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1 Differences between Men and Women in Periosteal Apposition and Bone Loss during Aging Seeman E. N Engl J Med. 2003;349:320.

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Presentation on theme: "1 Differences between Men and Women in Periosteal Apposition and Bone Loss during Aging Seeman E. N Engl J Med. 2003;349:320."— Presentation transcript:

1 1 Differences between Men and Women in Periosteal Apposition and Bone Loss during Aging Seeman E. N Engl J Med. 2003;349:320

2 Definitions CSACross-sectional area CSMICross-sectional moment of inertia  Shaft-neck angle YDistance from the center of mass to the superior neck margin d1Distance from head center to section of minimum CSMI along neck axis Femur Geometry on DXA

3 3 Femur Strength Index Study 4 Investigators 365 women with hip fracture 2141 controls Prodigy Femur Geometry Osteoporosis International January, 2006

4 4 Femur Strength Index Osteoporosis International January, 2006 “HAL and FSI were significant predictors of hip fracture… The FSI was a significant predictor of hip fracture even after adjustment for T score and HAL. The power for predicting fracture was significantly improved by combining T score, FSI, and HAL compared with T score alone.”

5 5 Color coded density plots  Three levels of density  Set cut points using histogram tool  Show densities 1SD above mean BMD  Bone profile tool Research: Femur Density Distribution

6 6 골다공증의 최신 진단지침과 유의사항 2006 ISCD guideline New guideline New guideline Vertebral fracture assessment (VFA) Vertebral fracture assessment (VFA) Beyond BMD Structure (size, geometry, trabecular architecture, etc) Structure (size, geometry, trabecular architecture, etc) Material property (mineral, collagen, microdamage) Material property (mineral, collagen, microdamage) Beyond T-score Absolute fracture risk assessment Absolute fracture risk assessment

7 7 골절 위험도 반영 전 세계적으로 널리 이용 80+ 70–79 60–69 50–59 50 –6–5 0 –4–1–3 –2 12 T-score T-score 를 이용한 WHO 골다공증 진단 기준 간편하며 쉽게 적용 간편하며 쉽게 적용 골절 진단의 특이도가 높음 Bone mineral density (SD units or T-score)

8 8 Treatment Guidelines NOF AACE NAMS ACOG ALL -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 RF Fragility Fracture (with or without low BMD) T-score ? NOF : National Osteoporosis Foundation, AACE : American Association of Clinical Endocrinologists, NAMS : North American Menopause Society, ACOG : American College of Obstetricians and Gynecologists Treat Don’t treat

9 F/58, L1-L4; -1.9 Total femur 0.4

10 10

11 11 WHO 골다공증 진단 기준의 단점 골절 진단의 예민도가 낮음 치료 여부 결정에 적합한 기준이 아님 연령, 골절 등 위험인자가 반영되지 않음 골의 질 (quality) 이 반영되지 않음 원칙적으로 백인 여성에 국한하여 적용 측정부위가 척추, 대퇴골, 요골에 국한 측정부위와 방법에 따라 다양한 결과 표준 정상치의 신뢰 정도에 영향을 받음 골절위험도의 지속적 증가 개념과 맞지 않음

12 12 Kanis Swedish Model 10-Year Risks of Any of 4* Fractures *Hip, humerus, wrist, or clinical spine. Data from Kanis JA, et al. Osteoporos Int. 2001;12:989-995. 30.824.519.415.211.89.17.0 28.422.818.314.611.59.07.1 23.919.315.612.610.08.06.3 20.216.213.010.48.26.55.1 16.813.410.78.56.75.34.1 14.111.39.27.45.94.73.8 75 70 65 60 55 50T-Score –3.0 T-Score –2.5 T-Score –2.0 T-Score –1.5 T-Score –1.0 T-Score –0.5 T-Score0Age(years)30.824.519.415.211.89.17.0 28.422.818.314.611.59.07.1 23.9 19.3 15.612.610.08.06.3 20.2 16.213.010.48.26.55.1 16.813.410.78.56.75.34.1 14.111.39.27.45.94.73.8 75 70 65 60 55 50 T-Score –3.0 T-Score –2.5 T-Score –2.0 T-Score –1.5 T-Score –1.0 T-Score –0.5 T-Score0Age(years)

13 13 WHO Scientific Group Meeting on Fracture Risk Reporting RotterdamEVOS/EPOSCaMosRochesterSheffieldDubboEPIDOSOFELYKupioHiroshima Gothenburg I, II 59,232 subjects (Female; 74 %) 249,898 person-years 5,444 total fractures 3,459 OP fractures 959 hip fractures

