences; ultimately, most important
factor
Positively reinforce desirable behavior
Strategies to Improve Compliance & Persistence
• Look for markers of non-persistence: missed
appointments, lack of response to medication, missed
refills
• Emphasize the value of the regimen and the effect of
compliance and persistence
• Elicit patient’s feelings about his or her ability to follow
the regimen; if necessary, design supports to promote
compliance
• Provide simple, clear instructions, and simplify regimen
as much as possible
• Consider nurse or other staff monitoring
Osterberg L, Blaschke T. N Engl J Med. 2005;353:487-497.
Osterberg Surgeon L, Blaschke General’s T. N Engl Report J Med. 2005;353:487-497. on Osteoporosis Clowes and JA, Bone et al J Clin Health, Endocrinol 2004. Metab. 2004;89:1117-1123.
2004 Surgeon General’s Report. Putting It All Together for the Busy Health Care Professional. Chapter 10, 275.
Osterberg L, Blaschke T. N Engl J Med. 2005; Clowes JA, et al J Clin Endocrinol Metab. 2004; 2004
Surgeon General’s Report.
Conclusions
Persistence with osteoporosis therapy remains
suboptimal
Non-compliance leads to poor outcomes
Key strategies for improved persistence may
include the following:
Improved patient education and participation
Better physician-patient relationship
Better efficacy and fewer side effects
Periodic positive reinforcement
Conclusions
Which medication factors are most likely to
positively influence compliance and
persistence?
Efficacy trumps everything else most of the time
Side effect profiles and ease of medication regimen
are also important
Hierarchy of factors changes with disease
• Patients may be willing to give up some efficacy to
avoid side effects
• Positive reinforcement of compliance is essential
• Attention to patient preferences critical
2

2/26/2008
Osteoporosis care around
the Globe
United Kingdom perspective
Professor Judith Adams
Professor of Diagnostic Radiology
University of Manchester
and
Consultant Radiologist
Royal Infirmary, Manchester
judith.adams@manchester.ac.uk
Epidemiology of Osteoporosis
• 1 in 2 women and 1in 5 men will suffer a fracture after
the age of 50 years Van Staa et al Q J Med 2000
• 310,000 patients present with fractures annually; 25%
are fractures of the hip Torgerson et al 2001
• Hip fractures have risen by 2% pa 1999-2006; will
increase further from 70,000 to 91,500 in 2015 and
101,000 in 2020.
• Costs of treating fragility fractures was £1.8 ($3.6)
billion pa in 2000; will increase to £2.2 ($4.4) billion in
2020
Burge et al J Med Economics 2001
Diagnosis of Osteoporosis
Central DXA provision England 2005
• Review by National Osteoporosis Society
• Population 48,695,400
• DXA scanners in NHS = 158 (156 static; 2 mobiles)
• 1 DXA for 308,199 population
• Estimated DXA scans: 13,300/1 million population
Kanis et al 2004
• Deficit 376,800 scans; required 126 more DXA scanners
• Calculated on 3000 patients scanned pa per scanner
Treatment of Osteoporosis
• National Institute of Clinical Excellence (NICE)
www://www.nice.org.uk
- Health Technology Appraisal HTA
(assesses cost effectiveness of drugs & determines what can be described)
- Guidelines Development Groups
Osteoporosis:
2001 – National Service Framework for older people
http://www.dh.gov.uk
2003 – vertebroplasty
2004 - prevention of falls
2005 – HTA treatment of secondary osteoporosis
2006 – kyphoplasty
2007 – strontium ranelate
also: http://www.sign.ac.uk
Future directions in Osteoporosis
Care
• Improve central DXA provision
• Alternative (to NICE) guidelines for management (June
2008)
• Implementation of WHO FRAX TM for 10 year fracture risk
• Inclusion of osteoporosis in Quality Outcome Framework
(QOF) for general practitioner contract
t
• Health Technology Appraisal for primary and secondary
osteoporosis treatment (NICE)
treatment not cost effective for those under 70y without
fractures
http://www.nice.org.uk/nicemedia/pdf/OsteoFADPrimary.pdf
WHO 10 year fracture risk
calculator (FRAX TM )
http://www.shef.ac.uk/FRAX/tool
The cost-effectiveness of alendronate in the management of osteoporosis.
Kanis et al Bone 2008 Jan;42(1):4-15. Epub 2007 Nov 12.
http://www.who.int/chp/osteoporosis.pdf
Kanis et al Osteoporos Int 2005
1

2/25/2008
OSTEOPOROSIS AROUND
THE WORLD.
CENTRAL - EASTERN EUROPE: POLAND
R.S Lorenc M.D., Ph.D.
DISCLOSURES: P.I.in
Aventis,Novartis,Roche,
Servier and Amgeen trials
The Children Memorial Hospital Warsaw, Poland
San Francisco, March 2008
Every 30 seconds someone in the
European Union suffers a hip
fracture as a result of osteoporosis
Multilevel EU system
A call to action !
EU
PARLAMENT
HEALTH
CARE
DECISION
MAKERS
PHYSICIANS
PATIENTS
EU Recommendation
From the 1998 European Commission „Report on Osteoporosis in the European Community – Action for Prevention”
2. More information is required about the incidence and prevalence of
osteoporotic fractures - (EDUCATION)
5. Access to bone densitometry systems should be universal for people
with accepted clinical indications and reimbursement should be
available for such individuals
6. Member states to use an evidence-based approach to determine
which treatment should be advised. Reimbursement should be
available for all patients receiving treatment according to accepted
indications
Europe
POLAND
Area (square km)
Population
(July 2004 est)
Fractures in women (per year)
Fractures in men (per year)
--------------------------------------------------------
TOTAL
Białystok
Warsaw
312,678
38,536,869
23832
11266
----------
35098
1

2/25/2008
Fracture probability
Anamnesis: risk factors→10RB
Lifetime and 10-year risk of hip
fracture among women in Poland
14
12
Lack
Diagnosis
BMD
Fx, steroids
Treat
re (%)
risk fractur
10
8
6
4
2
-2.5
0
40 50 60 70 80 90
age [yrs]
Treat
lifetime risk
10-yrs risk
2

Mean BMD at the spine in females from ME
Osteoporosis in Middle East
Ghada El-Hajj Fuleihan, MD, MPH.
Outline
BMD in ME
Applicability of WHO criterion in ME: database selection
ROC curves
Fracture risk RR/SD decrease
Prevalence of OP in ME by:
BMD data
Fracture data
BMD in fracture subjects in ME, compare to western data
Diagnosis and treatment of OP in ME
BMD Spin ne (g/cm 2 )
1.34 Quataris (Lunar Expert-XL)
1.26
Kuwaitis (Lunar Expert-XL)
1.18
Saudis (Lunar DPX-IQ)
1.10
Iranis (Lunar DPX)
102 1.02 Lebanese (Lunar DPX-L)
0.94
Lebanese (Population--Hol)
0.86
Caucasian (Lunar DPX-L)
0.78
0.70
10 20-29 30-39 40-49 50-59 60-69 70-79
80
Age group
Maturitas 2005; 52:319 CTI 2001; 68:225 Bone 2002; 31:520- JCD 2006; 9:367-
OI 2005; 16:43- OI 2000; 11;756 Bone 2007; 40: 1066-
r (g/cm 2 )
BMD femu
Mean BMD at the HIP in females from ME
1.1 Quataris (Lunar Expert-XL)
Kuwaitis (Lunar Expert-XL)
1.0
Saudis (Lunar DPX-IQ)
Iranis (Lunar DPX)
Lebanese (Lunar DPX-L)
0.9
Lebanese (Population--Hol)
Caucasian (Lunar DPX-L)
0.8
0.7
10 20-29 30-39 40-49 50-59 60-69 70-79
80
Age group
Fracture risk Assessment:
Local vs International Reference Database
Women, N=301 Men, N=159
Western Local Western Local
Sensitivity 52 27 38 11
Specificity 71 89 79 99
PPV 30 35 20 66
NPV 86 83 90 89
ROC 0.65 0.57 0.64 0.57
Maturitas 2005; 52:319 CTI 2001; 68:225 Bone 2002; 31:520- JCD 2006; 9:367-
OI 2005; 16:43- OI 2000; 11;756 Bone 2007; 40: 1066-
Adapted from Arabi et al,. ASBMR 2005; Plenary Poster SA081
Baddoura, .. El-Hajj Fuleihan G. Bone 2007; 40:1066-
BMD-fracture relationship
Age-Adjusted OR for VFX per SD BMD*
Lebanese Women compared to western standards
Site Lebanese 1 Western 2 Western 3
Local Western
LS 1.16 ns 0.99 ns 2.3 1.36
Hip 1.49 1.61 1.8 1.66
FA 1.47 1.58 1.7 -
*T-score used, NHANES (hip) or manufacturer database (FA, spine)
RR of Hip Fx /SD decrease in hip BMD
Risk assessment N RR
Per SD decrease in Hip BMD Crude Adjusted
Marshall BMJ 1996 2.6 [2-3.5]
AUB (in preparation) 60 2.5 [1.5-4.3]
Greenspan 56 1.7 [1.2-2.4]
Epidos (OI 1998) 154 2.0 [1.7-2.5] 1.9
Alonso (OI 2000) 295 4.5 [3.1-6.4]
1 Baddoura, .. El-Hajj Fuleihan. Bone 2007;40:1066
2 Marshall et al. B Med J 1996. (90 000 women) 3 Cauley et al. OI 2004 (2067 women)
1

Prevalence of OP by BMD at Total Hip
Lebanese & Swedish women*
Age Lebanese 1 Swedish 2
65-69 yrs 23% 20%
70-74 74 yrs 27% 27.9%
75-79 yrs 34% 37.5%
80-85 yrs 60% 47.2%
Prevalence of VFX by X-ray in Women
AUB Netherlands Mayo SOF EPIDOS
Age 73(6) 72(5) 80(3)
Range 65-85 ≥65 65-85 >65
25
20
15
%
10
5
SOF N=9575
EPIDOS N=770
Mayo N=762
Netherland N=267
0
Lebanon
*Western NHANES database used for both Lebanese and Swedish groups
1 Baddoura, .. El-Hajj Fuleihan. Bone 2007; 2 Kanis et al. Osteoporos Int 2005;16:581
Baddoura,… El-Hajj Fuleihan, Bone 2007; 40:1066- Pluijm et al-JBMR 2000; 15:1564-
Melton et al-OI 1993;3:113- Grados et al-Bone 2004;34:362- Kado et al-Arch Int Med 1999;159:1215-
BMD in Lebanese women with VFX and
comparison to SOF* population
Site Lebanese 1 SOF 2 P**
N=56 N=386
Age 75 ±4 75±5 NS
Height 148.11 ±6.77 156.9 ±6.00 0.001001
Spine 0.74 ±0.13 0.78 ±0.16 0.07
TH 0.67±0.13 0.69 ±0.12 0.2
FN 0.57 ±0.08 0.60 ±0.09 0.01
1 Baddoura, .. El-Hajj Fuleihan Bone 2007;
2 Cauley et al, Osteoporos Int, 2004 (age adjusted BMD values)
OP in Lebanon and … Middle East
• Peak BMD is the same or a bit lower than that of Western
countries by 0.3- 0.6SD ( Bone size, vitamin D, ..)
• BMD seems to be lower across all age groups
• Vertebral Fx prevalence >65 yrs similar to US/Europe
• Hip Fracture incidence close to Southern Europe: age
younger, mortality higher, care gap
• BMD/FX relation is the same as western standards
• Use Western database for fracture risk assessment is
superior to use of local databases in older individuals
(WHO model, Lebanese Guidelines 2002, Lebanese
Guidelines 2007)
Osteoporosis management in ME
The Challenges
• Require rigorous quality assurance protocols
• Use a universal standard BMD database
• Obtain data on incident fractures
• Obtain additional data locally and regionally to validate
use of WHO global fracture risk assessment model
• Assess burden of disease: morbidity and mortality
• Vitamin D supplementation
• Care Gap and financial constraints
• Further develop and disseminate OP guidelines
Lebanese Guidelines for Osteoporosis Assessment
and Treatment : First Update
Endorsed by
Lebanese Society of Endocrinology
Lebanese Society of Obstetrics and Gynecology
Lebanese Association of Orthopedics
Lebanese Society of Radiology
Lebanese Society of Rheumatology
WHO Eastern Mediterranean Region
LMJ 2002; volume 50(3)
LMJ 2007;
International Journal of Clinical Densitometry 2005
IOF website linkhttp://www.osteofound.org/health
2

