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Binney N. Reference-Class Problems Are Real: Health-Adjusted Reference Classes and Low Bone Mineral Density. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2024; 49:128-146. [PMID: 38418083 PMCID: PMC10938540 DOI: 10.1093/jmp/jhae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
Elselijn Kingma argues that Christopher Boorse's biostatistical theory (the BST) does not show how the reference classes it uses are objective and naturalistic. Recently, philosophers of medicine have attempted to rebut Kingma's concerns. I argue that these rebuttals are theoretically unconvincing, and that there are clear examples of physicians adjusting their reference classes according to their prior knowledge of health and disease. I focus on the use of age-adjusted reference classes to diagnose low bone mineral density in children. In addition to using the BST's age, sex, and species, physicians also choose to use other factors to define reference classes, such as pubertal status, bone age, body size, and muscle mass. I show that physicians calibrate the reference classes they use according to their prior knowledge of health and disease. Reference classes are also chosen for pragmatic reasons, such as to predict fragility fractures.
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Atlas G, Yap M, Lim A, Vidmar S, Smith N, King L, Jones A, Hong J, Ranganathan S, Simm PJ. The clinical features that contribute to poor bone health in young Australians living with cystic fibrosis: A recommendation for BMD screening. Pediatr Pulmonol 2021; 56:2014-2022. [PMID: 33724711 DOI: 10.1002/ppul.25375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/27/2021] [Accepted: 02/27/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND For Australians living with cystic fibrosis (CF), increased longevity means greater consideration needs to be given to long-term endocrine sequelae such as CF-related bone disease. Deficits in bone mass accrual are most likely to occur during childhood and adolescence. Current guidelines in Australia suggest repeat dual-energy X-ray absorptiometry (DXA) scans every 2 years. This study aims to stratify clinical factors that determine future bone health in the Australian CF population and use this to guide a more streamlined approach to bone health screening. METHODS This study was a retrospective audit of all patients diagnosed with CF who were treated at the Royal Children's Hospital Melbourne, Australia from 2000 to 2016 (n = 453). Two hundred and two patients had a DXA scan in the study period (191 with height-adjusted data) and 111 patients had more than one scan (108 with height-adjusted data). An investigation into the associations between bone mineral density (BMD) Z score and potential risk factors was conducted using DXA and historical data. RESULTS The main predictor of future BMD was the previous BMD Z score (p < .001). Other factors found to be determinants of BMD included nutritional status, lung function (FEV1 ), age, history of previous fracture, oral corticosteroid use, and the number of hospital admissions. However, after adjusting for previous BMD, evidence of an association remained only with nutritional status, FEV1 , and number of hospital admissions. CONCLUSION Second yearly scans may be unnecessary in children with an adequate DXA score on the initial scan who remain clinically stable. However, clinical deterioration in those whose BMD was previously normal, may require closer monitoring of bone health. We propose a guideline for the frequency of DXA monitoring in relation to clinical risk factors.
