1
Q
What is the NIH consensus definition of osteoporosis?
A
A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture
2
Q
Bone strength reflects the integration of which two features?
A
- Bone density
- Bone quality
3
Q
Does low bone mass have symptoms?
A
No
Unless a fracture occurs, then there is pain at fracture site
4
Q
How is a fragility fracture defined?
A
Fracture from a fall from standing position or less.
5
Q
Worldwide - what are the three ways osteoporosis can be diagnosed by?
A
- Fragility fracture
- T-score of -2.5 or less
- FRAX score with increased fracture risk
6
Q
What are give functions of the skeletal?
A
- Supports the body
- Protects internal organs
- Muscles attached for movement
- Cavities for blood formation
- Reservoir for minerals
7
Q
What region of the skeletal is included in the central skeletal?
A
Axial skeletal plus hips and shoulders
8
Q
What region of the skeletal is included in the peripheral skeletal?
A
Appendicular skeletal minus the hips and shoulders
9
Q
What kind of bone makes up the appendicular skeletal?
A
Cortical or compact bone
10
Q
What kind of bone makes up the axial skeletal?
A
Cancellous or trabecular bone
11
Q
What is osteomalacia?
A
A normal amount of bone that is inadequately mineralized
12
Q
What percentage of the adult skeleton is remodelled at any one time?
A
10%
13
Q
What is the turnover each year of cancellous bone?
A
25%
14
Q
What is the turnover each year of cortical bone?
A
3%
15
Q
What is the mass of cancellous bone?
A
20%
16
Q
What is the mass of cortical bone?
A
80%
17
Q
What is the surface area of cancellous bone?
A
80%
18
Q
What is the surface area of cortical bone?
A
20%
19
Q
What is bone modelling?
A
Change in size and shape of bone during growth
20
Q
What is remodelling of bone?
A
Renewal of mature bone through:
- involves replacement of old bone with new bone
- occurs in response to fatigue damage, micro-fractures, and other fractures
21
Q
How long is the bone remodelling cycle?
A
7 - 10 days
22
Q
How long does osteoblast bone formation take?
A
10 - 12 weeks
23
Q
What is the peak bone mass?
A
Peak bone mass is the maximum bone mass or density during a lifetime.
24
Q
At what age do you have peak bone mass (after which it starts declining)?
A
30 years old
25
What is consolidation?
When growth in size of bones and accumulation of bone mineral has stabilised.
26
Peak bone mineral density:
Trochanter?
Mid-teens
| 14.2 +/- 2.0
27
Peak bone mineral density:
Femoral neck?
Late teens
| 18.5 +/- 1.6
28
Peak bone mineral density:
Spine?
Early 20's
| 23 +/- 1.4
29
How much do heredity/genetics influence peak bone mass?
60 - 80%
30
Does gender influence peak bone mass?
Yes
31
What are the four nutritional factors influencing peak bone mass?
- Energy intake
- Protein intake
- Calcium intake
- Vitamin D
32
What are the three endocrine factors influencing peak bone mass?
- Sex steroids
- Calcitriol
- GH-IGF-1 axis
33
What are the two mechanical factors influencing peak bone mass?
- Physical activity
| - Body weight
34
How fast does age-related bone loss occur?
~ 0.5 - 1.0% per year
35
How fast does bone loss occur after menopause?
~ 1 - 2% per year
| Accelerated
36
What does a major BMD change in either direction require?
Evaluation for technical issues
37
Is post-menopausal osteoporosis common at age ~ 55 years (after about 5 years of menopause)?
No - it's unusual.
| Secondary causes must be sought.
38
Can you differentiate between osteoporosis or osteomalacia on DXA?
No
39
What should you think of if you have a 24 hour urine calcium
Celiac disease
40
What should you think of in a patient with unexplained iron deficiency and osteoporosis?
Celiac disease
41
What should you think of in a patient with irritable bowel symptoms and osteoporosis?
Celiac disease
42
What should you think of in a patient with decreased BMD, fractures or sustained high NTX/CTX despite oral therapies?
Celiac disease
43
How do you screen for celiac disease?
Tissue transglutaminase IgA antibody
44
What is the sensitivity of transglutaminase IgA antibody for Celiac disease?