2/25/2008
Osteoporosis Care Around the Globe
Japanese perspective
Akira Itabashi, MD
SCBR, Saitama Center for Bone Research
Saitama, Japan
Increasing aged population in Japan
x10 6
25.0
x10
150
6 20
18.5
Male
20.0 Fem ale
122 124 126 127 %
15.0
15.7
15
10.0
100
13.1
50
0
10.9
Total Population
> 65 O ld (%)
1987 1992 1997 2002
10
5
0
5.0
0.0
x10 6
12.0
10.0
8.0
6.0
1987 1992 1997 2002
Male
Fem ale
>65 yo
>75 yo
Aged population in Japan is increasing,
both in number and percentage.
4.0
2.0
0.0
1987 1992 1997 2002
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Epidemiology of osteoporosis in Japan
x10 3
12
X-ray film of spine
Lumbar BMD
Diagnostic criteria of primary osteoporosis (1995)
x10 3 Estimated hip fractures cases
120
Total
•
Hip fracture cases are still
100 Male
Cases with vertebral fractures on X-ray film
Fem ale
increasing both in females
cases with reduced bone mass (grade I or more severe radiographic
80
and in males in Japan,
osteopenia, or BMD less than –1.5SD of young adult mean (YAM)) and
nearly 120,00 cases a year.
60
with nontraumatic vertebral fracture should be diagnosed as having
osteoporosis.
40
20
• Cases without vertebral fractures on X-ray film
0
1987 1992 1997 2002 Estimated osteoporotic cases
10
Normal No radiographic osteopenia
Estimated osteoporotic
8
Osteopenia Grade I radiographic osteopenia Less than –1.5SD
cases exceed 10 million
6
of YAM
and increasing.
Osteoporosis Grade II or more severe Less than –2.5SD
4
radiographic osteopenia
of YAM
2
Orimo H. et al. : Nihonijishinpo 4180 25-30 (2004) 0
1987 1992 1997 2002
Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2006 edition)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
YAM, young adult mean (20-44 years old)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
% of YAM
Using percent of YAM instead of T-score in Japan
Speed of Bone Loss with Age (% of YAM)
120
100
80
60
40
20
0
70% of YAM
by DPX -Spine
by DPX femur
by DCS-600 radius1/3
by CXD finger
by DX-2000 calcaneus
Prevalence of osteoporosis in women more than
50 years old as diagnosed by WHO criteria
Site Method Prevalence(%)
Lumbar spine DXA 24.4
Hip DXA 10.9
Radius, one-third DXA 52.2
Calcaneus SXA 34.1
Metacarpal CXD 36.9
Orimo, H, et al: J Bone Miner Metab (1998) 16:139–150
T-score
Bone densitometer sales in Japan as 2005
29.5
2.8
1.9
7.5
10.5
50.6
A x ia l D X A
fo re arm D X A
heel D XA
heel ultrasound
m ic ro de n sito m e try
other
Speed of Bone Loss with Age (T-score)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
1.0
0.0
-1.0
-2.0
-3.0
-4.0
-5.0
-6.0
T=-2.5
20-
24
25-
29
30-
34
35-
39
40-
44
45-
49
50- 55-
54 59
Age
60-
64
65-
69
70-
74
75-
79
80-
84
85-
89
20-
24
25-
29
30-
34
35-
39
40-
44
45- 50- 55-
49 54 59
Age
60-
64
65-
69
70-
74
75-
79
80-
84
85-
89
by DPX spine
by DPX femur
by DCS-600
radius1/3
by CXD
metacarpal
by DX-2000
calcaneus
Diagnostic criteria of primary osteoporosis (revised in 1996)
• Cases with vertebral fractures on X-ray film
cases with reduced bone mass (grade I or more severe radiographic
osteopenia, or BMD less than 80% of young adult mean (YAM)) and
with nontraumatic vertebral fracture should be diagnosed as having
osteoporosis.
• Cases without vertebral fractures on X-ray film
X-ray film of spine
Lumbar BMD
Normal No radiographic osteopenia
Osteopenia Grade I radiographic osteopenia 70%-80% of YAM
Osteoporosis Grade II or more severe Less than 70%
radiographic osteopenia
of YAM
YAM, young adult mean (20-40 years old)
Note: In principle, BMD means bone mineral density of lumbar spine, but if lumbar
BMD is difficult to assess, that of radius, second metacarpal bone, femoral neck,
or calcaneus may be used
Orimo, H, et al: J Bone Miner Metab (1998) 16:139–150
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
1

2/25/2008
Current diagnostic criteria for osteoporosis in Japan
Presence of fragility fracture, or BMD less than
70% of YAM even without prevalent fracture
Diagnostic criteria for primary osteoporosis (2000 revision)
If the results of bone evaluation meet the following conditions and other diseases characterized by low
bone mass or secondary osteoporosis are not recognized, it is diagnosed as primary osteoporosis.
I With fragility fracture 1
II Without fragility fracture
Radiographic osteopenia Conventional bone atrophy
BMD 2
of the spine 3
standard
Normal
80% of YAM or
higher
Absent
No
Decreased bone mass 70-80% of YAM Possible Grade I
Osteoporosis
Less than 70%
of YAM
Present
Grade II or more severe
1 Fragility fracture is a nontraumatic bone fracture that is caused by slight external force to a bone with low BMD
(BMD less than 80% of YAM). Sites of fracture include the spine, femoral neck, and the distal end of the radius.
2 BMD usually refers to lumbar BMD. However, when the measurement is inappropriate for reasons such as
spinel deformity, the femoral neck BMD should be used. When measurement at that site is difficult, BMD of the
radius, second metacarpal bone, or calcaneus will be used.
3 Assessment of radiographic osteopenia of the spine is performed according to the conventional bone atrophy
standard.
YAM: young adult mean
From Orimo H, et al. J Bone Miner Metab 2001; 18: 76-82.
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Spine BMD
T-score
1.2
1.1
1.0
0.9
0.8
0.7
Spine L2-L4 BMD decline curve
C aucasian
0.6
20 25 30 35 40 45 50 55 60 65 70 75 80
Age
(Hologic QDR series)
1.0
0.0
-1.0
-2.0
-3.0
-4.0
BMD difference Caucasian vs Japanese
Japanese
Spine BMD T-score decline curve
Caucasian
Japanese
20 25 30 35 40 45 50 55 60 65 70 75 80
Age
Spine L2-L4 BMD
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
Spine L2-L4 BMD vs T-score
Caucasian
Japanese
1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0
T-score
Percent of YAM decline curve
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
% of YAM
120
100
80
60
40
Caucasian
Japanese
20 25 30 35 40 45 50 55 60 65 70 75 80
Age
al neck B M D
Fem ora
1.2
1
0.8
0.6
04 0.4
0.2
0
BMD difference Caucasian vs Japanese
Fem oralneck BM D
Caucasian vs Japanese
Caucasian
Japanese
Diagnosing osteoporosis in Japan
Markers
Reference range
Bone metabolism markers
Bone metabolism markers: valid means for
predicting osteoporotic fracture risk
Cutoff
level
Abnormally
high level
Bone resorption Urine DPD 2.8-7.6 *1 nmol/mmol・Cr 7.6 >13.1
Urine NTX 9.3-54.3 *1 nmolBCE/mmol・Cr 54.3 >89.0
Urine CTX 40.3-301.4 *1 μg/mmol・Cr 301.4 >564.8
Serum NTX 7.5-16.5 *2 nmolBCE/L 16.5 >24.0
Bone formation Serum BAP 7.9-29.0 *1 U/L 29.0 >75.7
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
-4.0
-4.5
-5.0
T-score
Caucasian : Mean 0.86 SD 0.12 -2.5SD 0.56
Japanese : Mean 0.76 SD 0.11 -2.5SD 0.49
(Hologic QDR series)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
*1:Premenopausal women aged between 30 to 44
*2:Premenopausal women aged between 40 to 44
・Cutoff levels are equivalent to the mean (for premenopausal women) + 1.96 SD.
・When abnormally high levels are detected, diseases other than primary osteoporosis should be considered.
・Currently data on serum CTX are insufficient.
DPD=free deoxpyridinoline
NTX=N-telopeptide
CTX=C-telopeptide
BAP=bone-specific alkaline phosphatase
Adapted from Committee on the Guidelines for the Use of
Biochemical Markers of Bone Turnover in Osteoporosis; Japan
Osteoporosis Society. J Bone Miner Metab 2005; 23: 97-104.
Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2006 edition)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Diagnosis of osteoporosis
Reimbursement
Almost all the Japanese population are generally covered with
medical insurances. (However, uninsured population is increasing.)
Examination fee:
Bone Densitometry
central DXA 3,600JPY 340USD
peripheral DXA 1,400JPY 130USD
heel ultrasound 800JPY 75USD
(Insurance covers when the patients are diagnosed
or suspected for osteoporosis, every 4 months)
Bone metabolic markers
Urinary NTx 1,600JPY 150USD
Serum NTx 1,600JPY 150USD
Urinary CTx 1,600JPY 150USD
Urinary DPD 1,600JPY 150USD
(Insurance covers when the patients are diagnosed
for osteoporosis, before and within 6 ms of treatment )
Serum Bone Specific Alkaline Phosphatase (BAP)
1,700JPY 160USD
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Treatment osteoporosis in Japan
Purpose of treatment: to control fracture risks
and to maintain or improve QOL
Criteria for initiation of pharmacotherapy for prevent fragility fractures
Prevalent fragility
fracture
Yes
Prevalent fragility
fracture
No
50 years old
(Male / Female)
BMD
< 70% of YAM
BMD 70-80%
of YAM
(Postmenopausal women
/ 50 years old male
At least one of the following
risk factors:
○Excessive alcohol consumption
(2 units per day)
○Current Smoking
○Family history of hip fracture
Initiate
Pharmaco-
therapy
(for
prevention
of fragility
fracture)
Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2006 edition)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
2

2/25/2008
Treatment of osteoporosis
Detailed and comprehensive recommendations
on each drugs based on all available evidences
Therapeutic agent
BMD
(Grade)
Veretbral fracture
(Grade)
Non-vertebral fracture
(Grade)
Overall evaluation
(Grade)
Calcium C C C C
Estrogen A A A C
Active Vitamin D3 B B B B
Viamin K2 B B B B
Etidronate A B B B
Alendronate A A A A
Risedronate A A A A
SERM: Raloxifene A A B A
Calcitonin ※ B B C B
Ipriflavone C C C C
Anabolic steroid C C C C
※Calcitonin: “analgetic, and reducing pain (Grade A)”
Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2006 edition)
Adapted from Osteoporosis Jpn 2006; 14: 665-8.
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Treatment of osteoporosis
Guidelines on the management and treatment
of corticosteroid-induced osteoporosis (2004 edition) a
Prednisolone equivalent d
< 5mg/day
Using or planning to use oral glucocorticoids
for 3 months or longer
Prior fragility fracture b or new fractures during treatment
No
General guidance and follow-up f
BMD c
BMD c
%YAM80
%YAM < 80
Prednisolone equivalent d
5mg/day e
Yes
General guidance and treatment
YAM: young adult mean (20-44 years old) BMD: bone mineral density
General guidance:
Lifestyle guidance, nutritional guidance, and exercise a These guidelines cover patients 18 years of age and older.
therapy are based on those hor primary osteoporosis. b Definition of fragility fractures is the same as that for primary
Follow-up observation:
osteoporosis.
Bone mineral density measurements and thoracic and c BMD measurements are based on those for primary osteoporosis
lumbar vertebra X-rays are performed on a regular basis (2000 revised edition).
(even 6 months or 1 year).
d Mean daily dose.
Drug treatment:
e Pationes administered 10mg or more per day are at risk of fractures
even when BMD is high (cut-off value, %YAM90).
1. Bisphosphonates are first-line drugs.
f Rsk of fractures is higher in the elderly.
2. Active vitamin D3 and vitamin K2 are second-line drugs.
From Nawata H, et al. J Bone Miner Metab 2005; 23: 105-9
Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2006 edition)
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
Future directions in osteoporosis care in Japan
How to deal with the delay of the development of the new drug?
Parathyroid hormone, strontium ranelate, ibandronate are currently being
evaluated and have not been approved for treatment of osteoporosis.
Alendronate, risedronate and raloxifene were approved several years after
US or EU approval. Weekly alendronate and risedronate were recently
approved.
Therefore, concurrent development is necessary, such as joining the
global trial.
How to evaluate the bone strength change in the clinical setting?
Introduction of central DXA to more sites where only the peripheral
measurements are available.
More precise DXA measurement and evaluation--- need for training.
Introduction of CT measurement for bone strength study.
Evaluation of bone metabolic markers and newer ones such as pentocidin,
under-carboxylated osteocalcin, etc.
Encouraging controlled clinical studies and bigger epidemiological studies.
Osteoporosis care around the globe Japanese perspective 2008 03 13 ISCD annual meeting in San Francisco
3