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Affiliation(s)
- Gabby Atlas
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Matthew Yap
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Angelina Lim
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Centre for Medicine Use and Safety, Monash University Parkville, Parkville, Victoria, Australia
| | - Suzanna Vidmar
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Nathan Smith
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Louise King
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Alicia Jones
- Monash Medical Centre, Clayton, Victoria, Australia.,Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
| | - Jason Hong
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sarath Ranganathan
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Peter J Simm
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Calella P, Valerio G, Brodlie M, Taylor J, Donini LM, Siervo M. Tools and Methods Used for the Assessment of Body Composition in Patients With Cystic Fibrosis: A Systematic Review. Nutr Clin Pract 2019; 34:701-714. [DOI: 10.1002/ncp.10247] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Patrizia Calella
- Department of Movement Sciences and Wellbeing; Parthenope University; Naples Italy
- Human Nutrition Research Centre; Institute of Cellular Medicine; Newcastle University; Newcastle on Tyne UK
| | - Giuliana Valerio
- Department of Movement Sciences and Wellbeing; Parthenope University; Naples Italy
| | - Malcolm Brodlie
- Institute of Cellular Medicine; Newcastle University and Great North Children's Hospital; Newcastle upon Tyne UK
| | - Jake Taylor
- Institute of Cellular Medicine; Newcastle University and Great North Children's Hospital; Newcastle upon Tyne UK
| | - Lorenzo Maria Donini
- Department of Experimental Medicine-Medical Pathophysiology; Food Science and Endocrinology Section; Food Science and Human Research Unit; Sapienza University of Rome; Rome Italy
| | - Mario Siervo
- Human Nutrition Research Centre; Institute of Cellular Medicine; Newcastle University; Newcastle on Tyne UK
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Cossio-Bolaños M, Lee-Andruske C, de Arruda M, Luarte-Rocha C, Almonacid-Fierro A, Gómez-Campos R. Hand grip strength and maximum peak expiratory flow: determinants of bone mineral density of adolescent students. BMC Pediatr 2018; 18:96. [PMID: 29499680 PMCID: PMC5834893 DOI: 10.1186/s12887-018-1015-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 01/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background Maintaining and building healthy bones during the lifetime requires a complicated interaction between a number of physiological and lifestyle factors. Our goal of this study was to analyze the association between hand grip strength and the maximum peak expiratory flow with bone mineral density and content in adolescent students. Methods The research team studied 1427 adolescent students of both sexes (750 males and 677 females) between the ages of 11.0 and 18.9 years in the Maule Region of Talca (Chile). Weight, standing height, sitting height, hand grip strength (HGS), and maximum peak expiratory flow (PEF) were measured. Furthermore, bone mineral density (BMD) and total body bone mineral content (BMC) were determined by using the Dual-Energy X-Ray Absorptiometry (DXA). Hand grip strength and PEF were categorized in tertiles (lowest, middle, and highest). Linear regression was performed in steps to analyze the relationship between the variables. Differences between categories were determined through ANOVA. Results In males, the hand grip strength explained 18–19% of the BMD and 20–23% of the BMC. For the females, the percentage of variation occurred between 12 and 13% of the BMD and 17–18% of the BMC. The variation of PEF for the males was observed as 33% of the BMD and 36% of the BMC. For the females, both the BMD and BMC showed a variation of 19%. The HGS and PEF were divided into three categories (lowest, middle, and highest). In both cases, significant differences occurred in bone density health between the three categories. Conclusions In conclusion, the HGS and the PEF related positively to the bone density health of both sexes of adolescent students. The adolescents with poor values for hand grip strength and expiratory flow showed reduced values of BMD and BMC for the total body. Furthermore, the PEF had a greater influence on bone density health with respect to the HGS of the adolescents of both sexes.
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Affiliation(s)
- Marco Cossio-Bolaños
- Faculty of Physical Education, State University of Campinas, Campinas, Brazil.,Departamento de Ciencias de la Actividad Física, Universidad Católica del Maule, Talca, Chile.,Universidad Nacional de San Agustín, Arequipa, Peru
| | - Cynthia Lee-Andruske
- Red Iberoamericana de Investigación en Desarrollo Biológico Humano, Arequipa, Peru
| | - Miguel de Arruda
- Faculty of Physical Education, State University of Campinas, Campinas, Brazil
| | | | | | - Rossana Gómez-Campos
- Faculty of Physical Education, State University of Campinas, Campinas, Brazil. .,Universidad Nacional de San Agustín, Arequipa, Peru. .,Universidad Autónoma de Chile, 5 Poniente, 1670, Talca, Chile.