14 14 WHO 연구에서 골절의 절대 위험도 평가에 이용된 위험인자 위험인자 상대위험도 (Relative risks) 흡연 1.7 골절 병력 1.8 대퇴골 골절의 가족력 2.3 음주 ( > 2 unit/ 일 ) 1.7 스테로이드 사용 2.3 류마티스 관절염 1.8 대퇴골 경부 Z-score 1.6 ( 골밀도 측정결과가 없으면 저체중 (BMI < 20 kg/m 2 ) 으로 대체 ) 저체중 (BMI < 20 kg/m 2 ) 으로 대체 ) Alcohol 2 units = 16 gm = 500ml = 100ml 2 잔 =

15 15 0.01 0.1 1 10 100 50556065707580 Age (years) 10 year hip fracture probability (%) T-score -4 -3 -2 0 1 No prior fracture 50556065707580 T-score -4 -3 -2 0 1 Prior fracture Female, BMI = 22 BMD and Hip Fracture Probability Kanis. J, et al.

16 16 Case : Swedish Hip and 3-Fracture Risk 10 Yr HIP 10 Yr Any 3* 0.9%7.8% At age 52, T-score -1.5 Kanis JA et al. 2001: J Bone Miner Res 16 (Suppl 1):S194. * Spine, hip, or wrist 52 세 여성 4 년 전 조기 폐경 체중 : 52.5 kg 모친 고관절 골절병력 2 년 전 HRT 중단

17 17 한국인 고관절 골절 빈도 조사 하용찬 등 ( 제주도 지역 50 세 이상 ): 2002. 1. 1 ~ 12. 31 50 세 이상 : 118,100 ( 여자 : 68,640, 남자 : 46,460) 골관절 골절 발생 평균 나이 : 77.1 세 (50 ~ 98 세 ) 발생률 : 128/100,000 ( 남자 : 93/100,000, 여자 : 168/100,000 ) 연령별 발생률 변화 노성만 등 ( 전남 지역 50 세 이상 ): 134/100,000/year 연령 발생률 (/100,000/year) 50-5916 60-6966 70-79240 > 80 821

18 18 골다공성 골절 치료의 국가적 비용 전체 환자수 50 대이상 환자 (%) 50 대이상 환자수 골절당 직접비용 ( 단위 : 원 ) 골절당 간접비용 ( 단위 : 원 ) 직접비용 ( 단위 : 백만원 ) 직간접비용 ( 단위 : 백만원 ) 고관절 23,2800.8118,8577,520,3997,309,058141,811279,636 척추 29,4190.720,5936,251,1277,922,785128,731291,888 손목 25,0370.338,2622,194,2129,580,31718,12997,284 총 668,807 골다공증성 골절 비용 : 6688 억원 /1 년 ( 골다공증성 골절비용연구, 박일형, 양규현, 문성환 등, 2006)

19 정상 자료의 중요성 KoreaUSAMid.east BMD0.823 (L1-L4) t-score-2.4-3.0-2.3 KoreaMid. eastUSA

20 20 2006. 9 ASBMR, Philadelphia

21

22 22 Female Young Adult BMD Values Comparison Country Spine L1-L4Femur NeckTrochanterTotal Femur Korean1.150 ±0.120.941 ±0.110.739 ±0.100.975 ±0.11 Japanese1.110 ±0.120.900 ±0.120.750 ±0.110.934 ±0.12 Chinese1.114 ±0.120.930 ±0.120.759 ±0.110.975 ±0.13 American Caucasian 1.180 ±0.120.980 ±0.120.790 ±0.111.000 ±0.12 (mean ± standard deviation, g/cm) (mean ± standard deviation, g/cm 2 )

23 23 2006. 9 ASBMR, Philadelphia 골다공증성 골절 비용 : 6688 억원 /1 년 한국인 고관절 골절율 : 128-134 명 /10 만명 한국인 정상 골밀도 연구

24 24 골다공증의 최신 진단지침과 유의사항 2006 ISCD guideline New guideline New guideline Vertebral fracture assessment (VFA) Vertebral fracture assessment (VFA) Beyond BMD Structure (size, geometry, trabecular architecture, etc) Structure (size, geometry, trabecular architecture, etc) Material property (mineral, collagen, microdamage) Material property (mineral, collagen, microdamage) Beyond T-score Absolute fracture risk assessment Absolute fracture risk assessment

25 척추골절계측 (Vertebral Fracture Assessment) 뼈의 크기와 기하학 (geometry) ; CSMI, Hip axis length, Fall index 골절의 절대위험도 (Absolute fracture risk) DXA 의 진화 ; Beyond BMD


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