Osteoporosis
care around the globe:
China and Hong Kong
Age-specific prevalence of vertebral fractures in
Asian women compared to Caucasian women
(Vertebral fracture is defined as more than 3SDs below the mean of
the vertebral height ratios)
Annie Kung
Sir David Todd Professor
Department of Medicine
Queen Mary Hospital, Hong Kong
Kung AWC J Bone Miner Metab 2004; 22: 170-175
Hip Fracture incidence in Hong Kong
10-year Probability of Osteoporotic Fracture
(Hip, Clinical Spine, Forearm) by Age and Country
Women
2500
Men
1400
Probability (%)
Inc
cidence
2000
1500
1000
1966
1985
1991
1996
2000
2004
In
ncidence
1200
1000
800
600
40
30
Age (years)
50 60 70 80
400
500
200
20
0
50-59 60-69 70-79 80 and above
Age group
0
50-59 60-69 70-79 80 and above
Age group
10
Kung et al. Osteoporos Arch (In Press)
0
China Spain UK Sweden Hong Kong
Kung AWC et al, JBMR 2007
Chinese 0.693 g/cm 2 0.521 g/cm 2 5
10
Diagnosing Osteoporosis
40
35
30
Caucasian values
25
20
Femoral Neck
15
Caucasian 0.772 g/cm 2 0.572 g/cm 2
10
Classification based on WHO recommendation
BMD T scores based on a large Chinese database of
>10,000 subjects
• absolute BMD in women about 10% lower than
• BMD at T-score = -2.5:
Spine
10-year Probability of Osteoporotic Fracture
(hip, clinical spine, forearm) by BMD T Score
and Country
Probability (%)
0
T-score femoral neck
0 -1 -2 -3 -4
China Spain UK Sweden Hong Kong
Kung AWC et al, JBMR 2007
1

Availability of Assessment
• Osteoporosis awareness of the population in
China and Hong Kong is gradually improving in
the past decade. Awareness campaign limited to
major cities. Central DXA limited to hospitals and
major clinics in a few large cities.
• BMD testing: China: Mostly younger at risk
patients and post-fracture ambulatory patients.
HK: Mostly health-conscious low risk women!
Majority of fractured patients do not receive any
measurements nor treatment.
Interaction of Age with Other Clinical Risk Factors
on 10-year Risk of Osteoporotic Fracture in
Hong Kong Chinese Women
Use of w alking aids
Homebound
Dietary calcium intake < 400 mg/day
Total hip BMD T-score ≤ -2.5
Previous history of fracture
BMI < 19 kg/cm2
Outdoor w alking < 30 min/day
Family history of fracture
Steroid use
Smoke / drink
Age ≥ 65 years
Age < 65 years
≥ 1 fall w ithin 1 year 0 5 10 15 20 25
None
10-year risk of fracture (%)
Kung AWC et al, JBMR 2007
Proposed Clinical Algorithm in Hong Kong
Clinical Risk Factors
HIGH INTERMEDIATE LOW
TREAT
DXA
REASSESS
PROBABILITY
LIFESTYLE
ADVICE
Treatment Availability
• Medications: Antiresorptives and bone formers
are available. China: limited reimbursement
mostly self-financed. Hong Kong: almost all selffinanced
except steroid-induced osteoporotic
fractures.
• Treatment decision lies in BMD results
and history of fracture.
• Monitoring during therapy: depend on individual
practice. Mainly by BMD at 1-2 yearly intervals.
Bone markers very limited availability.
HIGH
LOW
Clinical Managemnt Guidelines for Osteoporosis in HK (submitted)
Future directions in OP Care
• Well facilitated centres in large cities, increasing
interest in both medical and public sectors;
growing wealth of epidemiology data;
establishment of government and NGO bodies
to promote osteoporosis activity
• Challenges: huge and growing size of elderly
population; limited resources; limited auditing
and registry systems to collect patient
information
• Objectives: maintain the low fracture rate in
China!
2

OSTEOPOROSIS CARE AROUND THE GLOBE
UNITED STATES
1
WHO CRITERIA FOR
POSTMENOPAUSAL OSTEOPOROSIS
2
Nelson B. Watts, MD
Bone Health and Osteoporosis Center
Metabolic Bone Diseases and Mineral Disorders
Category
Normal
Low bone mass
(osteopenia)
Osteoporosis
T-score
-1.0 and above
Between -1.0 to -2.5
-2.5 and below
Kanis JA et al, J Bone Miner Res 1994;9:1137-1141
www.ucosteoporosis.com
www.ucosteoporosis.com
3
Prepared by Nelson Watts MD 2007
4
HOW MANY PEOPLE HAVE OSTEOPOROSIS?
FRACTURES IN 2005 (US)
Millions
US Figures from NHANES-III adjusted using 2000 US census data
Men and women age 60 and older
45
40
Low Bone Mass
35
30
25
20
15
10
5
0
Men Women Total
T-score
-1.0 to -2.5
Osteoporosis
T-score
-2.5 and below
2 million fractures in 2005
29% occurred in men
14% occurred in nonwhites
Pelvis 7%
Other 33%
Humerus
Clavicle
l
Wrist 19%
Hands/fingers
Patella
Tibia/fibula
Vertebra 27%
Hip 14%
Data from National Osteoporosis Foundation, America’s Bone Health 2002
www.ucosteoporosis.com
Burge R et al, J Bone Miner Res 2007;22:465-475
www.ucosteoporosis.com
Prepared by Nelson Watts MD 2007
COST OF FRACTURES IN 2005 (US)
Direct cost was $16.9 billion in 2005*
57% was spent on inpatient care
30% was spent on long-term care
13% was spent on outpatient care
Wrist 3%
Vertebra 6%
Pelvis 5%
Other 14%
Humerus
Clavicle
Hands/fingers
Patella
Tibia/fibula
Hip 72%
*Does not include lost productivity, unpaid
caregiver time, transportation and social services
Burge R et al, J Bone Miner Res 2007;22:465-475
www.ucosteoporosis.com
5
WHO SHOULD HAVE A
BONE DENSITY TEST?
• All postmenopausal women should be screened
– At age 65 if there are no risk factors
– Younger if there are risk factors:
• Low body weight
• Family history of osteoporosis
• Cigarette smoking
• Fracture age 45 or older
– Affected by diseases or conditions or use drugs that
cause bone loss
• Healthy men should be tested at age 70
– Higher risk men should be tested earlier
www.ucosteoporosis.com
6
1

7
Prepared by Nelson Watts MD 2007
8
OSTEOPOROSIS
DIAGNOSIS AND/OR TREATMENT
HEDIS ® Measures 2003
Medicare Disease Management Rates *
Disease / Management
Rates
Beta blocker after MI 94%
Breast cancer screening 74%
Colorectal cancer screening 50%
Dx or Rx after fracture 18%
(8% DXA, 10% prescription, 3% both)
HEDIS = Health Plan Employer Data and Information Set; MI = myocardial infarction.
UNDER-DIAGNOSIS OF OSTEOPOROSIS
5.1 million
osteoporotic
women
age ≥65*
21.6% treated
17.5% tested
Tested and Treated
10.7%
Treated, not tested
10.9%
*CMS BESS, MEDSTAT MarketScan, Kaiser Permanente
Tested, not treated
6.8%
Not tested or treated
71.6% (3.7 million
*The National Committee For Quality Assurance
The State of Health Care Quality 2004. NCQA Washington, DC
www.ucosteoporosis.com
King AB et al, Osteoporos Int 2005;16:1545-1557
www.ucosteoporosis.com
Prepared by Nelson Watts MD 2007
9
10
DECREASING REIMBURSEMENT FOR DXA
FUNDAMENTAL MEASURES
FOR BONE HEALTH
Year
Work
RVU
PE
RVU
MP
RVU
Total
RVU
Conversion
factor (CF)
Payment
2006 0.30 3.20 0.18 3.68 $37.90 $139.46
2007 018 0.18 259 2.59 018 0.18 295 2.95 $37.90 $111.81
2008 0.18 1.99 0.18 2.35 [$34.18] [$80.32]
2009 0.18 1.39 0.18 1.75 [$32.47] [$56.82]
2010 0.18 0.79 0.18 1.15 [$30.85] [$35.48]
CALCIUM
VITAMIN D
EXERCISE
MPFS = Medicare Physician Fee Schedule; BN = budget neutrality; SGR= sustained
growth rate; PE= practice expense; MP= malpractice; RVU = relative value units
[ ] = payments modeled with 5% reduction/yr. with freeze for 2007 only
Federal Register November 2006; CMS-1321-FC
www.ucosteoporosis.com
www.ucosteoporosis.com
WHOM TO TREAT WITH
PRESCRIPTION MEDICATION
11
FDA-APPROVED MEDICATIONS
INDICATIONS
Postmenopausal
Osteoporosis
Glucocorticoid-induced
Osteoporosis
Men
12
Drug Prevention Treatment Prevention Treatment
• Women who have osteoporosis
– Fragility fractures
– BMD T-score –2.5 25and dbelow
• Consider treating women whose BMD is
borderline low (e.g., T-score –1.5 and below)
if they have risk factors
Hodgson SF and Watts NB.
AACE Osteoporosis Guidelines
Endocrine Practice 2003:9:544-564
Estrogen
Calcitonin
(Miacalcin®, Fortical®)
Raloxifene
(Evista®)
Ibandronate
(Boniva®)
Alendronate
(Fosamax®)
Risedronate
(Actonel®)
Zoledronic acid
(Reclast®)
Teriparatide
(Forteo®)
www.ucosteoporosis.com
www.ucosteoporosis.com
2

POOR ADHERENCE IS COMMON IN
CHRONIC “SILENT” DISEASES
13
OSTEOPOROSIS IN THE US
14
• 50%-70% with comply with antihypertensives 1,2
• 36%-93% with oral hypoglycemics 3
• 24%-40% with statins 4,5
• 25%-75% with osteoporosis medications 6-9
• 48% of patients did not refill a second
prescription for an osteoporosis drug 10
1. Schroeder K et al, Arch Intern Med 2004;722
2. Conlin PR et al, Clin Ther 2001;1999
3. Cramer JA, Diabetes Care 2004;27:1218
4. Benner JS et al, JAMA 2002;455
5. Jackevicius CA et al, JAMA 2002;288:462
6. Clowes JA et al, J Clin Endocrinol 2004;89:1117
7. Papaioannou A et al, Osteoporos Int 2003;14:808
8. Turbi C et al, Clin Ther 2004;26:245
9. McCombs JS et al, Maturitas 2004;271-287
10. Watts NB et al J Manag Care Pharm 2004;10:142
GOOD
• DXA is widely available
• Multiple treatments are available, usually without
requirement for a particular T-score or prior fracture
BAD
• DXA reimbursement is too low and is decreasing
• Testing and treatments are overutilized in low risk
populations and underutilized in high risk populations
• Persistence with treatment is poor
www.ucosteoporosis.com
www.ucosteoporosis.com
3

HANDOUTS
Friday, March 14, 2008
The following sessions do not have slides included in this handout:
Bone and Fat: Obesity, Bariatric Surgery and Skeletal Health, Brian Sabowitz
Why do we need Quality in Densitometry Operation?, Neil Binkley, Steve Petak,
Michael Lewiecki
Clinical Application of Fracture Risk Assessment, Marjorie Lucky
Update on Male Osteoporosis, Eric Orwoll
Slides were not available at time of printing:

2/25/2008
Glucocorticoid-Induced Osteoporosis
Steroid-Induced Osteoporosis
and Stress Fractures
Nancy E. Lane, MD
Director, Aging Center
Professor of Medicine and Rheumatology
University of California at Davis
Sacramento, California
• Most common form of secondary osteoporosis
• Occurs at any age, in both sexes and across
ethnic groups
• Approximately 30-50% of patients sustain
osteoporotic fractures
• Common long-term uses:
– Pulmonary and Rheumatologic disorders
– Inflammatory bowel disease
– Organ transplantation
– Neurological diseases
– Skin diseases
Adinoff et al. NEJM 1983;309:265-268
Michel et al. J Rheumatol 1991;18:804-808
Lems at al. Clin Exp Rheumatol 1995;13:293-297
Pathophysiology of Glucocorticoid-Induced
Osteoporosis
GIOP Bisphosphonate Trials:
Fracture Rate
Glucocorticoids
Urinary calcium excretion
Osteoblast bone formation Estrogen
GI calcium absorption
Testosterone
Apoptosis
Adrenal androgens
Lifespan
Calcium
Function
Osteoclast bone resorption hPTH 1-84
Osteoporosis
Fracture
Rate
(%)
50
45
40
35
30
25
20
15
10
5
0
40%
risk
reduction
1 year
(Adachi 97)
Baseline
Placebo
1 year
(Reid 98 - Abstract)
Etidronate 400 mg Cyclical
Risedronate 5 mg
Alendronate 5 mg, 10 mg
Alendronate Ext 2.5 mg, 5 mg, 10 mg
70%*
risk
reduction
40%
risk
reduction
1 year
(Saag 98)
90%*
risk
reduction
2 year
(Saag 98 - Abstract)
*P < 0.05
Etidronate Risedronate
Alendronate
Definitions
Percent Change in Bone Mineral Density at the Lumbar
Spine and Total Hip from Baseline to 18 Months
• Stress fractures occur from repeated
cyclical loading of bone
– Stress fracture: Occur in bone with normal
resistance which has been loaded to
excessive demands. Frequent in young
adults
– Insufficiency fracture: Occur in weakened
bone. Often over age of 50
Saag K et al. N Engl J Med 2007;357:2028-2039
1