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Sharma S, Jaksic M, Fenwick S, Byrnes C, Cundy T. Accrual of Bone Mass in Children and Adolescents With Cystic Fibrosis. J Clin Endocrinol Metab 2017; 102:1734-1739. [PMID: 28323913 DOI: 10.1210/jc.2016-3459] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 02/17/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Low bone density is a complication of cystic fibrosis (CF). HYPOTHESIS Accrual of bone mass is most impaired in the sickest children, as judged by nutritional status and pulmonary function. DESIGN Retrospective analysis of correlation between lumbar spine bone mineral density (BMD), body mass index (BMI), and forced expiratory volume in 1 second (FEV1) z scores in children and adolescents with CF. SETTING Pediatric hospital specialist CF service. PATIENTS Sixty participants aged 5.9 to 18.8 years (24 female) with confirmed CF. INTERVENTIONS Lumbar spine BMD, BMI, and FEV1 z scores measured at first BMD scan; 40 participants had sequential scans. Change in L1-L4 z scores over time was used as a measure of bone accrual, and BMI as a measure of nutritional status. OUTCOME MEASURES Correlations between lumbar spine BMD, BMI, and FEV1 z scores. RESULTS Mean BMI and BMD z scores were strongly correlated at the initial scan (P < 0.0001), suggesting that nutritional status is a major determinant of BMD. In the sequential scan at a mean age of 16.1 years, height centile was maintained, indicating normal linear growth. Changes in BMI and BMD z scores were positively correlated (P = 0.001), indicating that patients failing to gain weight appropriately with growth were also failing to acquire bone normally. Change in FEV1 z score was correlated with change in both BMD (P < 0.0001) and BMI z scores (P = 0.02). CONCLUSION Although young people with CF may be maintaining normal growth in height, bone accrual is impaired in those with the poorest nutritional status and lung function.
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Affiliation(s)
- Sonakshi Sharma
- Department of Endocrinology, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - Mirjana Jaksic
- Department of Paediatrics, Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
- Respiratory Service, Starship Children's Hospital, Auckland 1023, New Zealand
| | - Sheryl Fenwick
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Catherine Byrnes
- Department of Paediatrics, Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
- Respiratory Service, Starship Children's Hospital, Auckland 1023, New Zealand
| | - Tim Cundy
- Department of Endocrinology, Greenlane Clinical Centre, Auckland 1051, New Zealand
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
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Naguib ML, Koura HM, Mahmoud MM, Mohamed AS, Wissa SS. Bone mineral density and its contributing factors in Egyptian children with cystic fibrosis. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2016. [DOI: 10.4103/1687-8426.184372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Turck D, Braegger CP, Colombo C, Declercq D, Morton A, Pancheva R, Robberecht E, Stern M, Strandvik B, Wolfe S, Schneider SM, Wilschanski M. ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis. Clin Nutr 2016; 35:557-77. [PMID: 27068495 DOI: 10.1016/j.clnu.2016.03.004] [Citation(s) in RCA: 306] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/04/2016] [Accepted: 03/05/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members. RESULTS The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended. CONCLUSION Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.
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Affiliation(s)
- Dominique Turck
- Univ. Lille, Inserm U995, LIRIC - Lille Inflammation Research International Center, Division of Gastroenterology, Hepatology and Nutrition, and Cystic Fibrosis Center, Department of Pediatrics, CHU Lille, F-59000 Lille, France.
| | - Christian P Braegger
- Division of Gastroenterology and Nutrition and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, CH-8032, 10 Zurich, Switzerland.
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico (IRCCS), Università degli Studi di Milano, Milan, Italy.
| | - Dimitri Declercq
- Department of Pediatrics, CF Centre, Ghent University Hospital, De Pintelaan 185, 9000 Gent, Belgium.
| | - Alison Morton
- Regional Adult CF Unit, St. James' University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Ruzha Pancheva
- Department of Hygiene, Faculty of Public Health, Prof. Dr. Paraskev Stoyanov Medical University of Varna, 55 Marin Drinov Str., 9002 Varna, Bulgaria.
| | - Eddy Robberecht
- Pediatric Gastroenterology, Hepatology & Nutrition, University Ghent, CF Centre Ghent, Princess Elisabeth Pediatric Hospital, B 9000 Ghent, Belgium.
| | - Martin Stern
- University Children's Hospital, University of Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany.
| | - Birgitta Strandvik
- Department of Bioscience and Nutrition, Karolinska Institutet, Novum, Hälsovägen 7-9, 14183 Huddinge, Stockholm, Sweden.
| | - Sue Wolfe
- Regional Pediatric CF Unit, The Leeds Children's Hospital, Belmont Grove, Leeds, LS2 9NS, UK.
| | - Stephane M Schneider
- Gastroenterology and Clinical Nutrition, Archet University Hospital and University of Nice Sophia-Antipolis, Nice, France.
