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Barmpa E, Karamagkiolis S, Tigas S, Navrozidou P, Vlychou M, Fezoulidis I, Koukoulis GN, Bargiota A. Bone Mineral Density in Adult Patients with Type 1 Diabetes Mellitus Assessed by Both DXA and QCT. J Diabetes Res 2023; 2023:8925956. [PMID: 37362256 PMCID: PMC10287513 DOI: 10.1155/2023/8925956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 07/14/2022] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Purpose Bone mineral density (BMD) was measured in uncomplicated young adult patients with type 1 diabetes mellitus (T1DM) and sex- and age-matched controls, using both dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) to investigate their diagnostic ability in detecting abnormal values in these patients. Methods 118 patients with T1DM (65 females, mean age 30.12 ± 8.78 years) and 94 sex- and age-matched controls were studied. BMD was assessed in all participants by DXA and QCT at lumbar spine (LS). Biochemical markers of bone metabolism were also measured. Results T1DM was associated with lower BMD at L1-L3 vertebrae measured by both DXA and QCT and lower bone turnover compared to sex- and age-matched controls. In T1DM subjects, QCT detected more patients with abnormal BMD values compared to DXA. BMI and HbA1c levels were the only determinants of BMD. Bone turnover markers were lower in patients with longer duration of diabetes. Conclusion QCT provides a higher sensitivity compared to DXA in detecting abnormal BMD values in patients with uncomplicated T1DM. In these patients, the diabetes-related decreased BMD may be present early, before it is detected by DXA, the clinical gold standard for BMD measurements, and before the presence of any other diabetes complications, stressing the importance of an early intervention for fracture prevention.
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Affiliation(s)
- Eleftheria Barmpa
- Department of Endocrinology and Metabolic Diseases, University General Hospital of Larissa, Larissa, Greece
| | | | - Stelios Tigas
- Department of Endocrinology, Medical School, University of Ioannina, Ioannina, Greece
| | - Parthena Navrozidou
- Radiology Department Clinical and Laboratory Research, University General Hospital of Larissa, Larissa, Greece
| | - Marianna Vlychou
- Radiology Department Clinical and Laboratory Research, University General Hospital of Larissa, Larissa, Greece
| | - Ioannis Fezoulidis
- Radiology Department Clinical and Laboratory Research, University General Hospital of Larissa, Larissa, Greece
| | - Georgios N. Koukoulis
- Department of Endocrinology and Metabolic Diseases, University General Hospital of Larissa, Larissa, Greece
| | - Alexandra Bargiota
- Department of Endocrinology and Metabolic Diseases, University General Hospital of Larissa, Larissa, Greece
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Body composition assessment in adult females with anorexia nervosa and bulimia nervosa - a cross-sectional study comparing dual-energy X-ray absorptiometry scan and isotopic dilution of deuterium. J Nutr 2023; 153:1309-1322. [PMID: 36934952 DOI: 10.1016/j.tjnut.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Eating disorders (EDs) compromise individuals' nutritional status, affecting among other organs and systems, bone health. OBJECTIVE This study aimed to assess and compare bone mineral density (BMD) from dual-energy x-ray absorptiometry (DXA) scan and deuterium (D2O) dilution of adult females with anorexia nervosa (AN) and bulimia nervosa (BN). METHODS This was a cross-sectional study with 53 female participants (18-49 years) with a diagnosis of AN (N = 25) or BN (N = 28). DXA scan was performed to assess BMD, fat mass, and fat-free mass, and D2O dilution was used to assess total body water (TBW), fat mass, and fat-free mass. Interviews/questionnaires were used to assess symptoms, illness trajectory, and physical activity. T-test, Chi-squared test, Pearson's linear correlation, linear regressions, and Bland-Altman analyses were performed, with a significance level of 5%. RESULTS TBW below the recommended level for adult females (≥ 45%) was more frequent in BN (60%) compared with AN (21%; P = 0.013). FMI (soft tissue only) (t-test P = 0.06), and FFMI (t-test P = 0.08) agreed between DXA scan and D2O dilution. Only FFMI did not show systematic bias of proportion (β:-0.2, P = 0.177). The diagnosis of BN, binge-eating episodes, and physical activity in AN were associated with the differences in the methods' results. FMI was positively associated with BMD in AN, and both FMI and FFMI were positively associated with BMD in BN. CONCLUSION In adult females with EDs, DXA scan and D2O dilution achieved agreement for FMI and FFMI. Changes in fat mass and fat-free mass are important in understanding the mechanisms behind bone loss in EDs. Protocols for body composition assessment in EDs can help to minimize the effect of the ED diagnosis, ED behaviors (i.e., excessive exercise and purging behaviors) and weight on the accuracy of measurements.