2/25/2008
Evidence Based Guidelines for the
Prevention and treatment of GIOP
• Prevention of GIOP is recommended for all
subjects treated with GCs
• Prednisone = 800IU/d supplementation only
• Prednisone >= 7.5mg a day or > 3 months of
therapy
– Bisphosphonates for patients with low bone mass
– rhPTH 1-34 may be the drug of choice for GC
treated patients with osteoporosis
Devoglear et al Osteo.
International 2005
Epidemiology of Stress
Fractures
• Fatigue fractures: Military recruits, athletes,
dancers, children associated with change in
intensity or regularity
• Established risk factors: thin bones, low BMD,
less physical fitness
• Fractures are present in areas of maximal
stress-lower extremities, eg tibia, fibula, pelvic
ring and feet
Stress Fracture vs. Pathologic
Fracture
Typical locations of Stress Fractures
by activity
• X-ray: endosteal thickening,
benign
• Periosteal reaction
• CT-endosteal thickening,
benign periosteal reaction
• MRI-linear to bandlike
abnormality, edema on T2,
• Bone scan or PET-focal or
linear abnormality
• X-ray and CT Aggressive bone
marrow pattern of destruction,
mineralized matrix, endosteal
scalloping, aggressive
periosteal reaction, soft tissue
mass
• MRI-Well defined T1 bone
marrow abnormality, endosteal
scalloping
• Bone Scan or PET- diffuse
uptake,
• Ulna-coronoid-pitching
• Humerous-distal diaphyses-throwing
• Ribs- carrying heavy objects, gold
• Lower cervical spine-clay shoveling
• Obturator ring-bowling, gymnastics
• Femur diaphyses and neck-ballet, running
• Fibula, tibia-running and jumping
• Calcaneus-jumping
• Tarsal navicular-marching, running
• Metatarsal diaphyses-marching
2

2/25/2008
Alternative Therapies for
Osteoporosis:
Effects on BMD and Fracture
Risk
Rogene Tesar, PhD, CMRT, RD, LD
Austin Thyroid & Endocrinology
Austin, TX
Alternative Medicine
• Alternative medicine ---sometimes called complementary
medicine---- is rapidly growing in popularity.
• Surveys show that over 40 million Americans use some form of
alternative therapy (nutritional supplements, herbs, meditation,
prayer, acupuncture, Ayurveda, etc.)
• Why? Standard Western medicine does not have all the
answers.
• NIH has responded to this overwhelming interest several years
ago by opening a branch dedicated to alternatives: the National
Center for Complementary & Alternative Medicine
Alternative Therapies
• In US, value of a drug is determined by large-scale, double-blind,
placebo-based studies
• Many alternative e therapies are naturally occurring substances; they
cannot be patented
• No incentive for pharmaceutical companies to invest millions of
dollars on clinical trials to determine effectiveness
Standard Preventive & Treatment
Methods for Osteoporosis
• Adequate calcium Vitamin D
• Weight-bearing & resistance type exercise
• Avoiding smoking
• Avoiding excessive alcohol consumption
• Bisphosphonates: alendronate, risedronate, ibandronate,
zoledronate
• Raloxifene Teriparatide Estrogen Calcitonin
• Numerous relatively small-scale studies on alternative therapies; many
show promise. Pharmaceutical firms are testing some synthetic forms
for their potential in treating various diseases.
Soy Isoflavones
Ipriflavone
• Soy contains phytoestrogens which act like mild estrogens
(phytoestrogens in soy are called isoflavones)
• Receptors for estrogen are on both osteoblasts and
osteoclasts
• Estrogen enhances calcium & phosphorus absorption and
bone deposition
• Observational studies suggest that women who consume
large amounts of soy have fewer fractures
• Laboratory-manufactured derivative of daidzin (substance
found in soy)
• Used for many years in Japan and Italy to preserve bone
strength and density in PMP women
• May encourage osteoblast action & discourage osteoclast
action
• Some studies from Japan & Europe: ipriflavone can help
slow bone loss rate
1

2/25/2008
Vitamin K 2
• Factor discovered in fatty components of food in 1939 that
aids in clotting of blood
• Vitamin K: really 3 related substances
• K 1 (phylloquinone) found in plants
• K 2 (menaquinones) produced in human digestive tract
by bacteria
• K 3 (Menadione) a synthetic variant
Strontium
• A naturally occurring mineral present in water and food
• Different from radioactive “strontium-90” formed by
nuclear fission
• Trace amounts in human skeleton with affinity for bone
• Incorporated onto the crystal surface of bone
• Researched since 1950; recent findings: promotes bone
formation and decreases bone resorption
• Supplemental forms: over 20 different compounds
• Strontium renelate ~340 mg strontium/1 g compound
DHEA
• DHEA: dehydroepiandrosterone
• Most abundant hormone found in the human body
• Produced in the adrenals, ovaries, testes, brain & skin
• Regulates 18 or more other steroid hormones; increasing lean muscle
mass, burning fat, and stimulating bone growth
• Converted in bone cells into estrogen (estrone), progesterone &
testosterone
• Only (?) hormone that increases cellular activity of osteoblasts and
also inhibits osteoclasts .S.LeVert, The Promise of Eternal Youth 1997
• Requires D 3 to form estrone; D 3 requires DHEA to stimulate
osteoblasts
• Positive correlation between DHEA levels & BMD in women > 50
• DHEA levels decline with age, concurrent with onset of osteoporosis*
Natural Progesterone
• Manufactured in the laboratory from wild yams and soy beans; not to
be confused with yam extracts sold in health food stores.
• Recommended for treating everything from menopausal symptoms,
migraine, loss of libido and depression to water retention and
fibrocystic breasts. Skepticism abounds in the health field; however,
many women find it effective in bringing relief from premenstrual
syndrome, menopausal symptoms, dysfunctional bleeding and
endometriosis. Most information is anecdotal.
• Isolated studies since the 1970s have suggested a bone effect. Proof
of protection against osteoporosis is lacking.
• In 1990, a study by John Lee, MD, generated excitement about 63
women who gained bone using Pro-Gest® cream.
Summary
• “In terms of osteoporosis prevention, the rules are that drugs must be shown to
reduce the risk of fracture in properly designed, executed, presented, and interpreted
clinical trials. If this is not done, the drug may well be efficacious, but the evidence
is not there one way or another, so the decision of whether to prescribe the drug will
be according to feeling-based medicine or opinion-based medicine but not evidencebased
medicine.
• The studies must be double-blind, ,p placebo controlled, involve large sample sizes and
have few drop-outs, predefined primary end points, etc.
• The studies must be reproducible and consistent, done by different investigators in
different parts of the world, with similar results observed
• The best studies follow most of the criteria mentioned; the best studies available are
those of alendronate, risedronate, raloxifene, parathyroid hormone, and strontium
ranelate. The quality of data for other drugs such as calcitonin, etidronate,
menopausal hormone therapy, vitamin D metabolites, and calcium is not as
compelling so that inferences are more difficult to make.”
Ego Seeman, MD, PhD
2

Obesity, Bariatric Surgery, and
Skeletal Health
Brian N. Sabowitz, MD, FACP, CCD
Medical Director
Arizona Medical Weight Loss Clinic
Arizona Osteoporosis Centers
Disclosures
• Eli Lilly Speaker’s Bureau
• Proctor and Gamble Speaker’s Bureau
• Sanofi Aventis Spearker’s Bureau
What Is Bariatric Surgery?
• Surgery that alters the normal
gastrointestinal anatomy.
– Results in weight loss by one or more of
the following mechanisms
• Restriction - limits amount of food consumed at
any given time
• Malabsorption - reduces absorbing surface
area of the intestinal tract.
• Changes in neuro-hormonal control of appetite.
Common Procedures
• The two most common procedures are:
– Gastric Banding
• Purely restrictive procedure
– Roux-En-Y Gastric Bypass
•Restrictive
• Mal-absorptive
• Neuro-hormonal changes
Adjustable Gastric Banding
• Single
mechanism
of action
– restrictive
Roux-en-Y Gastric Bypass
• Has become the
gold standard.
– Affects all three
mechanisms of
action
– Excellent safety
profile in
experienced hands
– Excess weight loss
of 40% at 5 years.
– 60 % reduction in
mortality at seven
years
Busetto L, et al Surgery for Obesity and Related Diseases, 2007: 3:496-502
1

Association Between Body Weight
and Bone Mineral Density
• Both Cross Sectional and Longitudinal
Studies confirm that obesity confirms
higher BMD and lower fracture rates
Cross Sectional Studies
• Cross Sectional Studies
– Compared to a BMI of 20 kg/m 2 a BMI of ~
30 kg/m 2 is associated with
– 4-8% greater AP spine BMD
– 8-9% greater total hip BMD
– 25% greater BMD at the radius.
Osteoporosis vol 1 pg 756
Longitudinal Studies
• Longitudinal Studies
– Tremollieres et al*
• 31 month study compared overweight postmenopausal women
(BMI>25 kg/m2) to normal weight postmenopausal women
(BMI < 25 kg/m2)
• Annual rate of vertebral bone loss:
– Overweight 0.54-1.1%
– Normal weight 1.46-1.6%
– P

So What To Do?
• Expert (?) Opinion
– Optimize pre-operative status
• Vitamin D status
• 24 hour calcium excretion
•PTH
• Baseline Bone Density
– Full Central if possible
– Bilaterally forearms
• Bone Turnover Markers
– Post operative monitoring and treatment
• Liquid or chewable calcium and vitamin D
supplementation.
• Monitor Vitamin D, PTH, 24 hour urine
excretion, bone turnover markers quarterly
• Follow DXA annually
• Treat at same T-score you normally would.
• Insufficient evidence to justify treating “bone
loss” at this time.
• DO NOT use oral bisphosphonates in
gastric bypass or gastric band patients.
– The risk of pill esophagitis, esophageal
leak is very high.
– Further, Poly-Cystic Ovarian Syndrome is
common in this patient group and post
operative, unexpected pregnancy is not
uncommon.
3

Bone and Fat: Effects of
Diabetes and Antidiabetic
Therapies on Bone
Sophie A Jamal, MD, FRCPC, PhD
Assistant Professor of Medicine, University of Toronto
Director, Osteoporosis Clinical and Research
Programs, Women’s College Hospital
Objectives
• To understand the effects of diabetes
on bone
• To understand how agents used to treat
diabetes might influence bone
Type 1 Diabetes
• Low BMD and increased fracture risk
• Meta analysis of 5 studies: hip fracture 6.9
( 3.2 to 14.8)
• Tromso study: 3x risk of nonvertebral
fractures compared with nondiabetics
• Case control study: RR of any fracture 1.9
(1.2 to 3.0)
Vestergaard P, et al. Osteoporosis Int 2007
Ahmed LA, et al. Osteoporosis Int 2006
Vestergard P, et al. Diabetologia 2005
Why Might Patients with Type 1
DM Fracture?
• Reduced bone density
• Altered bone mineral
• Low 25(OH)
• Hyerpercalciuria, hypomagnesemia
• Reduced renal function
• Altered turnover
• Increases in cytokines
• Altered architecture
• Microvascular disease may reduce blood flow to
bone
Type 2 Diabetes and Fracture:
A Paradox
• Increase in BMD
• Increase in weight
• mechanical loading
• hormonal factors: insulin, estrogen, leptin
• Increased circulating insulin
• promotes bone formation in vitro via
increased proliferation and differentiation of
osteoblasts
• Increase in fractures
Observational Data: Type 2 DM
• An increased risk of hip, proximal
humerus, ankle fractures
• RR of hip fracture: 1.1 to 5.8 in women
• RR of hip fracture: 1.0 to 7.7 in men
• ? Increased risk of vertebral fracture
De Liefde et al. Osteoporosis International 2005
Bonds et al. JCEM 2006
Schwartz et al. JCEM 2001
Forsen et al. Diabetologia 1999
Nicodemus et al. Diabetes Care 2001
Janghorbani et al. Diabetes Care 2006
Ahmed et al. Osteoporosis International 2006
1

Why Might Type 2 DM Increase
Fractures?
• Increased risk of falls (by 50 to 60%)
• Increased risk for injurious falls
• Impaired vision
• Stroke
• Hypoglycemia
• Neuropathy
Increase in Falls Not the Entire
Explanation
• SOF: Association persisted after adjustment
history of falls, RF for falls, injurious falls
• Nord-Trondelag Health Survey: RR hip
fracture 1.8 partly accounted for by risk factors
• Older Mexican-American adults: 50% increase
in hip fracture risk after adjusted for RF
Schwartz et al. JCEM 2001
Forsen et al. Diabetologia 1999
Ottenbacher et al. J Gerontol A Biol Sci Med Sci 2002
Type 1 versus Type 2 DM
• Increased risk in type 1 DM may be partly
explained by lower BMD
• Factors common to BOTH type 1 and type 2
may also contribute to fracture risk
• Hyperglycemia
• Neuromuscular disability
• Neuropathy, visual impairment
• Insulin deficiency?
Insulin
• Associated with an increased risk of
fracture and falls
• Marker for more severe diabetes
• Hypoglycemia
Thiazolidinediones
• Increase risk of fracture in women
• Increased rate of bone loss
• BUT- most studies on DM and fractures
before agents available
Short R, et al. BMJ 2007
Grey A, et al. J Clin Endocrinol Metab 2007
2

