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Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi Assistant Professor of Rheumatology Alimohammad Fatemi.

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Presentation on theme: "Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi Assistant Professor of Rheumatology Alimohammad Fatemi."— Presentation transcript:

1 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Alimohammad Fatemi Assistant Professor of Rheumatology Alimohammad Fatemi Assistant Professor of Rheumatology 1

2 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Why Diagnosis Is Important? 2

3 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 The most common metabolic bone disease − 1/3 of women > 50 − 1/5 of men > 50 High Morbidity and Mortality Asymptomatic − 30-50% of vertebral fracture The most common metabolic bone disease − 1/3 of women > 50 − 1/5 of men > 50 High Morbidity and Mortality Asymptomatic − 30-50% of vertebral fracture 3 Why Diagnosis Is Important?

4 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 OSTEOPOROSIS A skeletal Disorder: – Compromised Bone Strength – Increased Risk of Fracture A skeletal Disorder: – Compromised Bone Strength – Increased Risk of Fracture 4 Adams, Nat Rev Endocrinol. 2013

5 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BONE STRENGTH 5 Bone MineralBone QualityBone Material Adams, Nat Rev Endocrinol. 2013

6 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BONE STRENGTH 6 Bone Mineral DXA Quantitative CT Bone Material Adams, Nat Rev Endocrinol. 2013 Bone Quality

7 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BONE STRENGTH 7 Bone Mineral DXA Quantitative CT Bone Quality DXA Quantitative CT Bone Turnover Markers High Resolution CT/MRI Bone Material Adams, Nat Rev Endocrinol. 2013

8 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BONE STRENGTH 8 Bone Mineral DXA Quantitative CT Bone Quality DXA Quantitative CT Bone Turnover Markers High Resolution CT/MRI Bone Material Nano Imaging Adams, Nat Rev Endocrinol. 2013

9 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 D ual E nergy X -ray A bsorptiometry (Gold Standard) 9

10 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 D ual E nergy X -ray A bsorptiometry (Gold Standard) Epidemiologic Studies Pharmacological Studies Reproducibility Safety − Low Radiation : 1/10 of Chest x-ray Diagnostic Criteria Epidemiologic Studies Pharmacological Studies Reproducibility Safety − Low Radiation : 1/10 of Chest x-ray Diagnostic Criteria 10

11 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DEXA MACHINE X-ray Source (Tube) X-ray Collimators X-ray Detectors X-ray Source (Tube) X-ray Collimators X-ray Detectors 11

12 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DXA MACHINE 12 X-ray Source Patient

13 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DXA MACHINE 13 X-ray Source (2 photon energies with different attenuation profiles) Photons Patient

14 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DXA MACHINE 14 X-ray Source (2 photon energies with different attenuation profiles) Photons Patient Collimator

15 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DXA MACHINE 15 X-ray Source (2 photon energies with different attenuation profiles) Photons Patient Collimator Detector (detects 2 tissue types - bone and soft tissue)

16 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DEXA MACHINE 16

17 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIFFERENT MACHINE MACHINES – Hologic – Lunar – Norland – MedLink MACHINES – Hologic – Lunar – Norland – MedLink

18 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Which Bones? Spine Femur Forearm Spine Femur Forearm 18

19 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 19

20 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 FEMUR 20

21 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 FOREARM 21

22 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? 22

23 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? BMD 23

24 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? BMD Bone Mineral Content (g) /Area (cm ) BMD Bone Mineral Content (g) /Area (cm ) 24 2

25 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 25

26 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? BMD g/cm² % BMD g/cm² % 26

27 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BMD 27 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 Patient’s BMD

28 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BMD 28 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 PBM ( Peak Bone Mass) Patient’s BMD

29 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BMD 29 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 PBM ( Peak Bone Mass) Patient’s BMD The reference standard is calculated is the female, white, age 20-29 years, NHANES III database

30 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Comparison to Young Adult BMD × 100 PBM BMD × 100 PBM 30

31 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 31

32 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? BMD g/cm² % T-Score BMD g/cm² % T-Score 32

33 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 T-SCORE 33 (Patient’s BMD) – (Young-Adult Mean BMD) 1 SD of Young-Adult Mean BMD

34 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 T-SCORE 34 (Patient’s BMD) – (Young-Adult Mean BMD) 1 SD of Young-Adult Mean BMD T-score = 0.7 g/cm 2 - 1.0 g/cm 2 0.1 g/cm 2 - 3.0=

35 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 35

36 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What DXA Really Measures? BMD g/cm² % T-Score Z-Score BMD g/cm² % T-Score Z-Score 36

37 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 BMD 37 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 Patient’s BMD Age-Matched BMD

38 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Comparison to Same Age/Sex (Z-SCORE) Patient’s BMD – Age-Matched Mean BMD 1 SD of Age-Matched Mean BMD Patient’s BMD – Age-Matched Mean BMD 1 SD of Age-Matched Mean BMD 38