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Anderson F, Payne C, Pannier L, Pethick D, Gardner G. The potential for dual energy X-ray absorptiometry to predict lamb eating quality. Meat Sci 2021; 181:108434. [DOI: 10.1016/j.meatsci.2021.108434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/25/2022]
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Llorente-Pelayo S, Docio P, Lavín-Gómez BA, García-Unzueta MT, de las Cuevas I, de la Rubia L, Cabero-Pérez MJ, González-Lamuño D. Modified Serum ALP Values and Timing of Apparition of Knee Epiphyseal Ossification Centers in Preterm Infants with Cholestasis and Risk of Concomitant Metabolic Bone Disease of Prematurity. Nutrients 2020; 12:nu12123854. [PMID: 33348603 PMCID: PMC7766077 DOI: 10.3390/nu12123854] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 11/21/2022] Open
Abstract
The usefulness of serum alkaline phosphatase (ALP) and phosphorous in screening and monitoring of metabolic bone disease of prematurity (MBDP) still has some limitations, especially in preterm infants with concomitant conditions such as cholestasis. We aimed to assess a modification of serum ALP (M-ALP) as a biomarker for MBDP in preterm infants, and the use of ultrasound monitoring for the apparition of knee ossification centers as marker of bone mineralization. Biochemical and clinical registers were taken from 94 preterm newborns <32 weeks. A significant correlation existed between serum ALP and direct bilirubin (DB), expressed by the regression equation: M-ALP (IU/L) = 302.1 + 96.9 (DB (mg/dL)). The ratio ALP/M-ALP > 1 was demonstrated to be more specific (87.5%) in the diagnosis of MBDP than the cut-off value of serum ALP > 500 IU/L (62.5%). ALP/M-ALP > 1 showed 100% sensitivity and specificity for the diagnosis of MBDP, and a good correlation with specific bone ALP (B-ALP). Patients with the knee nucleus by post-menstrual week 37 had lower B-ALP compared to patients with no nucleus, and no patients with MBDP presented the nucleus by the 40th week. In the absence of reliable specific B-ALP, reinterpreting serum ALP values by M-ALP plus monitoring of knee ossification centers contribute to better management of MBDP in preterm infants with cholestasis.
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Affiliation(s)
- Sandra Llorente-Pelayo
- Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (S.L.-P.); (P.D.)
| | - Pablo Docio
- Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (S.L.-P.); (P.D.)
| | - Bernardo A. Lavín-Gómez
- Biochemical Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (B.A.L.-G.); (M.T.G.-U.)
| | - María T. García-Unzueta
- Biochemical Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (B.A.L.-G.); (M.T.G.-U.)
| | - Isabel de las Cuevas
- Neonatology Unit, Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain;
- Departmento de Ciencias Médicas y Quirúrgicas, University of Cantabria, 39005 Santander, Spain;
| | - Luis de la Rubia
- Departmento de Ciencias Médicas y Quirúrgicas, University of Cantabria, 39005 Santander, Spain;
- Gastroenterology and Hepatology Unit, Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain
| | - María J. Cabero-Pérez
- Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (S.L.-P.); (P.D.)
- Departmento de Ciencias Médicas y Quirúrgicas, University of Cantabria, 39005 Santander, Spain;
- Correspondence: (M.J.C.-P.); (D.G.-L.); Tel.: +34-942-202604 (D.G.-L.)
| | - Domingo González-Lamuño
- Pediatric Department, University Hospital Marqués de Valdecilla—Research Institute Valdecilla (IDIVAL), 39008 Santander, Spain; (S.L.-P.); (P.D.)
- Departmento de Ciencias Médicas y Quirúrgicas, University of Cantabria, 39005 Santander, Spain;
- Correspondence: (M.J.C.-P.); (D.G.-L.); Tel.: +34-942-202604 (D.G.-L.)