Clinical Application of Fracture Risk
Assessment: How does it translate to
clinical practice?
Most Osteoporotic Fractures Occur in
Non-Osteoporotic People!
William D. Leslie, MD MSc FRCPC CCD
Marjorie M. Luckey, MD CCD
Cranney, A. et al. CMAJ 2007;177:575-580
Comparison: Fracture Risk Systems
OC Manitoba WHO
BMD Minimum site Total hip Femoral neck
Clinical Fracture after age 40
Steroids >3 m
BMI (3 m) Ever use steroids
Arms to stand Alcohol >2 units/d
Rheumatoid arthritis
Output Semi-quantitative Quantitative 10 y Quantitative 10 y
High risk >20% >20% Country defined
OC Semi-Quantitative System
• A simplified risk assessment system
from gender, age, minimum T-score,
and two clinical risk factors (CRFs) -
prior fracture and systemic
corticosteroid (CS) use - has been used
in Canada since 2005
OC Categorization of Fracture Risk
Absolute fracture risk in 10 years:
low: 20%
Additional Clinical Factors
• Selected clinical factors:
– Fragility fractures after age 40
– Systemic glucocorticoid therapy >3 months
Systemic glucocorticoid therapy 3 months
• Each factor effectively increases risk
categorization to the next level:
– from low risk to moderate risk, or
– from moderate risk to high risk
CARJ 2005; 56(3):178-188 (www.osteoporosis.ca)
1

Manitoba Model
WHO Scientific Group Meeting
on Fracture Risk Reporting
Brussels, Belgium, May 5-7, 2004
• Goal: To develop a standardized methodology for
expressing fracture risk and intervention thresholds for
men and women worldwide
• Leader: Prof. John Kanis, WHO Collaborating Centre,
Centre for Metabolic Bone Diseases, University of
Sheffield, UK
• Method: Study correlations of BMD and clinical risk
factors with fracture outcomes in large observational
studies
• Organizations Represented: ASBMR, IOF, ISCD, NOF
Lifetime hip fracture risk in men and women aged 50 years
Clinical Risk Factors:
FRAX TM predictions for woman age 65, T-score -2.5
%)
10-y ear risk (%
10
8
Hip fractures
6
4.6 4.6
5
3.9 4.1
4
2.7 2.6 2.9
2
0
None
BMI 20
Previous #
Parent hip
Sm oking
Steroids
RA
EtOH 3+
10-y ear risk ( % )
40
30
20
10
0
19
16
All osteoporotic fractures
30
34
20
29
24 23
None
BMI 20
Previous #
Parent hip
Sm oking
Steroids
RA
EtOH 3+
Women
Sweden
Norway
Switzerland
Iceland
Australia
Italy
Czech
Denmark
USA
Netherlands
Germany
UK
Canada
Japan
France
Finland
Spain
Greece
Portugal
Thailand
Taiwan
Hong Kong
Mexico
Hungary
China
Turkey
Cameroon
Men
http://www.shef.ac.uk/FRAX/index.htm
30%
20%
10%
0%
0% 5% 10% 15%
Country/Ethnicity and Risk:
FRAX TM predictions for woman age 65,
T-score -2.5, weight 70 kg, height 165 cm
Sex and Risk:
FRAX TM predictions for age 65,
T-score -2.5, weight 70 kg, height 165 cm
( % )
10-y ear risk (
10
8
Hip fractures
6
4.9
4
2.7
3.1
1.2 1.5 1.5 1.3 2.1 2 1.7
2.1
2
0.5
0
US-Caucasian
US-Black
US-Asian
US-Hispanic
China
France
Italy
Japan
Spain
S w eden
Turkey
UK
%)
10-y ear risk (%
All osteoporotic fractures
25
19
20
15
15
9 11 11 12
9.9 10
10
4.3 6.1 5.6
5
1.8
0
US-Caucasian
US-Black
US-Asian
US-Hispanic
China
France
Italy
Japan
Spain
Sweden
Turkey
UK
%)
10-y ear risk (%
10
8
6
4
2
0
3.4
2.7
US-
Caucasian
Woman
Hip fractures
Man
2
1.21.4
1.5 1.5
1.9
US-Black
US-Asian
US-
Hispanic
10-y ear risk ( % )
25
20
15
10
5
0
19
15
US-
Caucasian
All osteoporotic fractures
9
6.4
US-Black
11 11
9 8.8
US-Asian
US-
Hispanic
http://www.shef.ac.uk/FRAX/index.htm
http://www.shef.ac.uk/FRAX/index.htm
2

ROC for hip fracture prediction
at the ages of 50 and 70 years:
9 derivation cohorts
Incremental Change in Fracture Risk
Prediction from CRFs
Global Chi-squ uare
600
500
400
300
200
100
P < .0001 P < .0001 P < .0001
Without CRFs *
With CRFs
* 10 year risk from
age and BMD only
0
Femoral Neck Total Hip Minimum Site
Kanis J et al. Osteoporos Int. 2007 Aug;18(8):1033-46.
Leslie WD et al. ASBMR 2007.
What Do Doctors Say?
The BMD report contains the information I need
to manage my patients…
50
40
30
20
10
T-score report
0
50
40
30
20
10
1 2 3 4 5
10-year risk report
0
1 2 3 4 5
strongly
strongly
agree
disagree
Leslie WD. Osteoporos Int 2008; in press.
3

A Crisis in Healthcare: Will DXA and VFA Disappear From the Office Setting?
Andrew J. Laster, MD FACR, CCD
Abstract: Osteoporosis is a major chronic disease that affects up to 50% of Medicare
beneficiaries. DXA is the gold standard for diagnosing this disease and monitoring
response to medical therapy. Once identified, medical therapies are available which
reduce fracture risk and save lives. Significant health care savings could be realized if
preventive efforts could be expanded. CMS has recently championed the importance of
preventive health and DXA testing as part of the “Welcome to Medicare Exam”. Despite
this, screening rates for osteoporosis using DXA remain extremely low at slightly less
than 10% annually. Unfortunately, the recent Medicare 5 year review has assigned a
new RVU to central DXA that so profoundly undervalues this service that virtually all
physicians in the non-facility setting will abandon DXA testing by 2010, thereby crippling
CMS efforts to increase screening rates and recognition of this serious but preventable
disease. Based on a series of surveys that the ISCD has participated in with other
clinical societies, we have identified errors in data input used to calculate the new DXA
RVUs that, if corrected, would more appropriately value DXA reimbursement. A recent
analysis by the Lewin Group also points to a DXA cost that approximates
reimbursement previously provided at the 2006 RVU level. Appropriately valued, DXA
could be the centerpiece tool in the CMS effort to prevent osteoporosis among Medicare
beneficiaries.
Osteoporosis causes fractures in approximately half of women and one quarter of men.
Over 20% of adults who sustain a hip fracture die within the following year and many
more never regain independence. Annual direct health care costs for fracture care in the
United States currently approximate $16.9 billion and are projected to exceed $25 billion
by 2025. Despite the epidemic proportions of osteoporosis, the test used to diagnosis
this preventable disease, and hailed by the Surgeon General in 2004, as “one of the
most significant advances in the last quarter century,” is in danger of being eliminated
from the women’s health care arsenal by Medicare payment policies. The test, DXA
(Dual Energy X-Ray Absorptiometry) (CPT code 77080), and a companion procedure,
VFA (Vertebral Fracture Assessment) (CPT code 77082), are critical for osteoporosis
diagnosis and for monitoring response to treatment. The 40% reduction in the Medicare
Physician Fee Schedule reimbursement for DXA in the non-facility setting (implemented
in 2007 with the Deficit Reduction Act) has already caused some physicians to lay off
staff, to delay or cancel the purchase of new bone density measurement equipment, or
to discontinue offering this vital service. By 2010, DXA reimbursement will have dropped
approximately 75%. With reimbursement far below operating costs, over 90% of
physicians have indicated that they will stop performing DXA studies by 2010, and this
essential preventive service will largely disappear from the non-facility environment.
The ISCD in conjunction with ACR, AACE, ASBMR and TES has provided information
regarding methodology and results from 3 surveys that were conducted within the last
16 months that identify flaws in data input, data omission, and erroneous assumptions
that have contributed to the incorrect calculation of reimbursement for DXA. These

surveys include the following:
• a clinical society survey in 2006 of physician work and direct practice
expense;
• a clinical society survey in 2007 of physician responses to the scheduled;
DXA reimbursement cuts to be phased in over the next 4 years; and
• a DXA cost analysis performed by the Lewin Group.
Utilizing the results of the first two surveys outlined above to assign more accurate
values for physician work and direct and indirect practice expenses, the reimbursement
for DXA more closely approximates the 2006 Medicare reimbursement rate of $139.
That these inputs mirror real world expenses are confirmed by the Lewin Group report
of a survey of physicians performing DXA in the non-facility setting. One of the purposes
of this study was to determine the true operating costs for DXA. The Lewin Group
concluded that the median DXA operating cost in the non-facility setting was $134; far
exceeding not only CMS recommendations for reimbursement in 2010 but also current
(2007) reimbursement rates.
If CMS does not fairly value DXA and grossly underestimates operating costs, then the
agency is not serving the people’s mandate as articulated by the Medicare Payment
Advisory Committee (MedPAC) in their March 2007 report to Congress. Undervalued
services will always see a fall in volume and thus will undermine CMS’ very own efforts
to improve recognition of osteoporosis through increased DXA testing. In the case of
central DXA, the current RVUs from this most recent 5 year review are so far below
operating costs for the procedure, that virtually all physicians in the non-facility setting
will stop performing DXAs. The result will be the virtual dismantling of the infrastructure
for delivering osteoporosis care in this country.
Despite osteoporosis screening being a service emphasized by CMS in their recent
preventive services campaign, in 2006 only 9.34% of qualified women enrolled in
Medicare had a DXA test. As DXA reimbursement in the office setting is currently far
below operating costs and is slated for much greater reduction by 2010, it is not
surprising that a recent survey found that virtually all physicians will stop DXA testing of
Medicare patients. As 2/3 rds of DXA studies are currently done in the office setting,
migration of these patients to the hospital setting is problematic. Although some might
argue that centralizing DXA testing in the hospital setting would be more efficient,
placing additional barriers to performance of an essential, and currently underutilized,
procedure is unlikely to increase screening rates among Medicare patients.
Moreover, moving DXA testing to the hospital setting would increase complexity of care
as the patient must now go to another location for DXA testing with another provider
and a different DXA machine. Additionally, the patient must then make another visit
with their primary doctor to review study results. It is well documented that reduced
access to care acutely affects vulnerable populations such as rural, ethnic, low-income
and elderly particularly. Moreover additional costs are incurred in transporting patients

and forwarding records. Finally, there is discontinuity of care and an inability to assess a
patient’s response to medical therapy over time when one switches bone density
measuring machines.
Screening rates which are sub-optimal now, would decline further with the increased
barriers to care. Instead of saving money, a decline in reimbursement rates for DXA
would lead to increased costs as fracture rates increase. The Lewin Group conducted a
Congressional Budget Office (CBO)-style scoring analysis of 5 year costs to Medicare if
the DRA and Medicare Physician Fee Schedule reimbursement cuts were reversed,
thus restoring the DXA reimbursement rate to the 2006 level of $139. The Lewin
analysis found that program costs over a five-year period resulting from the increase in
direct DXA payment would equal $648 million. However, after accounting for savings
associated with avoided fractures and the cost of treating at-risk individuals, restoring
DXA payments will actually save the Medicare program $1.14 billion over the same five
year period.
Since becoming aware of the reimbursement cuts in June of 2006, the ISCD has
devoted a significant amount of its energies to trying to reverse these potentially
devastating changes. The ISCD has also increased its activities at the individual state
level and tracks regulations of insurance companies that may impact osteoporosis care.
What follows is a brief summary of these initiatives.
FEDERAL INITIATIVES
In January of 2007, ISCD spearheaded formation of the DXA Task Force, comprised of
patient advocacy groups and other clinical societies including NOF, AACE, ACRheum,
ASBMR and TES. The DXA Task Force agreed upon a multi- pronged plan of action to
restore DXA Medicare payments to appropriate levels. With your help and the
commitment of our coalition partners, we made significant progress, including:
1. Introduction of Federal legislation-- HR 4206. On November 15, 2007,
Representative Shelley Berkley introduced H.R. 4206, the “Medicare Fracture
Prevention and Osteoporosis Testing Act of 2007.” The bill has bi-partisan support
with 48 co-sponsors. The DXA issue also caught the attention of key members of
Congress who tried to include a remedy in the Medicare package that was under
consideration in December. While this effort to reverse the DXA cuts in the Medicare
package was ultimately unsuccessful, the fact that our issue was on the table for
inclusion in the package demonstrated the importance of DXA testing among key
lawmakers. The threat of a presidential veto caused Congress to pass a scaled
down, bare bones Medicare package---one that ultimately did not include a fix for
DXA or other new Medicare initiatives.
2. Information and data generation—The Lewin Group Study: The DXA Task
Force commissioned the Lewin Group, a nationally respected healthcare research
organization, to study the impact of the DXA reimbursement cuts. The Lewin Group
final report (issued October 2007) concluded that: a) the median cost of performing a