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, PO Box 24035 Jerusalem, 91240, Israel.
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Sands D, Mielus M, Umławska W, Lipowicz A, Oralewska B, Walkowiak J. Evaluation of factors related to bone disease in Polish children and adolescents with cystic fibrosis. Adv Med Sci 2015; 60:315-20. [PMID: 26183540 DOI: 10.1016/j.advms.2015.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 04/28/2015] [Accepted: 05/20/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of the study was to evaluate factors related to bone formation and resorption in Polish children and adolescents with cystic fibrosis and to examine the effect of nutritional status, biochemical parameters and clinical status on bone mineral density. MATERIALS AND METHODS The study group consisted of 100 children and adolescents with cystic fibrosis with a mean age 13.4 years old. Anthropometric measurements, included body height, body mass and body mass index (BMI); bone mineral densitometry and biochemical testing were performed. Bone mineral density was measured using a dual-energy X-ray absorption densitometer. Biochemical tests included serum calcium, phosphorus, parathyroid hormone and vitamin D concentrations, as well as 24-h urine calcium and phosphorus excretion. Pulmonary function was evaluated using FEV1%, and clinical status was estimated using the Shwachman-Kulczycki score. RESULTS Standardized body height, body mass and BMI were significantly lower than in the reference population. Mean serum vitamin D concentration was decreased. Pulmonary disease was generally mild, with a mean FEV1% of 81%. Multivariate linear regression revealed that the only factors that had a significant effect on bone marrow density were BMI and FEV1%. There were no significant correlations between bone mineral density and the results of any of the biochemical tests performed. CONCLUSIONS Nutritional status and bone mineral density were significantly decreased in children and adolescents with cystic fibrosis. In spite of abnormalities in biochemical testing, the factors that were found to have the strongest effect on bone mineral density were standardized BMI and clinical status.
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Affiliation(s)
- Dorota Sands
- Cystic Fibrosis Centre, Institute of Mother and Child, Warsaw, Poland.
| | - Monika Mielus
- Cystic Fibrosis Centre, Institute of Mother and Child, Warsaw, Poland
| | | | - Anna Lipowicz
- Unit of Anthropology, Polish Academy of Sciences, Wrocław, Poland
| | - Beata Oralewska
- Department of Gastroenterology, Hepatology and Feeding Disorders Children's Health Memorial Institute, Warsaw, Poland
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology & Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
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Brookes DSK, Briody JN, Munns CF, Davies PSW, Hill RJ. Cystic fibrosis-related bone disease in children: Examination of peripheral quantitative computed tomography (pQCT) data. J Cyst Fibros 2015; 14:668-77. [PMID: 25957706 DOI: 10.1016/j.jcf.2015.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 04/02/2015] [Accepted: 04/20/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The investigation of skeletal health data beyond dual X-ray absorptiometry (DXA) is limited in young individuals with CF. We assessed volumetric bone mineral densities (BMD), and bone and muscle parameters using peripheral quantitative computed tomography (pQCT) in individuals with CF and controls, 7.00-17.99 years. METHODS Peripheral QCT (XCT 3000, Stratec) measurements were made in 53 individuals with CF and 53 controls. Bone mineral content (BMC), total volumetric BMD (vBMD) and cross sectional area (CSA) of the bone were measured at the 4% and 66% sites of the non-dominant tibia and radius. Additionally, trabecular vBMD and bone strength index (BSIc) were measured at the 4% sites, and cortical vBMD, muscle CSA (mCSA) and strength strain index (SSI) were measured at the 66% sites. RESULTS Pre-pubertal males with CF had greater trabecular vBMD (p=0.01) and total vBMD (p=0.00) at 4% tibia, and greater total vBMD (p=0.02) at 