Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

Dr. Adler is correct regarding our comments regarding the OST. We did test it in the HNANES data (as part of our study) and by sensitivity and specificity and ROC it was essentially the same. (Using the same cutpoint that he reported in his study, the OST had sl less specificity than the MORES but not significant.) My difficulty with the OST was in my reading of the studies of its development I became confused as to what the cut point should be and how the cut point is/should be derived. The other studies I read, Koh et al and Kung et al (see bib in paper) did not seem to use a standard cutpoint. I found the MORES easier to compute (and the cutpoint does not change), but both should help clinicians identify men at risk for osteoporosis.

Angela J. Shepherd, MD UTMB Family Medicine

Competing interests:   None declared

We appreciate the comments from Dr. Reginster from Belgium. In our ongoing literature research, we have been impressed that osteoporosis in men and women is a significant concern and research topic on a worldwide scale. Research teams in China, Japan, northern and southern Europe, the US and Canada are publishing studies on a regular basis. We hope that our study will stimulate more investigations so that we can further understand and identify risks in our patients and ultimately negatively impact the number of future osteoporosis cases and fractures.

Angela Shepherd Alvah Cass Laura Ray Carol Carlson

Competing interests:   None declared

Shepherd et al present a potential screening tool for osteoporosis in men, based on age, weight, and COPD. Using NHANES data, the MORES score predicted hip bone density well and was validated using other NHANES data. The authors stated that the OST score, used in several populations of men was cumbersome to calculate and different cut-offs had been used in different populations. The authors base their work solely on the total hip bone density. For younger men, osteoporosis may first be seen in the spine, so the predictive value of MORES may be worse than it seems. In addition, the authors assume that there is good concordance for total hip and femoral neck in men, which needs to be proven. While I think MORES is a good method, I personally did not find it less cumbersome than OST. OST has been used in several populations that the authors do not cite, including African-American men (1), Moroccan men (2), and white men (3) responding to an advertisement or attending an orthopedic clinic. In addition, Zimering (4) has reported that OST worked well in another male veteran population, similar to what we had found previously (5). All screening methods are aimed at identifying men at higher risk for osteoporosis by DXA, and all seem to work reasonably well. Unless the authors calculated the OST score for their population, it is impossible to state that one score truly is better than another.

References

1. Sinnott B, Kukreja S, Barengolts E. Utility of screening tools for the prediction of low bone mass in African American men. Osteoporos Int. 2006:17:684-692. 2. Ghazi M, Mounach A, Nouijai A, et al. Performance of the osteoporosis risk assessment tool in Moroccan men. Clin Rheumatol. 2007;26:2037-2041. 3. Skedros JG, Sybrowsky CL, Stoddard GJ. The osteoporosis self-assessment tool: a useful tool for the orthopaedic surgeon. J Bone Joint Surg Am. 2007;89:765-772. 4. Zimering MB, Shin JJ, Shah J, et al. Validation of a novel risk estimation tool for predicting low bone density in Caucasian and African American men veterans. J Clin Densitom. 2007;10:289-297. 5. Adler RA, Tran MT, Petkov VI. Performance of the osteoporosis self- assessment tool for osteoporosis in American men. Mayo Clin Proc 2003;78:723-727.

Competing interests:   None declared

Osteoporosis in men constitutes an increasingly important health issue. Risk factors for men’s osteoporosis have been described (1) Simple and effective methods are needed to identify patients at risk for osteoporosis or osteoporosis-related fracture so that they can be screened with dual x-ray absorptiometry (DEXA) and switched for treatment. In the last years, different methods of risk assessment have been published (ORAI, SCORE, ABONE, OST score…) (2)(3) Recently, Sheperd (4) and al have proposed a new and simple method to screen men at risk for osteoporosis (MORES) which includes three variables (age, weight and history of COPD) finding an excellent predictive validity. However, as the population samples described in this paper were 50 and older other variables, as concomitant diseases (thyroidal, inflammatories, hypogonadism, levels of 25OH-D…), current/past medical therapy known to induce bone loss (a.s. corticosteroids) should have been considered. Moreover, many authors state that in the future biochemical markers of bone resorption may be used clinically to predict fracture risk independent of BMD values. For that reason, determinations of urinary resorption markers (NTx, CTx…) also constitute interesting points to determine risk of loosing bone mass or actual bone resorption (5).

1. Orwoll ES. Osteoporosis in men. Endocrinol Metab Clin North Am 1998;27:349-672. 2. Cadarette SM, Jaglal SB, Murray TM, McIsaac WJ, Joseph L, Brown JP. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. The Canadian Multicentre Osteoporosis Study. JAMA. 2001;286:57-633 3. Skedros JG, Sybrowsky CL, Stoddard GJ. The osteoporosis self-assessment screening tool: a useful tool for the orthopaedic surgeon. J Bone Joint Surg Am. 2007;89:765-724 4. Angela J. Shepherd, MD, Alvah R. Cass, MD, SM, Carol A. Carlson, BA and Laura Ray, MA Development and Internal Validation of the Male Osteoporosis Risk Estimation Score. Annals of Family Medicine 5:540-546 (2007) 5. Iki M, Morita A, Ikeda Y, Sato Y, Akiba T, Matsumoto T, et al; JPOS Study Group. Biochemical markers of bone turnover may predict progression to osteoporosis in osteopenic women: the JPOS Cohort Study. J Bone Miner Metab. 2007;25:122-9

Competing interests:   None declared