DXA in the office setting is $134; and b) enacting the Berkley bill would actually save
Medicare $1.14 billion over a five-year period. ISCD and our partners are using the
Lewin report findings in Congressional meetings and briefings.
3. Grassroots advocacy: In May 2007, ISCD signed a contract with Vocus, an e-
advocacy system to facilitate ISCD grassroots efforts. This easy to use, customized
system has facilitated more than 7500 letters to members of Congress regarding the
DXA issue. Additionally, ISCD members and staff participated in Congressional
briefings and made Congressional visits both in the district and in Washington to
deliver the DXA message.
4. Public Relations: In March 2007, ISCD hired a media consultant, Big Voice
Communications, to coordinate ISCD media activities regarding the DXA cuts. ISCD
has placed articles in key Congressional districts regarding the effect of DXA cuts on
patient access.
5. Continued Dialogue with CMS: ISCD, the DXA Task Force and the American
College of Radiology were successful in convincing CMS and the AMA to change a
number of inputs used to calculate reimbursement for DXA; the result will be an
approximate $15 increase in the Medicare reimbursement for DXA from the
estimated $35 reimbursement that would take effect in 2010.
STATE AND INSURANCE INITIATIVES
In March 2007, ISCD began a weekly review of state legislation and regulations of
relevance to our members. As these proposals appear at the individual state level,
ISCD attorneys analyze, and when appropriate respond, submit testimony and make
comments to the respective legislative body or agency. We are working to keep ISCD
members apprised of these activities. As a result, ISCD is now a proactive organization
on the state level.
ISCD continues to monitor the private insurance market, where restrictions on the
qualifications of technicians and clinicians may impact reimbursement for services
provided. We will continue to analyze these insurance issues, intervene when
appropriate, and will make coverage requirements available on the ISCD website.
Where do we go from here?—Plans for 2008
It is essential that we continue to support HR 4206, by enlisting as many co-sponsors as
possible in the U.S. House of Representatives and locating a strong advocate to
sponsor companion legislation in the Senate.
From coordinating Congressional visits to putting into place state of the art web-based
advocacy systems and research tools and hiring supplemental staff for Public Relations
and lobbying activities, all of these efforts require significant resources from the Society.

In 2007, ISCD recognized the magnitude of the public policy issues facing the
osteoporosis care community and established a dedicated education and advocacy
fund to specifically address these critical but costly advocacy activities. In the coming
year, ISCD will continue the fight to preserve quality DXA testing. This battle goes to the
heart of the ISCD mission—to provide quality skeletal assessment to our patients. We
cannot do this without the continued support of our members. When the osteoporosis
community needed our help, the ISCD stepped up to the plate and committed the
resources necessary to get the job done. We urgently need your continued support. If
you have not renewed your membership, please do so now.
On behalf of the Public Policy Steering Committee and ISCD staff, many thanks to
our members who have been so responsive throughout the year and who have
been key to moving our public policy agenda forward. We look forward to
building on these successes in 2008.

2/25/2008
The Relationship Between Declining BMD and
Increasing Vertebral Fracture Risk
ure Incidence
tient-years)
Vertebral Fractu
(per 1,000 pat
60
50
40
30
20
10
Spine
Distal radius
Calcaneus
0
2 SD 1 SD Mean –1 SD –2 SD
Bone Mass
Wasnich RD et al. J Nucl Med 1989;30:1166–1171.
Bone Density and Fracture Risk by Age
10-Year Hip Fract ure Probability
20
18
Age
16
14
12
80
70
60
10
50
8
6
4
2
0
1 0.5 0 -0.5 -1 -1.5 -2 -2.5 -3
BMD in SD Units
Kanis JA, et al. Osteoporos Int 2001;12:989-995
Δ% Spine
BMD v PBO
Spine Fx Risk
Reduction
Publication
Date
FIT I 6.2% 47% 1996
FIT II 6.8% 44% 1998
MORE 2.1% 30% 1999
RVN 4.3% 41% 1999
RVE 5.9% 49% 2000
PROOF ~0.6% 36% 2000
Black DM, et al. Lancet 1996;348;1535-1541. Cummings SR, et al. JAMA 1998;280:2077-2082.
Ettinger B, et al. JAMA 1999;282:637-645. Harris ST, et al. JAMA 1999;282:1344-1352.
Reginster JY, et al. Osteoporos Int 2000;11:83-91. Chesnut CH, et al. Am J Med 2000;109:267-276.
Relationship Between Endpoint Lumbar Spine BMD and
Vertebral Fracture Risk After 18-Months of TPTD Treatment
re Risk
Fractu
0.30
Placebo
A-B = Abs. Risk Reduction Due to BMD Alone
0.25
B-C = Abs. Risk Reduction Due to non-BMD
0.20
Components
(A-B) + (B-C) = A-C = Total Abs. Risk Reduction
0.15 A
B
0.10
0.09
0.05
C
TPTD
0.00
0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3
Endpoint Lumbar Spine BMD (g/cm 2 )
Chen P, et al. J Bone Miner Res 2006;21:1785-1790.
To Find Your Short-Term Precision
The Root-Mean-Square Standard Deviation
Scan...
10 people 4 times each
15 people p 3 times each
30 people 2 times each
Complete the scans in 2 weeks
to 1 month
SD
RMS
=
SD
m
m 2
∑
j = 1
where “m” is the number of subjects
1

2/25/2008
3 Things Required to Determine
the LSC
1 x 1Least Significant Change
-2 Sided
Z′ 2( Pr)
1. Your Precision (Pr) as the
RMS-SD or RMS-CV
2. The number of
measurements at each time
point (n 1 and n 2 )
1 1
Z′( Pr ) +
n n
1 2
• 1x1 LSC 95-2
• 1x1 LSC 80-2
1.96 x 1.414 (Pr) = 2.77 (Pr)
1.28 x 1.414 (Pr) = 1.81 (Pr)
3. The Z´ value for the desired
level of confidence & approach
But Do I Care?
• There is a statistically significant relationship between increasing
BMD vs. placebo and decreasing fracture risk.
– The magnitude of this relationship is the subject of debate but not the
existence of the relationship itself.
– The majority of fracture risk reduction appears to be due to non-density
related factors, but the increase in BMD, as a single quantifiable factor,
does indeed account for a sizable proportion of the reduction in spine
fracture risk.
• Although no change in BMD vs placebo in patients on therapy still
appears to confer a reduction in fracture risk, greater reductions in
spine fracture risk are seen in patients on therapy who gain BMD than
in those on therapy who lose it.
• There is no evidence that fracture risk reduction is achieved on
therapy if a significant loss in BMD is seen.
• A significant loss of BMD may indicate lack of therapeutic
responsiveness, a previously undetected secondary cause of bone
loss requiring treatment or non-compliance.
• At present, when it comes to objectively assessing therapeutic
efficacy, there is nothing better than the measurement of BMD.
2

2/25/2008
Why Do We Scan?
What Do We Expect?
Michelle Heater, RT ( R)(M)(BD), CDT
Why Are Bone Mass
Measurement Studies
Performed?
• To make a Dx of osteopenia & osteoporosis
• To predict fracture risk
• To follow serial monitoring to measure
response to intervention(s) or
medication/disease that effect bone
The Dx of Osteopenia &
Osteoporosis
• World Health Organization criteria for the
diagnosis of osteopenia & osteoporosis
Osteopenia = T-score < -1.0 and > -2.5 SD
Osteoporosis = T-score < -2.5 SD
The Prediction of
Fracture Risk
• Low bone mass is the most important
prediction of fragility fracture
• The three most powerful risk factors are low
BMD, increasing age, and prevalent
vertebral fractures. Falling is an important
risk factor for hip fracture.
Serial Assessment of
Bone Mass
• Can be used for monitoring of the natural
progression of disease process
• For monitoring the response of bone to
pharmacological interventions
• The change observed between serial BMD can be
expressed as a percentage change between two
measurements or absolute change (in grams/cm2)
between two measurements
What Do We Expect?
• Is it possible to see low bone mineral
density with patients who have a history of
Turner’s Syndrome, vertebral fractures,
cigarette smoking, alcohol use, and
hyperparathyroidism? Yes.
1

HANDOUTS
Saturday, March 15, 2008
The following sessions do not have slides included in this handout:
Non-Pharmacologic Therapies for Vertebral Fractures, Orlando Ortiz
Non-DXA Approach to Osteoporosis: Assessment of Bone Structure, Tony Keaveny
Non-DXA Approach to Osteoporosis: Role of the Radiologist in Osteoporosis Care,
Bradford Richmond
Treatment UpdateCurrent Update and Future Therapies for Osteoporosis, John
Bilezikian
Slides were not available at time of printing.

2/25/2008
Location of fractures in children
Bone density, bone geometry
and forearm fractures in
healthy children
Heidi J. Kalkwarf, PhD
General & Community Pediatrics
Forearm/ wrist 24%
Hand/ finger 21%
Toe/ foot 11%
Upper arm 8 %
Head/ nose/ jaw 8 %
Leg 7 %
Ankle 5 %
Other 6 %
Jones 2002
Bone characteristics
& fracture risk
Density & dimensionsi
4%
20%
Forearm pQCT Scan
4% site
20% site
Total vBMD
Trabecular vBMD
Bone area
Cortical vBMD
Cortical thickness
Circumferences
SSI
2
Percent difference in DXA measures of BMD
between cases & controls
2
Percent difference in 4% site peripheral QCT measures
between cases & controls
p=0.008 p=0.01 p=0.005 p=0.01 p=0.13 p=0.65
p = 0.03 p = 0.78 p = 0.67
1
1
0
* * * *
0
*
ence
% Differe
-1
-2
nce
% Differen
-1
-2
-3
-3
-4
-4
-5
Lumbar Spine Total Hip Femoral Neck Neck Neck 1/3 radius Ultradistal Radius Total Body
Skeletal Site
-5
Total vBMD Trabecular vBMD Total area
Measure
1

2/25/2008
Percent difference in 20% site peripheral QCT measures
between cases & controls
2
1
0
p = 0.01 p = 0.09 p = 0.04 p = 0.33 p = 0.88 p = 0.04
*
* *
nce
% Differen
-1
-2
-3
-4
-5
Cortical vBMDCort thickness Cort area Peri circ. Endo circ. SSI
Measure
2

Bone Age and Its
Relationship to Bone
Density Assessment in
Children
Babette Zemel, PhD
Division of GI, Hepatology and Nutrition
The Children’s Hospital of Philadelphia
University of Pennsylvania School of Medicine
Bone Age and Bone Density
• Bone age is “associated” with bone density
• Few studies have examined the value of
bone age as a predictor of bone mineral
density
• Bone age is also associated with body size.
• Is the effect of bone age on bone density
mediated by body size?
Greulich and Pyle Atlas of Skeletal
Development of the Hand and Wrist
• Used in the U.S.
• Developed in the 1930’s based on a longitudinal
sample of 1000 well-nourished White children
measured 1931 to 1942
• The atlas was used to assess bone age in an
independent sample (Brush Foundation Study)
to establish the mean age and s.d. for each
bone age “category”
• Bone age “categories” up to age 18 in girls and
19 in boys
Important limitations of bone age
• Bone age deviates from chronological
age in U.S. children
• Deviations are related to growth status
• Deviations vary by age, gender and
ethnicity (adjusting for growth and
sexual maturation)
Summary – Effect of bone age on
BMD
• Bone age deviation has a small but significant
effect on BMD Z-score
• The effect of bone age deviation on BMD Z-
score is partly or completely attenuated by
the effect of growth status on BMD Z-score
• Growth status (height and BMI Z-score) has a
large and significant effect on BMD Z-score
controlling for bone age deviation
Summary
• Substitution of bone age for chronological
age to calculate BMD Z-score
overcompensates
• Adjustment t for delayed bone age results in an
overestimation of BMD Z-score
• Adjustment for advanced bone age results in
an underestimation of BMD Z-score
• Bone age should not be substituted for
chronological age to calculate BMD Z-score
1

Summary
• Significant misclassification of children as
skeletally advanced or delayed likely occurs
in clinical assessments due to shortcomings
of reference values
• These data support the need for new
reference ranges for bone age in U.S.
children
Summary
• BMD reference data relative to body size is
needed to account for the known effect of
size on areal-BMD measurements by DXA
• BMD reference data relative to bone age
• BMD reference data relative to bone age
categories are needed so that bone age can
be used in the clinical assessment of children
with advanced or delayed puberty
2