> 90%
45
What is the specificity of transglutaminase IgA antibody for Celiac disease?
> 95%
46
Falsely negative transglutaminase IgA antibody screening for Celiac disease may occur in case of IgA deficiency.
True or false?
True
47
What percentage of Celiac disease patients have IgA deficiency?
2 - 3%
48
In what two situations may the transglutaminase IgA antibody screening for Celiac disease be falsely negative?
- IgA deficiency
| - Mild disease
49
What is the gold standard for celiac disease diagnosis?
- Duodenal biopsy
50
What is the treatment of osteoporosis caused by celiac disease?
- Gluten-free diet
| - Calcium and vitamin D supplementation
51
Are oral bisphosphonates preferable in patients with malabsorption issues?
No
52
What view is VFA?
Lateral or PA?
Lateral view
53
What does VFA stand for?
Vertebral fracture assessment
54
When should VFA or spine imaging be obtained?
When fracture status would alter therapy.
55
By approximately how much does 1000 IU of vitamin D raise the serum vitamin D levels?
6 - 10 ng/dL
56
How soon after repleting vitamin D should the level be repeated?
~ 3 months
57
Should pharmacologic therapy for osteoporosis be delayed if vitamin D level is between 20 - 30 ng/mL?
No
58
What is the criteria for treating post menopausal women and men over 50 years on chronic steroids equivalent to prednisone of 7.5 mg a day or greater?
They require treatment.
59
What is the criteria for treating post menopausal women and men over 50 years on chronic steroids equivalent to prednisone of 7.5 mg a day or less?
If the FRAX is 10% or less they don't require treatment; if the FRAX is more than 10% they require treatment.
60
What is the criteria for treating pre-menopausal women (non-childbearing) and men under 50 years on chronic steroids equivalent to prednisone of 5 mg a day or greater?
Treat only if they have a fracture.
61
What is the criteria for treating pre-menopausal women (childbearing) on chronic steroids equivalent to prednisone of 7.5 mg a day or greater?
Treat only if then have a fracture
62
When is lateral spine imaging (radiography or VFA) indicated?
- Women aged 70 or more; men aged 80 or more
- Historical height loss > 4 cm (1.5 inch)
- Self reported but undocumented prior vertebral fracture
- Glucocorticoid therapy equivalent to more than or equal to 5 mg of prednisone per day for 3 or more months.
63
What is the sensitivity of serum protein electrophoresis (SPEP)?
82%
64
What is the sensitivity of serum immuno-fixation (IPEP)?
93%
65
What is the sensitivity of serum and urine IPEP?
97%
66
Persistently low serum phosphate leads to inadequate bone mineralization and osteomalacia.
True or false?
True
67
Name three causes of decreased phosphate.
- Renal phosphate wasting due to excess FGF-23
- Malabsorption
- Malnutrition
68
Name two causes of phosphate wasting due to excess FGF-23.
- Genetic mutations
| - Mesenchymal tumors
69
What syndrome can a small, slow-growing mesenchymal tumor secreting FGF-23 cause?
Acquired paraneoplastic syndrome
70
Clinical features:
- Progressive muscle and bone pain
- Weakness
- Fatigue
- Multiple fractures
- Low phosphorus
Diagnosis?
Tumor-Induced Osteomalacia
| Acquired paraneoplastic syndrome caused by small, slow-growing mesenchymal tumors secreting FGF-23.
71
What does laminectomy do to spine BMD?
Lowers it.
72
If you've already treated a patient with a few years of zoledronic acid then what drug could you consider next...?
Teriparatide
73
When can testosterone therapy be used to treat osteoporosis secondary to hypogonadism (in men)?
When the serum testosterone is below 200 ng/dL on two different occasions.
74
Is family history of osteoporotic fracture or fragility fracture a risk factor for low bone mass?
No - it's a risk factor for osteoporotic fracture
75
Are falls a risk factor for low bone mass?
No - they are a risk factor for osteoporotic fracture
76
Is sarcopenia a risk factor for low bone mass?
No - it's a risk factor for osteoporotic fracture
77
Is sarcopenia a risk factor for low bone mass?