39 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 39

40 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DEFINITIONS Normal Bone − -1 ≤ T-Score < +1 Osteopenia − -2.4 < T-Score < -1 Osteoporosis − T-Score ≤ -2.5 Normal Bone − -1 ≤ T-Score < +1 Osteopenia − -2.4 < T-Score < -1 Osteoporosis − T-Score ≤ -2.5 40

41 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 When We Should Use Z-Score? 41

42 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 When We Should Use Z-Score? 42 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 PBM ( Peak Bone Mass) Patient’s BMD Age-Matched BMD

43 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 When We Should Use Z-Score? In children − Z < -2 Low BMD for chronological age In children − Z < -2 Low BMD for chronological age 43

44 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 When We Should Use Z-Score? In children − Z < -2 Low BMD for chronological age Secondary osteoporosis In children − Z < -2 Low BMD for chronological age Secondary osteoporosis 44

45 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 When We Should Use Z-Score? 45 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1015202530354045505560657075 PBM ( Peak Bone Mass) Patient’s BMD Age-Matched BMD

46 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Using T-scores vs. Z-scores 46

47 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Using T-scores vs. Z-scores T-scores – WHO diagnostic  Postmenopausal women and  Men ≥ 50 – Not for:  Healthy premenopausal women  Men <50  Children T-scores – WHO diagnostic  Postmenopausal women and  Men ≥ 50 – Not for:  Healthy premenopausal women  Men <50  Children 47

48 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Using T-scores vs. Z-scores T-scores – WHO diagnostic  Postmenopausal women and  Men ≥ 50 – Not for:  Healthy premenopausal women  Men <50  Children T-scores – WHO diagnostic  Postmenopausal women and  Men ≥ 50 – Not for:  Healthy premenopausal women  Men <50  Children 48 Z-scores – Used for:  Healthy premenopausal women  Men <50  Children Z-scores – Used for:  Healthy premenopausal women  Men <50  Children

49 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 49

50 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? Every Patient Spine – L1-L4 Every Patient Spine – L1-L4 50

51 Internal Medicine Weekly Conference 1392 51

52 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? Every Patient Spine – L1-L4 Hip – Total Hip – Femoral Neck Every Patient Spine – L1-L4 Hip – Total Hip – Femoral Neck 52

53 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 53

54 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 54

55 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 55

56 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 56

57 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 57

58 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What Is Ward’s Area? 58

59 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What Is Ward’s Area? A small calculated area – the mid portion of the femoral neck – BMD is the lowest A small calculated area – the mid portion of the femoral neck – BMD is the lowest 59

60 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What Is Ward’s Area? A small calculated area – the mid portion of the femoral neck – BMD is the lowest Overestimate the prevalence of osteoporosis A small calculated area – the mid portion of the femoral neck – BMD is the lowest Overestimate the prevalence of osteoporosis 60

61 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 What Is Ward’s Area? A small calculated area – the mid portion of the femoral neck – BMD is the lowest Overestimate the prevalence of osteoporosis Not part of WHO Criteria A small calculated area – the mid portion of the femoral neck – BMD is the lowest Overestimate the prevalence of osteoporosis Not part of WHO Criteria 61

62 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? Every Patient Spine – L1-L4 Hip – Total Hip – Femoral Neck Every Patient Spine – L1-L4 Hip – Total Hip – Femoral Neck Some Patients Forearm – If hip or spine cannot be measured – Hyperparathyroidism – Very obese 62

63 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 63 33% radius

64 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Which Skeletal Sites Should Be Measured? 64 1/3 radius

65 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS 65

66 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration 66

67 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration 67

68 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration 68

69 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 69

70 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE Region of Interest 70

71 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 71

72 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 72

73 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 SPINE 73

74 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 HIP 74

75 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 HIP Region of Interest 75

76 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 HIP 76

77 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 HIP 77

78 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 HIP 78

79 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration 79

80 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 ARTIFACT 80

81 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 ARTIFACT 81

82 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 ARTIFACT 82

83 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 DIAGNOSTIC PITFALLS Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration Patient’s demographic data Patient’s positioning Scan analysis Artifact Calibration 83

84 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 Calibration 84 Phantom

85 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 85

86 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 MONITORING – Lumbar Spine 2.8% – Femoral Neck 5.6% – Lumbar Spine 2.8% – Femoral Neck 5.6% 86

87 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 MONITORING – Lumbar Spine 2.8% – Femoral Neck 5.6% (change in BMD ÷ prior BMD ) x100=significant percentage change – Lumbar Spine 2.8% – Femoral Neck 5.6% (change in BMD ÷ prior BMD ) x100=significant percentage change 87

88 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 INDICATIONS 88

89 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 INDICATIONS Women ≥ 65 Younger Women with ≥ 1 risk factors Postmenopausal women with fracture Estrogen Deficiency Long-Term steroid Monitoring of Therapy Women ≥ 65 Younger Women with ≥ 1 risk factors Postmenopausal women with fracture Estrogen Deficiency Long-Term steroid Monitoring of Therapy 89

90 Internal Medicine Weekly Conference 1392 Internal Medicine Weekly Conference 1392 90

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