Glucocorticoid-Induced Osteoporosis
in Children
Mary B. Leonard, MD, MSCE
The Children’s Hospital of Philadelphia
Center for Clinical Epidemiology and Biostatistics
Glucocorticoid-Induced Osteoporosis
• Glucocorticoids are widely used in pediatrics
• Glucocorticoids
– Bone formation
– Bone resorption
• Glucocorticoids are associated with increased
fracture rates in children
• Assessment of GC effects may be confounded by
– effects of the underlying disease
– altered growth, maturation and body composition
– limitations of DXA techniques
Glucocorticoid & Cytokine Effects
on Bone Cells
Whole Body Bone Mineral Content in
Crohn Disease Compared with Controls
Glucocorticoid Effects
Decrease Bone Formation
• Shift cellular differentiation of stem
cells away from osteoblasts
• Inhibit osteoblast production of
bone matrix
• Promote osteoblast apoptosis
• Impair osteocytes
Increase Bone Resorption
• Promote osteoclastogenesis by ↑
RANKL and ↓ OPG expression in
osteoblasts
TNF-α Effects
Decrease Bone Formation
• Shift cellular differentiation of stem cells away
from osteoblasts
• Inhibit collagen synthesis by
osteoblasts
• Promote osteoblast apoptosis
• Impair osteocytes
Increase Bone Resorption
Promote osteoclastogenesis by ↑
RANKL and ↓ OPG expression in
osteoblasts
Covariates
BMC Z-
score
95% CI p
Age and Race -1.16
(-1.51,
- 0.82) < 0.001
Age and Race
-0.63
063 (-0.95,
095 - 0.30) < 0.001
001
+ Height
Age, Race, Height
+ Tanner Stage
Age, Race, Height, Tanner
+ Muscle Mass
-0.50
(-0.85,
- 0.15) < 0.01
-0.19
(-0.43, 0.06) 0.15
Burnham, et al. J Bone Miner Res 2004
Nephrotic Syndrome and DXA BMC
Skeletal Effects of the Underlying Disease
Ln (Whole Body BMC)
8.5
Control
8.0
Nephrotic
7.5
7.0
6.5
6.0
5.5
5.0
4.5
4.5 4.6 4.7 4.8 4.9 5.0 5.1 5.2 5.3
Ln (Height)
• Mean cumulative
prednisone = 23,000 mg
• Mean BMI Z = + 1.24
• 40% obese
• Glucocorticoid-induced induced
obesity resulted in:
• increased whole body BMC
• preserved spine BMC
Leonard, et al. N Engl J Med 2004
Foster, et al. Am J Clin Nutr 2004
Steroid Sensitive
Crohn
Nephrotic
Disease
Syndrome
Poor Growth ++
Delayed Maturation +
Decreased Muscle ++
Nutritional Deficiencies +/- ++
Persistent Inflammation ++
1

Femoral Shaft HSA Z-Scores in Crohn
Disease and Nephrotic Syndrome
Peripheral Quantitative CT
Z Scores
1.00
0.50
000 0.00
-0.50
-1.00
*** ***
***
Group differences
eliminated after
adjustment for
lean mass for
height z-score
66%
38%
Muscle
CSA
Cortical
Dimensions
-1.50
-2.00
Subperiosteal
-2.50
Width
Cross-Sectional
Area
CD
SSNS
Section
Modulus
Burnham, et al. JBMR 2007
3%
Trabecular
BMD
Summary: Cortical Bone
Renal Osteodystrophy
Control CD SSNS
1,25(OH) 2 Vitamin D
Phosphorus Retention
Serum Calcium
PTH
Parathyroid VDR
density & eCaSR
function
VDR: Vit D Receptor; eCaSR: extracellular ca ++ sensing receptor
Acknowledgements
• Children’s Hospital of Philadelphia & UPENN
– Babette Zemel, PhD
– Jon Burnham, MD, MSCE
– Justine Shults, PhD
– Robert Baldassano, MD
– Meena Thayu, MD
• Hip Structural Analysis
– Moira Petit, PhD and Thomas Beck, PhD
• Whole Body Vibration
– Clint Rubin, PhD and Juvent, Inc.
• NIH
– NIDDK, NICHD
2

2/25/2008
Disclosures - None
Skeletal Sequelae in
Childhood Cancer Survivors
Sue C. Kaste, DO
Full Member, Radiological Sciences
St. Jude Children’s Research Hospital
ISCD 2008
• I have no financial relationships to
disclose.
• Id do not tintend dto reference offlabel/unapproved
uses of drugs or
devices in my presentation.
Overview
• Background of childhood cancer
survivorship
• General review of oncotherapy-related
factors contributing to skeletal morbidity
• Focused discussion of bone mineral
density deficits
• Focused discussion of osteonecrosis
Background
• 1 in 570 adults aged 20-34y is a survivor of
childhood cancer
• In U.S. among cancer cases diagnosed before
age 15y, acute lymphoblastic leukemia (ALL)
accounts for 25%; more than 2000 new
cases/year
• Long-term event free survival rates ALL now
85%; approaching 90%
Pui CH, Evans WE. N Engl J Med 2006:354:166-178.
• Hormonal Regulation
– Parathyroid hormone
– Calcitonin
– Insulin
– Growth hormone
– Vitamin D
– Glucocorticoids
– Sex steroids
– Thyroid hormones
Regulation of bone
remodeling
• Local Regulation
– Osteogenic growth
polypeptides
• Insulin-like like growth factors
• Transforming growth factor-B
family
– Fibroblast growth factors
– Platelet-derived growth factor
– Cytokines
• interleukin, tumor necrosis factor,
colony-stimulating factor,
leukemia inhibitory factor
Disease-related causes of
bone loss
Radiation therapy:
– hypoxia
– hypocellularity from
Chemotherapy:
– acts at parenchymal
stem cell level
– methotrexate
l ti id
– ifosfamide
– cyclosporine
– cyclophosphamide
– ? vincristine
chondroblast
damage (2-2020 Gy
– glucocorticoids
inhibit cartilage cell
proliferation)
– hypovascularity
Disease:
- endocrinopathies
- irradiation
- nutritional
deficits
it
- sedentary
activity
- heparinization
- surgery
1

2/25/2008
Known pediatric cohorts at-risk
for BMD deficits
Osteonecrosis
15y/o male with ALL
• Childhood cancers
– Acute lymphoblastic leukemia
– Brain tumors
– Allogeneic bone marrow transplant
– Sarcomas
• Hematologic diseases
– Thalessemia
– Sickle cell
• Infection
– HIV
• Others
– Patients requiring repeated or chronic
steroids
– Patients with limited mobility
– Malabsorption
– Etc.
3 y/o boy off therapy abdominal
germ cell tumor
• Exact etiology uncertain
• Associated risk factors
– High-dose steroid therapy
– Alcohol
– Dysbaric
– Radiation
– Sickle cell disease
– Gaucher’s disease
– Trauma
• Idiopathic
– direct effect on osteoblasts
(inhibiting bone formation)
– direct effect on osteoclasts
(accelerating bone resorption)
– premature apoptosis
– increase adipocytosis
– increase intraosseous
pressure
Osteonecrosis– Natural history
• Inciting “event”
• Bone necrosis = bone death
• Intraosseous hypertension
• Reactive zone formation about
necrotic area
• Revascularization and creeping
substitution
• New bone on dead bone
• Subchondral collapse
• Articular instability
• Joint collapse / arthritis
2

2/25/2008
QCT
PAST - PRESENT - FUTURE
Early QCT for Spinal BMD
HARRY K GENANT, MD, FACR, FRCR
PROFESSOR EMERITUS, UCSF
C Cann and H K Genant
Early Conventional (2D) QCT BMD
• Single 8-10mm slice
through each vertebra
• Angle CT scanner gantry
to scan through midplane
• Susceptible to patient
motion, artifacts in scans, 5
min procedure time
• Analysis restricted to in-
plane regions of interest
Early Conventional (2D) QCT BMD
• Single 8-10mm thick scans
through 3 or 4 lumbar
vertebrae
• Standard elliptical regions
of interest to measure
trabecular BMD in mg/cc
• Can also be extended to
measure area of vertebral
body, estimate cross
sectional moment of inertia
C Cann and H K Genant
C Cann and H K Genant
Early Volumetric (3D) QCT BMD
• Contiguous 3mm thick scans
through 2 or 3 lumbar
vertebrae, 25-35 images over
8-12 cm volume
• No CT scanner gantry
angulation
• No patient motion artifacts
• Data acquisition

2/25/2008
Early QCT RESULTS
Early Comparison QCT vs DXA
TECHNIQUE
(World Distribution)
Precision
Error
[%]
Accuracy
Error
[%]
CV Young
Normals
[%]
Decrement
Young-old
[%]
Dose
Equiv.
[µSv]
55 women with at least one vertebral fracture
compared to 168 non-fracture women
QCT (4000)
spine trabecular
spine integral
2-4
2-4
5-15
4-8
~18
~12
~60
~40
~50
~50
Technique
t-value
Odds Ratio
AP DXA 3.36 1.47
Lat DXA 5.22 1.88
QCT 8.45 3.17
Volumetric & High Res Spiral CT
vQCT – 3D Trabecular ROI
T. Lang & H. Genant
Hip Volumetric QCT
Advanced Spine Analysis VOIs
Engelke, Glueer, Genant
VOIs are combinations of
• bone compartment
– cortical
– trabecular
mid
– peeled trabecular
• VOI shape
– integral
– cylinder
– Osteo
• VOI location
– superior
– inferior
– Mid
– total
Examples:
• integral superior cortical VOI
• Osteo mid peeled trab VOI
• cylinder total trabecular VOI
superior
inferior
Klaus Engelke, Erlangen
cortical VOI
peeled
trabecular
VOI
Cylinder-VOI
Integral-VOI
trabecular VOI
Osteo-VOI
2

2/25/2008
vQCT FOR IN VIVO FINITE
ELEMENT MODELING (FEM)
3D Hip Finite Element Modeling
Tony M. Keaveny, UCB
STRAIN
DISPLACEMENT
Faulkner & Cann, UCSF
37,776 8-noded elements
Elastic-plastic; tension-compression strength
asymmetry; isotropic
HIGH RESOLUTION THIN SLICE
COMPUTED TOMOGRAPHY
High-Resolution CT of the Spine
HRCT Protocol:
one vertebra: T 12
thin slices: 0.3 -0.5mm
high in-plane resolution: 160 - 300 µm
Virtual
bone 3-D
biopsy
T12
Binarized & Skeletonized
Quantitative image processing
C.Graeff, C.C. Glüer , Kiel
2-D
3

QUANTITATIVE COMPUTED TOMOGRAPHY
QCT
Practical aspects in clinical and research studies
Professor Judith Adams
Clinical Radiology
Imaging Science and Biomechanical Engineering
University of Manchester, UK
judith.adams@manchester.ac.uk
CT Technical aspects - acquisition
A
C
B
Single slice
• step and scan mode
• 8-10mm slices
• 3-4 vertebrae included
• T12-L4 (L1-3 scanned)
(3-4 vertebrae)
3D volume
• Multi-slice spiral CT
• Improved spatial
resolution
D
• slice width 1-3mm
• L1-3 (2 vertebrae)
• L1 and L2 scanned
Correlations high r = 0.99
Link et al Radiology 2004
Technical Requirements
• Constant table height
• Same scanner
• Pad between body and phantom
• Same bone equivalent phantom
• Same gantry angle
• Same scan protocol
• Few, experienced technical staff
Limited commercial analysis packages available
Mindways, Siemens, Image Analysis
Peripheral QCT (pQCT) forearm
Bone densitometry - QCT
Established as a clinical tool early 1980’s
• Strengths
• Limitations
• separate measure of
• radiation dose
• cortical and trabecular bone
true volumetric density
• (central site 90µSv=12 days
natural background radiation)
(mg/cm 3 ) -not size dependent
• pQCT < 1µSv
• not so affected by spinal
• not applicable to hip*
artefacts as DXA
• Precision*
• provides cross-sectional
• availability
area bone and muscle:
• cost
• biomechanical properties
• (*2D, not 3D method)
Fracture prediction
ISCD Position
• Spinal trabecular BMD measured by QCT:
• Same ability to predict vertebral fracture as AP
spinal DXA BMD a in postmenopausal women
• Lack of evidence for men
• Lack of evidence to recommend spinal QCT for hip
fracture prediction in either women or men
• pQCT of the ultra-distal forearm (4%) predicts hip,
but not spine, fragility fractures in postmenopausal
women
• Lack of evidence in men
1

Monitoring of BMD
ISCD Position
• Trabecular spinal QCT BMD can be
used to monitor age, disease and
treatment related changes
• Trabecular and total BMD of ultra-distal
radius from pQCT can monitor age
related changes
Statistically significant change = precision (CV%) X 2.77
Take into account precision and rate of change in BMD to
calculate Monitoring Time Interval (MTI); spine QCT 1.9-3.7 years
Therapeutic Decisions
ISCD position
Ankylosing spondylitis
• Central DXA BMDa at the spine and hip preferred methods
for making therapeutic decisions
• If central DXA not available treatment decisions can be
initiated if fracture probability using QCT of the spine or
pQCT of the radius using device specific thresholds, and in
conjunction with clinical risk factors, is sufficiently high
Gluer J Bone Miner Res1999;14:1952–1962
Radiation doses
Examination Site EDE (µSv) NBR FC
DXA Spine 2.4 - 4 13 hours