No - it's a risk factor for osteoporotic fracture
78
Is loss of height a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
79
Is late age at menarche a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
80
Is menopause a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
81
Is time since menopause a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
82
Is dietary calcium a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
83
Is alcohol intake a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
84
Are medications a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
85
Are inflammatory diseases a risk factor for osteoporotic fracture?
No - it's a risk factor for low bone density.
86
Are clinical risk factors good predictors of low BMD?
No
87
Does acromegaly cause osteoporosis?
We are not sure.
88
Do loop diuretics cause osteoporosis?
We are not sure
89
Does immobilization cause osteoporosis?
Yes
90
Does HIV/AIDS cause osteoporosis?
Yes
91
Does organ transplantation cause osteoporosis?
Yes
92
Does COPD cause osteoporosis?
Yes
93
Does anorexia cause osteoporosis?
Yes
94
Does malignancy cause osteoporosis?
Yes
95
How often is osteoporosis associated with secondary disorders?
~ 50% of the time
96
What does tryptase test for?
Mastocytosis
97
Increased bone resorption independently predicts fracture risk in post-menopausal women.
True or false?
True
98
Most vertebral fractures occur below ____.
T6
99
What are two problems with quantitative morphology?
- May over-diagnose abnormalities that are not fracture
| - May under-diagnose mild end-plate deformities
100
How and how often should height be measured?
Annually, preferably with a wall mounted stadiometer.
101
Trabecular bone - age related bone loss differs between men and women...
Women?
Perforation
102
Trabecular bone - age related bone loss differs between men and women...
Men?
Thinning
103
Name the three main sites of osteoporotic fractures starting with most common to least common.
- Vertebral fractures
- Hip fractures
- Distal forearm fractures
104
What percentage of hip fracture survivors are permanently incapacitated?
~ 50%
105
What percentage of hip fracture survivors require long-term nursing home care?
~ 20%
106
Is the radius or the ulnar used for BMD measurement in the forearm?
Radius
107
Does a T-score of less than -2.5 always mean that the patient has osteoporosis?
No
108
Name five examples of non-osteoporotic causes of low BMD.
- Osteomalacia
- Genetic disorders e.g. osteogenesis imperfecta
- Renal bone disease
- Multiple myeloma / other malignancies
- Marrow infiltrative diseases e.g. mastocytosis
109
What does it mean if the T-score goes down but Z-score stays the same?
The patient lost as much bone density as was expected.
110
Is the diagnosis of osteoporosis based on the mean T-score value or the lowest value?
The lowest value
111
Fracture risk increases exponentially with declining BMD.
True and false?
True
112
Should FRAX be used to monitor treatment response?
No
113
How long should a patient not have had estrogen therapy / hormone therapy to be considered 'untreated'v
One year
114
How long should a patient not have had calcitonin to be considered 'untreated'?
One year
115
How long should a patient not have had PTH to be considered 'untreated'?
One year
116
How long should a patient not have had denosumab to be considered 'untreated'?
One year
117
How long should a patient not have had bisphosphonates to be considered 'untreated'?
Two years
Taking oral bisphosphonates for less than two months is okay.
118
How long should a patient not have had calcium and vitamin D to be considered 'untreated'?
Calcium and vitamin D do not count as treatment in this regard.
119
If you have serial studies on the same machine should you compare T-scores or BMD?
BMD
120
What is the minimum acceptable precision error (LSC) for an individual technologist for...
Lumbar spine?
1.9% (LSC = 5.3%)
121
What is the minimum acceptable precision error (LSC) for an individual technologist for...
Total hip?
1.8% (LSC: 5%)
122
What is the minimum acceptable precision error (LSC) for an individual technologist for...
Femoral neck?
2.5% (LSC = 6.9%)
123
Which precision error should be used if there are multiple technologists at a center?
The average precision error for all the technologists is used
124
How is a precision analysis done?
Measure 15 patients 3 times, or 30 patients 2 times, repositioning patients after each scan.
125
Does precision assessment require IRB approval?
No
126
What is least significant change?
The precision error at a center ~ desired confidence level 95%
127
How is LSC calculated?
LSC = (precision error) x 2.77
| to have 95% confidence that the change is real
