Angela J. Shepherd

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

PURPOSE We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA). METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture. RESULTS The MORES included 3 variables—age, weight, and history of chronic obstructive pulmonary disease—and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85–0.97), a specificity of 0.59 (95% CI, 0.56–0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807–0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population. CONCLUSIONS Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Osteoporosis Risk Assessment and Ethnicity: Validation and Comparison of 2 Clinical Risk Stratification Instruments

BACKGROUND: Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population.OBJECTIVE: To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans.DESIGN: Blinded comparison of the instruments in a cross-sectional sample.PARTICIPANTS: Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded.MEASUREMENTS: Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan.RESULTS: The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar’s test P value=37). The accuracy between instruments differed significantly in African-American women (McNemar’s test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis.CONCLUSIONS: The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.

Validation of the Male Osteoporosis Risk Estimation Score (MORES) in a Primary Care Setting

Background: Primary care physicians are positioned to promote early recognition and treatment of men at risk for osteoporosis-related fractures; however, efficient screening strategies are needed. This study was designed to validate the Male Osteoporosis Risk Estimation Score (MORES) for identifying men at increased risk of osteoporosis. Methods: This was a blinded analysis of the MORES, administered prospectively in a cross-sectional sample of men aged 60 years or older. Participants completed a research questionnaire at an outpatient visit and had a dual-energy X-ray absorptiometry (DXA) scan to assess bone density. Sensitivity, specificity, and area under-the-curve (AUC) were estimated for the MORES. Effectiveness was assessed by the number needed-to-screen (NNS) to prevent one additional major osteoporotic fracture. Results: A total of 346 men completed the study. The mean age was 70.2 ± 6.9 years; 76% were non-Hispanic white. Fifteen men (4.3%) had osteoporosis of the hip. The operating characteristics were sensitivity 0.80 (95% confidence interval [CI], 0.52–0.96); specificity 0.70 (95% CI, 0.64–0.74), and AUC of 0.82 (95% CI, 0.71–0.92). Screening with the MORES yielded a NNS to prevent one additional major osteoporotic fracture over 10 years with 259 (95% CI, 192–449) compared to 636 for universal screening with a DXA. Conclusion: This study validated the MORES as an effective and efficient approach to identifying men at increased risk of osteoporosis who may benefit from a diagnostic DXA scan.

Determining risk of vertebral osteoporosis in men: validation of the male osteoporosis risk estimation score.

Background: Vertebral fracture, one of the most frequent osteoporotic fractures in both sexes, is a powerful indicator of future osteoporotic fractures. Vertebral fractures are associated with increased mortality and decreased quality of life. Osteoporosis is a major predictor of low-trauma fracture. The Male Osteoporosis Risk Estimation Score (MORES), a clinical prediction tool that uses age, weight, and a history of chronic obstructive pulmonary disorder, was developed and validated previously to identify men at risk for hip osteoporosis who might benefit from bone densitometry. This study evaluated the effectiveness of the MORES to identify men at risk of lumbar osteoporosis. Methods: US population data from the National Health and Nutrition Examination Survey (NHANES, 1999–2004) were used to test the validity of the MORES to identify men at risk of lumbar osteoporosis. Results: The MORES value was compared with vertebral done densitometry (DXA) scores for men 50 years of age and older. The sensitivity was 0.582 (95% CI, 0.460–0.694) and specificity was 0.652 (95% CI, 0.627–0.676). Comparing universal DXA screening in 50-year-old men, the number needed to screen (NNS) to prevent one case of vertebral fracture would be reduced from 9418 to 3641 by prescreening with the MORES. In 70-year-old men, the MORES reduced the NNS from 4987 with universal screening to 3583. Conclusion: This analysis validated the MORES as a clinical tool to identify men at risk for lumbar osteoporosis. Compared with universal screening, the MORES was able to reduce the NNS to prevent one additional vertebral fracture across all age groups except in men 85 to 89 years of age. The magnitude of the NNS to prevent one additional vertebral fracture does not support using the MORES to screen solely for osteoporosis of the lumbar spine.

Comparison of the Male Osteoporosis Risk Estimation Score (MORES) With FRAX in Identifying Men at Risk for Osteoporosis

PURPOSE We wanted to compare the male osteoporosis risk estimation score (MORES) with the fracture risk assessment tool (FRAX) in screening men for osteoporosis. METHODS This study reports analysis of data from the Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative sample of the US population, comparing the operating characteristics of FRAX and MORES to identify men at risk for osteoporosis using a subset of 1,498 men, aged 50 years and older, with a valid dual-energy x-ray absorptiometry (DXA) scan. DXA-derived bone mineral density using a T score of −2.5 or lower at either the femoral neck or total hip defined the diagnosis of osteoporosis. Outcomes included the operating characteristics, area under the receiver-operator characteristic curve, and agreement of the FRAX and MORES. RESULTS Sixty-seven (4.5%) of the 1,498 men had osteoporosis of the hip. The sensitivity, specificity, and area under the curve (AUC) for the MORES were 0.96 (95% CI, 0.87–0.99), 0.61 (95% CI, 0.58–0.63), and 0.87 (95% CI, 0.84–0.91), respectively. The sensitivity, specificity, and AUC for the FRAX were 0.39 (95% CI, 0.27–0.51), 0.89 (95% CI, 0.88–0.91), and 0.79 (95% CI, 0.75–0.84) respectively. Agreement was poor. CONCLUSIONS Compared with the MORES, the FRAX underperformed as a screening strategy for osteoporosis using the threshold score suggested by the US Preventive Services Task Force (USPSTF). An integrated approach that uses the MORES to determine which men should have a DXA scan and the FRAX to guide treatment decisions, based on the risk of a future fracture, identified 82% of men who were candidates for treatments based on National Osteoporosis Foundation guidelines.

NUCHAL CORD (NC) AS A CAUSE OF NEONATAL ANEMIA

Although NC occurs in 20% of deliveries and may be associated with perinatal asphyxia, anemia has not been emphasized as a complication of NC. We documented the occurrence of NC in 437 consecutive births and compared the incidence of anemia (venous hemoglobin <13.2 mg/dl or hematocrit <39.17%) in the group with NC to a group of 49 normal controls derived from the same population. NC occurred in 86 (19.7%). Tight NC (TNC), defined as nonreducible and clamped early, occurred in 39 (8.9%). Loose NC (LNC), defined as reducible, occurred in 47 (10.8%). None of the controls were anemic. Of 27 babies studied who had TNC, 5 (18.5%) were anemic (p<0.01) early (< 8 hours of age). Three of the 5 were hypotensive and anemic at birth and required blood transfusion. Of 30 babies studied who had LNC, 4 (13.3%) were anemic (p<0.05). None of the 4 were anemic early, but were anemic by 36 hours of age. These data suggest: 1) TNC and LNC are associated with increased risk of anemia 2) Anemia due to TNC is present at or soon after birth and may require transfusion. 3) Anemia due to LNC is not present at birth but occurs (> 24 hours). 4) Babies with NC should have hemoglobin/hematocrit determinations soon after birth, if symptomatic, or before discharge, if asymptomatic.