4% radius. Pre-pubertal females with CF had greater total vBMD at 66% tibia (p=0.02) and radius (p=0.04), and cortical vBMD (p=0.04) at the radius. At puberty, the CF cohort had less BMC at 4% tibia (males, p=0.02; females, p=0.01), and smaller mCSA at 66% tibia (males, p=0.02; females, p=0.01). Pubertal CF females had a smaller bone CSA (p=0.01) at 4% tibia, and lower bone strength (SSI) at the tibia (p=0.00) and radius (p=0.05) sites. CONCLUSIONS Bone strength parameters were not compromised prior to puberty in this CF cohort. At puberty, the bone phenotype changed for this CF cohort, showing several deficits compared to the controls. However, bone strength was adapting to the mechanical demands of the muscle. Altered bone parameters and their implications for lowered bone strength with increased age may be greatly influenced by: the CF cohort remaining smaller for age and/or a reduced bone strain, secondary to reduced muscle force.
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Affiliation(s)
- Denise S K Brookes
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia.
| | | | - Craig F Munns
- The Children's Hospital at Westmead, Sydney, Australia; University of Sydney, School of Medicine, Sydney, Australia
| | - Peter S W Davies
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia
| | - Rebecca J Hill
- The University of Queensland, Queensland Children's Medical Research Institute, Children's Nutrition Research Centre, Brisbane, Australia; The University of Queensland, School of Medicine, Brisbane, Australia
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Bianchi ML, Colombo C, Assael BM, Dubini A, Lombardo M, Quattrucci S, Bella S, Collura M, Messore B, Raia V, Poli F, Bini R, Albanese CV, De Rose V, Costantini D, Romano G, Pustorino E, Magazzù G, Bertasi S, Lucidi V, Traverso G, Coruzzo A, Grzejdziak AD. Treatment of low bone density in young people with cystic fibrosis: a multicentre, prospective, open-label observational study of calcium and calcifediol followed by a randomised placebo-controlled trial of alendronate. THE LANCET RESPIRATORY MEDICINE 2013; 1:377-85. [DOI: 10.1016/s2213-2600(13)70064-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rana M, Munns CF, Selvadurai H, Briody J, Craig ME. The impact of dysglycaemia on bone mineral accrual in young people with cystic fibrosis. Clin Endocrinol (Oxf) 2013; 78:36-42. [PMID: 22757766 DOI: 10.1111/j.1365-2265.2012.04484.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 04/10/2012] [Accepted: 06/24/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The effect of dysglycaemia on bone mineral density (BMD) has not been studied in young people with CF. We examined factors associated with BMD in a tertiary paediatric CF clinic. DESIGN Retrospective, clinic-based study at The Children's Hospital at Westmead, Sydney. PATIENTS Young people with CF aged ≤ 18 years. MEASUREMENTS Bone mineral density was measured by dual-energy X-ray absorptiometry; main outcome measures were total body (TB), lumbar spine (LS) and femoral neck (FN) BMD and bone mineral content (BMC), and LS volumetric BMD (vBMD), reported as z scores for height. Dysglycaemia, based on oral glucose tolerance test, was defined as CF-related diabetes (CFRD) or impaired glucose tolerance (IGT). RESULTS Overall, 14 of 81 (17%) had CFRD, 6 (7%) IGT and 61 (76%) normal glucose tolerance (NGT). Mean age was 14.9 ± 2.4 years and mean height z score -0.68 ± 1.39. Osteopenic (z score ≤-2) TB, LS or FN BMD was present in 30 of 81 (37%), BMC in 42 (52%) and vBMD in 10 (5%). Across the three groups, there were differences in LS vBMD (CFRD, -0.67 ± 0.76; IGT, -0.52 ± 0.76; NGT, -0.05 ± 1.39; P = 0.04), LS BMD (P < 0.01), LS BMC (P = 0.01) and TB BMD (P = 0.01). In multivariate linear regression, LS BMC was associated with dysglycaemia (β = 0.56; 95% CI, 0.00-1.13; P = 0.05) and approached significance for FEV(1) (β = 0.01; 95% CI, 0.00-0.02; P = 0.06). CONCLUSIONS Dysglycaemia is associated with reduced bone mass accrual in youth with CF, in addition to recognized factors such as abnormal lung function, poor nutritional status and disease severity. Bone health assessment is essential in youth with CF.