2/25/2008
Disclosures - None
QCT in Pediatric Patients
Sue C. Kaste, DO
Full Member, Radiological Sciences
St. Jude Children’s Research Hospital
ISCD 2008
• I have no financial relationships to
disclose.
• Id do not tintend dto reference offlabel/unapproved
uses of drugs or devices
in my presentation.
Issues unique to pediatric patients
• Small size
• Changing bony morphology
• Longitudinal growth
• Influence of skeletal maturation on BMD
• Possible need for sedation
Axial QCT
• Fast – seldom need for sedation
• Direct BMD assessment
• Norms: age- and gender-matched
• Limited pediatric norms
• Ability to distinguish cortical from trabecular bone
• Radiation exposure limited to upper lumbar spine
– Low dose technique
– ALARA principle
Peripheral QCT
• Limitations
– Sparse pediatric norms
– Inconsistency in sampling
site(s)
– Changing configuration
and size in growing
bones
• Advantages
– Low radiation dose
– Radiation exposure
peripheral
1

2/25/2008
ISCD
San Francisco
March 12-15, 15, 2008
Fred S. Vernacchia, MD
(fredv@sldiagnostic.com)
QCT/CTXA Compared to DXA
Advantages/Shortcomings
QCT/CTXA Compared to DXA
How are QCT and CTXA performed
How to interpret a QCT/CTXA Exam-a systematic
approach
See how QCT/CTXA can find life-threatening
diseases
How QCT/CTXA can be compared to a DXA
Advantages of QCT/CTXA over DXA
Economics of QCT/CTXA
Systematic Approach to Interpretation
ALWAYS review the images of both the pelvis and
the spine BEFORE reviewing the Quantitative
Report.
Review the lateral scout image to perform the
Vertebral Fracture Analysis.
After reviewing the images, then interpret the
Quantative Report by applying ACR and WHO
standards
3D-QCT: How is it performed?
Aortic Ca Not included
Area of Interest
How is CTXA Performed?
How do CTXA results compare with
DXA?
Correlation of NHANES III (DXA) with CTXA
TOTAL Hip Comparison
(“Total” hip is the measurement of Choice)
Ave rage BM D ve rs us Age
Average T-Score versus Age
BMD (g/cm2)
1
0.95
0.9
0.85
0.8
0.75
0.7
20 30 40 50 60 70 80
Age (years)
CTXA
NHA NES III
T-Score
0
-0.4
-0.8
-1.2
-1.6
-2
20 30 40 50 60 70 80
Age (years)
CTXA
NHA NES III
1

2/25/2008
Correlation coefficient is not the same
as standard error.
1 Standard error is about 0.05 g/cm 2 .
1 T-Score unit is 0.12 g/cm 2 .
Therefore, 1 Standard Error is about 0.40 T-Score
units.
Said differently, about 67% of the time T-Scores by
DXA and CTXA are within 0.40 T-Score units, 95%
of the time, they are within 0.80 T-Score.
Precision of QCT is 1.5 mg/cm 3 and .012g/cm 2 .
Not great, but that is the same as is reported by
comparing DXA’s from different manufacturers.
Hence, the need for a standard phantom/Fracture
Risk score.
QCT/CTXA to DXA Diagnostic Categories
QCT Spine BMD
Total Hip or
Femoral Neck T–score
WHO Diagnostic
Category
or equivalent
BMD > 120 mg/cm 3 +1 to -1 Normal
80 mg/cm 3 ≥ BMD ≥ 120 -1 to -2.5 Osteopenia
mg/cm 3
BMD < 80 mg/cm 3 < -2.5 Osteoporosis
Cost
DXA vs. QCT
DXA
ISCD’s Estimate Yearly Costs
(w/Purchase price $85,000)
Depreciation $17,000
($85,000/5yrs)
Interest on loan $2,600
(6% for 5yrs)
Maintenance contracts $6,000-$9,000
Space $2,400-$4,500
(@ $16-$30/sq ft)
Overhead $10,000-$40,000
Total Cost $38,000-$73,100
(per year)
QCT
CT scanner
Calibration & Software upgrade
$25,000
(fixed)
DXA Cost Estimates
(Lewin Group for ISCD)
Payments based on Medicare Region 99
Exam 2005 2006 2007 2008 % of 2006 2010
DXA $ 142.54 $ 137.60 $ 115.24 $ 83.51 -41.4% $35.00
QCT $ 134.03 $ 129.42 $ 115.24 $ 85.89 -35.9% ??
VFA $ 40.17 $ 38.64 $ 35.72 $ 30.16 -24.9% ??
Payment under DRA-San Luis Obispo vs. San Francisco
% of
Physician Fee Schedule Payments San Luis Obispo San Francisco SLO
CODE #
Name
74170 ct abd w/wo cont $444.94 $624.96 140.5%
72194 ct pelvis w/wo cont $416.99 $586.65 140.7%
71250 ct chest w/o cont $298.78 $416.11 139.3%
70553 mri brian w/wo cont $1,059.31 $1,497.97 141.4%
73721 mri knee $539.80 $765.53 141.8%
72148 mri lumbar w/o cont $575.85 $812.39 141.1%
73221 mri shoulder w/o cont $537.00 $761.42 141.8%
Why use QCT/CTXA?
Follows all WHO and NOF Standards for diagnosis
Provides comparison to “conventional” DEXA (as long as
outside institution is using a current NHANES III DB)
Provides the most sensitive way to measure change in bone
mineral content
Includes a VFA
Summary: SLDC provides your patient with the best in
diagnosis and the best for treatment monitoring
SHOW ME THE LAST DXA THAT SAVED YOUR
PATIENT’S LIFE!!!!
78815 PET/CT Skull to Mid-Thigh $2,029.38 $2,998.88 147.8%
78816 PET/CT Whole Body $2,032.46 $3,002.44 147.7%
2

2/25/2008
Safety of Long Term
Bisphosphonate Therapy for
Osteoporosis
Aliya Khan MD, FRCPC, FACP
Clinical Professor of Medicine
Endocrinology & Geriatrics
McMaster University
Director, Calcium Disorders Clinic
Safety of Long Term BP Rx
• Learning objectives:
• 1.Know the long term safety data
for bisphosphonates
• 2U 2.Understand d what ti is known about
bisphosphonate associated ONJ
• 3. Be aware of the knowledge gaps
pertaining to ONJ associated with BP use
Disclosures
• Advisory Board : Amgen , Merck, Lilly,
Novartis, Servier, P&G
• Research Grants: Aventis, Merck, P&G,
Lilly, Novartis, NPS Allelix
Functional Domains of
Bisphosphonates
When R 1 is an OH group, binding
to bone is enhanced
R 1
R 2 site determines antiresorptive
potency and
affects binding to
hydroxyapatite
R 2
C
O
P
P
O
OH
OH
OH
OH
Both phosphonate
groups act as a “bone
hook” and are
essential both for
binding to
hydroxyapatite and
biochemical
mechanism of action
R 1 = –OH, R 2 = –(CH 2 ) 2 NH 2
R 1 = –OH, R 2 = –(CH 2 ) 3 NH 2
pamidronate
alendronate
R 1 = –OH, R 2 = –CH 2
R 1 = –OH, R 2 = –CH 2
risedronate
N
Nzoledronic N acid
Biochemical Mechanism of Action of Nitrogen-Containing
Bisphosphonates
Statins
HMG-CoA
X
Mevalonate
N-BPs inhibit FPP synthase, thus blocking
the prenylation of small
GTPase signaling proteins essential
for cell function and survival
Bone et al 2004 – 10 yr ALN data
Geranyl pyrophosphatephosphate
FPP X
synthase
Farnesyl pyrophosphate phosphate (FPP)
Cholesterol
Geranylgeranyl pyrophosphate
(GGPP)
Ras
Rho
Rab
S
S
S
1

2/25/2008
FLEX : Bone Biopsies following 5 and 10 yrs of
Alendronate Rx- Black JAMA 2006, Recker 2004
• Normal bone mineralization
• Normal trabecular and cortical bone
histology
• Dual labelling lli noted in all specimens
• Activation frequency in the premenopausal
range
• 10 yr bone biopsy data demonstrates
safety by histomorphometry
rom Baseline
Mean Percent Change fr
0
-10
-20
-30
-40
-50
-60
Risedronate 150 mg Phase III Study
Urine NTX/Cr
150 mg OAM (N=650)
5 mg Daily (N=642)
Baseline Month 3 Month 6 Month 12 Endpoint
Delmas PD, et al. Bone 2007, doi;10.1016/J.bone.2007.09.0001.
Baseline
Mean Percent Change from B
Risedronate 150 mg Phase III Study
0
-10
-20
-30
-40
-50
-60
Serum CTX
Baseline Month 3 Month 6 Month 12 Endpoint
150 mg OAM (N=650)
5 mg Daily (N=642)
Delmas PD, et al. Bone 2007, doi;10.1016/J.bone.2007.09.0001.
-CTX (ng/mL)
Mean Serum β-
Zoledronic Acid Reduced Mean Serum β-CTX
ZOL 5 mg
1.0
0.9
0.8 Annual dose
Placebo
Premenopausal
reference range
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0 6 12 18 24 30 36
Months
ZOL n = 257 237 201 136 191 190 174
PBO n = 260 248 214 156 196 197 170
Adapted from Black DM, et al. N Engl J Med. 2007;356:1809-1822.
Zoledronic Acid Reduced Mean Serum Bone-Specific Alkaline
Phosphatase
Prolonged urinary excretion of APD in children post treatment -
Papapoulos NEJM 07
ne ALP (ng/mL)
Mean Serum Bon
20
18
16
Annual dose
ZOL 5 mg
Placebo
Premenopausal
reference range
14
12
10
8
6
4
2
0
0 6 12 18 24 30 36
Months
ZOL n = 299 288 240 147 230 211 177
PBO n = 305 295 258 166 237 223 174
Adapted from Black DM, et al. N Engl J Med. 2007;356:1809-1822.
2

2/25/2008
ONJ- agreed upon definition
• Condition characterized by accumulation
of dead alveolar or palatal bone that is
exposed to the oral cavity and has
persisted for at least 8 weeks in the
absence of a history of local malignancy or
head and neck irradiation ~ expected
majority of lesions would have healed
Incidence of ONJ
• Incidence data limited to retrospective
chart reviews, case series and survey data
• Limitations include small sample size and
little clinical information regarding co-
morbidity and other risks for ONJ (
ie
ie chronic
glucocorticoid use ,immunosuppression
immunosuppression, diabetes,
periodontal disease, tori etc.)
• Frequency of 1 in 10,000- .7/100,000
pt/years in osteoporosis , 1 in 10 in
myeloma reported ( Durie 2005,Cheng
2005,Migliorati 2005, tarassoff 2003, Bamias 2005,Badros
2006)
Prevention and Treatment recommendations
• Oral dental exam at initiation of BP in oncology
patients , 6 montly assessments for osteoporosis
patients as recommended for general public .
• Maintain good oral hygiene
• If oral surgery , invasive dental procedures,
extractions, implants advise dentist and MD
• Limit invasive procedures to necessary
• Suspected lesions refer to oral surgeon
• Management focussed on pain control, treament
of infection, debridement of necrotic tissue &
sequestra
Conclusions
• Association of ONJ with long term high
dose BP use is a concern
• Direct causal relationship has not been
confirmed
• Need to distinguish i between LMSU and
ONJ
• Need prospective data to further
understand true incidence, risk factors
and pathophysiology
• Need prospective data to refine
management recommendations-
3

2/25/2008
HOW REIMBURSEMENT
ISSUES WILL AFFECT THE
TECHNOLOGIST’S FUTURE
Sharon Wartenbee, RTR,BD,CDT
Sioux Falls, South Dakota
REIMBURSEMENT RATES CUT
• 2006 National Average for Screening:
$140.00
• 2007 National Average for Screening:
$82.00
• 2010 National Average for Screening:
$35.00
TWO MAIN REASONS
BEHIND CUTS
LEWIN GROUP STUDY cont.
• Deficit Reduction Act (DRA)
• CMS used flawed assumptions to
create reimbursement rates for
DXA and VFA
• Retaining adequate payment of
$140.00 would result in a fiveyear
savings of $1.14 Billion in the
cost of treatment
LEWIN GROUP STUDY
IMPACT ON PATIENT CARE
• 2/3 of all DXA procedures are
currently yperformed in office
setting
• Physicians indicate they could be
forced to eliminate DXA service
REDUCTION IN QUALITY OF
CARE
• DXA services will be discontinue
• Patients t no longer tested t • DXA equipment sold
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2/25/2008
NEED FOR LEGISLATIVE
REMEDY
• ISCD and interested stakeholders
have pursued talks with Center
Medicare Services
• Given minimal success with CMS in
restoring cuts, the only clear solution
is LEGISLATIVE action
TAKE ACTION
• Be a “PATIENT ADVOCATE”
• Get involved to “SAVE DXA”
CONSEQUENCES
• Job elimination
• Financial burden
• Loss of Benefits
• Cross-train
BE PREPARED
• Learn new skills
• Be flexible and willing to accept
change
CONCLUSION
• Your involvement is important
• Patient’s depend on you
• You can make a difference
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