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86 Tsunou et al. | Journal of Clinical and Translational Research 2024; 10(1): 85-92
risk factor. Diagnosing osteoporosis with comorbidities is difficult, mass index, lean mass, body water content, muscle mass,
especially in patients with NI who have spent long periods in body fat mass, body fat percentage, extracellular water/total
nursing homes or other facilities without bone mineral density body water ratio, skeletal muscle mass, protein content,
(BMD) measurement equipment. Overlooking the complications bone mineral content, somatic cell mass, basal metabolic
of osteoporosis in patients with NI can lead to the development rate, appendicular skeletal muscle mass index, and phase
of fractures and non-traumatic brain injury and reduce their QoL. angle.
Therefore, in this study, we developed an easy-to-measure index that (4) BMD measurements, including the T-score of lumbar
could serve as a substitute for BMD measurement and an alternative vertebrae L1-4 that was measured by dual-energy X-ray
index that would aid in diagnosing osteoporosis in patients with absorptiometry (DEX) using PRODIGY (Lunar iDXA; GE
NI. The study showed that an alternative index to BMD can help Healthcare Japan Co., Tokyo, Japan). T-score was calculated
detect osteoporosis and its related complications at early stages in using the following equation: ([measured BMD – young adult
patients with NI, allowing early treatment and improving their QoL. average BMD]/[BMD-SD of young adult aged 20 – 44 years
Institutionalized patients with NI often present with fragile bones as of the same sex and ethnicity]) [5]. Patients with a T-score of
facilities often do not have the necessary equipment for measuring <−2.5 SD were diagnosed with osteoporosis.
BMD, for example, in the case of care-related fractures. Therefore, (5) Nutritional measures, including average energy intake
addressing this issue can improve the patient’s condition as well as (kcal/kg/day) and average protein intake (g/kg/day) for a total
their family, caregivers, and facility staff. However, not all facilities of 3 days, including the days before and after the day of body
have the equipment to measure BMD to diagnose osteoporosis. composition measurement. The average Vitamin D intake
A surrogate index can help diagnose osteoporosis in patients (μg/day) and average calcium intake (mg/day) were based on
living in such institutions without adequate BMD measurements. the 42-day cycle menu of the research center’s diet, and the
Consequently, the objective was to develop an easy and reliable intake of both Vitamin D and calcium varied daily, and the
index for patients with NI to diagnose osteoporosis when BMD average salary for a 42-day cycle was used
measuring equipment is unavailable. (6) Outcome measures.
2. Methods The primary outcome was the presence of osteoporosis
(diagnosed using the T-score), and the factors that most influenced
2.1. Participants this outcome were compared. These data did not suffer from any

In this single-center and retrospective study, all patients with source bias since the blind collection methodology was adopted.
NI hospitalized at a single medical center between August 2020 As hormones strongly influence bone mineral quantification
and June 2022 were included in the study. Patients diagnosed with in female participants, they were excluded from this study. All
NI who stayed at the hospital for more than 3 months during the collected data were compared between those with and without
study period were included. Patients were excluded from the study osteoporosis to characterize the group with osteoporosis. In
if they were as follows: (1) female, (2) younger than 18 years, addition to BMD, we examined the presence or absence of
(3) had missing BMD data, (4) had hepatic and renal dysfunction indicators that can be used to diagnose osteoporosis, particularly
(serum total bilirubin level 1.5 mg/dL or serum creatinine level using test data that can be more easily collected.
1.5 mg/dL, and (5) died during hospitalization. • Method 1: Participants were divided into two groups, and
the data collected were compared between the two groups to
2.2. Data collection analyze the factors influencing osteoporosis.

Data for catabolic measurements were collected in the same • Method 2: Multiple logistic regression analysis on the factors
month as the body composition measurements. The following identified in method 1 was performed to clarify the factors
information was collected: influencing osteoporosis.
(1) Patient information including age, sex, height, weight, • Method 3: Receiving operating characteristic (ROC) curve
antiepileptic drug (AED) use, and gross motor function analysis was used to determine the cutoff values for the most
classification scale (GMFCS) score (Appendix) evaluated by influential factors in osteoporosis.
a single physician. All procedures conformed to the ethical standards of the
(2) Blood work data, including serum albumin level (Alb), serum institutional and national review boards and the tenets of the
creatinine level, serum total bilirubin level, hemoglobin level, 1964 Declaration of Helsinki.
platelet count, total lymphocyte count (TLC), neutrophil 2.3. Statistical analysis
count, eosinophil count, basophil count, monocyte count,
25-hydroxyvitamin D (25-(OH) VD), and Onodera’s We used a thumb rule for at least 12 people in each group and
prognostic nutritional index (PNI) calculated by 10 × Alb + listed the main cross-tabulations required to ensure that the total
0.005 × TLC [4]. number of participants in each table cell would be adequate and
(3) Body composition indices measured using a bioelectrical decided on the number of subjects.
impedance analysis (BIA) Inbody S10 (Inbody, Tokyo, Japan) In method 1, data were presented as medians and 25%, 75%,
device and the following components were measured: body or percentage points, and differences between the two groups
DOI: https://doi.org/10.36922/jctr.00110