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Affiliation(s)
- Malay Rana
- Institute of Endocrinology and Diabetes, Sydney Children's Hospital Network, Westmead, Australia
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Gore AP, Kwon SH, Stenbit AE. A roadmap to the brittle bones of cystic fibrosis. J Osteoporos 2010; 2011:926045. [PMID: 21209785 PMCID: PMC3010683 DOI: 10.4061/2011/926045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 11/05/2010] [Indexed: 12/17/2022] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disorder which despite advances in medical care continues to be a life-limiting and often fatal disease. With increase in life expectancy of the CF population, bone disease has emerged as a common complication. Unlike the osteoporosis seen in postmenopausal population, bone disease in CF begins at a young age and is associated with significant morbidity due to fractures, kyphosis, increased pain, and decreased lung function. The maintenance of bone health is essential for the CF population during their lives to prevent pain and fractures but also as they approach lung transplantation since severe bone disease can lead to exclusion from lung transplantation. Early recognition, prevention, and treatment are key to maintaining optimal bone health in CF patients and often require a multidisciplinary approach. This article will review the pathophysiology, current clinical practice guidelines, and potential future therapies for treating CF-related bone disease.
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Affiliation(s)
- Ashwini P. Gore
- Division of Endocrinology, Diabetes & Medical Genetics, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425-6300, USA
| | - Soon Ho Kwon
- Division of Endocrinology, Diabetes & Medical Genetics, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425-6300, USA
| | - Antine E. Stenbit
- Division of Pulmonary, Critical Care, Allergy & Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425-6300, USA,*Antine E. Stenbit:
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Sparks AA, McGee SJ, Boone CE, Neuringer IP, Jones SK, Aris RM. 'Old' bones in young bodies: the tale of cystic fibrosis. Curr Opin Endocrinol Diabetes Obes 2009; 16:407-14. [PMID: 19816169 DOI: 10.1097/med.0b013e3283329b16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is the most common genetic disease within the white population and leads to premature respiratory failure. Approximately, 60 000 individuals are currently living with CF in North America and Europe, almost half of whom are adults. RECENT FINDINGS Dozens of studies across the globe indicate that CF adults have low bone density and increased rates of fractures. This genesis of the problem appears to be in late childhood to adolescence. SUMMARY Prevention and treatment of CF-related bone disease must address the myriad risk factors (decreased absorption of fat-soluble vitamins due to pancreatic insufficiency, altered sex hormone production, chronic lung infection with increased serum levels of proinflammatory, bone-active cytokines, malnutrition and low body weight, physical inactivity and glucocorticoid therapy) for poor bone health. This review will address the pathogenesis, diagnosis and treatment of bone disease in CF. It will also discuss best practice guidelines for optimizing bone health in patients with CF.
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Affiliation(s)
- Amy A Sparks
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:470-80. [PMID: 19858911 DOI: 10.1097/med.0b013e3283339a46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lucidi V, Bizzarri C, Alghisi F, Bella S, Russo B, Ubertini G, Cappa M. Bone and body composition analyzed by Dual-energy X-ray Absorptiometry (DXA) in clinical and nutritional evaluation of young patients with Cystic Fibrosis: a cross-sectional study. BMC Pediatr 2009; 9:61. [PMID: 19785733 PMCID: PMC2760551 DOI: 10.1186/1471-2431-9-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 09/28/2009] [Indexed: 11/10/2022] Open
Abstract
Background the improved general therapy has led to reduced morbidity and mortality from Cystic Fibrosis (CF), and bone status may have a potentially greater clinical impact. We investigated the correlation between the severity of the clinical condition, bone status and body composition parameters, in a group of children and young adults with CF. Methods we measured lumbar spine bone density and total body composition by dual energy x-ray absorptiometry (DXA) in 82 consecutive CF patients (42 males; median age: 13 years - range: 5-30). Eighty-two healthy subjects, matched for age, gender, height and pubertal stage were recruited as a control group. Results 37 patients (45.1%) had a normal bone mineral density (BMD). A BMD reduction were observed in 45 (54.8%) patients. Lumbar spine Z score was positively related to Body Mass Index (BMI) and a higher Shwachman-Kulczycki score, and negatively related to Crispin-Norman score. A positive and significant correlation was also observed between lumbar spine Z score and total body composition. Conclusion a significant BMD reduction can be present early in CF children and adolescents. A careful follow up of bone status is required starting in childhood.
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Affiliation(s)
- Vincenzina Lucidi
- Unit of Cystic Fibrosis, Department of Pediatric Medicine - Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Sermet-Gaudelus I, Castanet M, Retsch-Bogart G, Aris RM. Update on cystic fibrosis-related bone disease: a special focus on children. Paediatr Respir Rev 2009; 10:134-42. [PMID: 19651384 DOI: 10.1016/j.prrv.2009.05.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A high prevalence of low bone mineralization is documented in adult patients with cystic fibrosis (CF). Osteopenia is present in up to 85% of adult patients and osteoporosis in 10% to 34%. In children, study results are discordant probably because of comparisons to different control populations and corrections for bone size in growing children. Malnutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity are well known risk factors for poor bone health. Puberty is a critical period for bone mineralization and requires a careful follow-up to achieve optimal bone peak mass. Strategies for optimizing bone health, such as monitoring bone mineral density (BMD) and providing preventive care are necessary from childhood through adolescence to minimize CF-related bone disease in adult CF patients.
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Affiliation(s)
- Isabelle Sermet-Gaudelus
- Centre de Référence et de Compétence en Mucoviscidose, Hopital Necker-Enfants Malades, INSERM U 845, Université René Descartes, Paris, France
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Symposium 6: Young people, artificial nutrition and transitional care The nutritional challenges of the young adult with cystic fibrosis: transition. Proc Nutr Soc 2009; 68:430-40. [DOI: 10.1017/s0029665109990176] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cystic fibrosis (CF) is a complex multisystem disorder affecting mainly the gastrointestinal tract and respiratory system. Intestinal malabsorption occurs in approximately 90% of patients. In the past, malnutrition was an inevitable consequence of disease progression, leading to poor growth, impaired respiratory muscle function, decreased exercise tolerance and immunological impairment. A positive association between body weight and height and survival has been widely reported. The energy requirements of patients with CF vary widely and generally increase with age and disease severity. For many young adults requirements will be 120–150% of the age-related estimated average requirement. To meet these energy needs patients are encouraged to eat a high-fat high-energy diet with appropriate pancreatic enzyme supplements. Many patients are unable to achieve an adequate intake as a result of a variety of factors including chronic poor appetite, infection-related anorexia, gastro-oesophageal reflux and abdominal pain. Oral energy supplements and enteral tube feeding are widely used. Nutritional support has been shown to improve nutritional status and stabilise or slow the rate of decline in lung function. With such emphasis on nutritional intake and nutritional status throughout life, poor adherence to therapies and issues relating to body image are emerging. The median survival of patients with CF is increasing. CF is now considered a life-limiting disease of adulthood rather than a terminal childhood illness. With increased longevity new challenges are emerging that include the transition of young adults with CF to adult services, CF-related diabetes, disordered eating, osteoporosis, liver disease and transplantation.
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