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Zürcher SJ, Jung R, Monnerat S, Schindera C, Eser P, Meier C, Rueegg CS, von der Weid NX, Kriemler S. High impact physical activity and bone health of lower extremities in childhood cancer survivors: A cross-sectional study of SURfit. Int J Cancer 2020; 147:1845-1854. [PMID: 32167159 DOI: 10.1002/ijc.32963] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 11/06/2022]
Abstract
Childhood cancer survivors (CCS) are at risk of reduced bone health and premature osteoporosis. As physical activity with high impact loading (IL-PA) is known to promote bone health, we compared bone densitometry and microstructure between groups of CCS who performed different amounts of physical activities in their daily life. We used baseline data of a single-center PA trial including 161 CCS from the Swiss Childhood Cancer Registry, aged <16 at diagnosis, ≥16 at study and ≥5 years since diagnosis. Lower body bone health was assessed with peripheral quantitative computed tomography (pQCT) and dual-energy X-ray absorptiometry (DXA). Daily IL-PA (duration in activities >2 g acceleration and numbers of vertical impacts/hr >2 g) was captured using hip-worn accelerometers (1-3 weeks). For both IL-PA approaches, we formed low, middle and high activity groups based on tertiles. Bone health of the high and middle active groups was compared to the low active group. 63% of CCS had indication of at least one bone mineral density z-score ≤ -1 measured by pQCT or DXA. The high IL-PA group performing 2.8 min/day or 19.1 impact peaks/hr > 2 g (median) showed about 3-13% better microstructural and densitometric bone health as compared to the low IL-PA group with 0.38 min/day or 0.85 peaks/hr > 2 g. Just a few minutes and repetitions of high IL-PA as easily modifiable lifestyle factor may be sufficient to improve bone health in adult CCS. Future longitudinal research is needed to better understand pattern and dosage of minimal impact loading needed to strengthen bone in growing and adult CCS.
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Affiliation(s)
- Simeon J Zürcher
- Department of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Ruedi Jung
- Department of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Sophie Monnerat
- Department of Pediatric Hematology and Oncology, University Children's Hospital Basel (UKBB) and the University of Basel, Basel, Switzerland
| | - Christina Schindera
- Department of Pediatric Hematology and Oncology, University Children's Hospital Basel (UKBB) and the University of Basel, Basel, Switzerland.,Swiss Childhood Cancer Registry, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Prisca Eser
- Preventive Cardiology and Sports Medicine, University Clinic of Cardiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Christian Meier
- Division of Endocrinology, Diabetes and Metabolism, University Hospital Basel, Basel, Switzerland
| | - Corina S Rueegg
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Nicolas X von der Weid
- Department of Pediatric Hematology and Oncology, University Children's Hospital Basel (UKBB) and the University of Basel, Basel, Switzerland
| | - Susi Kriemler
- Department of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Liu C, Li B, Li Y, Mao W, Chen C, Zhang R, Ta D. Ultrasonic Backscatter Difference Measurement of Bone Health in Preterm and Term Newborns. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:305-314. [PMID: 31791554 DOI: 10.1016/j.ultrasmedbio.2019.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/24/2019] [Accepted: 10/26/2019] [Indexed: 06/10/2023]
Abstract
Metabolic bone disease of prematurity remains a significant problem for preterm infants. Quantitative ultrasound (QUS) has potential as a non-invasive tool for assessing bone health of newborns. The aim of this study was to assess bone health in preterm and term newborns using ultrasonic backscatter difference measurement. This study analyzed a total of 493 neonates, including 239 full-term infants (gestational age [GA] >37 wk), 201 preterm I infants (GA: 32-37 wk) and 53 extreme preterm II infants (GA <32 wk). Ultrasonic backscatter measurements were performed on the calcaneus of infants at birth, and the normalized mean of the backscatter difference spectrum (nMBD) was calculated as an ultrasonic index of neonatal bone status. Simple and multiple linear regressions were performed to determine the association of ultrasonic nMBD with GA, anthropometric characteristics and biochemical markers. Statistically significant differences in GA, anthropometric characteristics (birth weight, birth length [BL], birth head circumference and body mass index [BMI]) and biochemical markers (alkaline phosphatase, serum calcium and serum phosphate) were observed among preterm and term infants. The nMBD for term infants (median = 3.72 dB/μs, interquartile range [IR] = 1.95 dB/μs) was significantly higher than that for preterm I infants (median = 1.95 dB/μs, IR = 3.12 dB/μs), which was, in turn, significantly higher than that for preterm II infants (median = 0.19 dB/μs, IR = 3.50 dB/μs). The nMBD yielded moderate correlations (ρ = 0.57-0.62, p < 0.001) with GA and anthropometric characteristics and weak correlations (|ρ| = 0.08-0.21, p < 0.001 or not significant) with biochemical markers. Multivariate regressions revealed that only BL (p = 0.002) and BMI (p = 0.032) yielded significantly independent contributions to the nMBD measurement, and combinations of BL and BMI could explain up to 42% of the variation of nMBD in newborn infants. This study found that ultrasonic backscatter difference measurement might be helpful in bone health evaluation in preterm and term newborns. The utility of ultrasonic backscatter measurement in diagnosis of metabolic bone disease in infants should be investigated further.
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Affiliation(s)
- Chengcheng Liu
- Institute of Acoustics, School of Physics Science and Engineering, Tongji University, Shanghai, China
| | - Boyi Li
- Department of Electronic Engineering, Fudan University, Shanghai, China
| | - Ying Li
- Department of Electronic Engineering, Fudan University, Shanghai, China
| | - Weiying Mao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Rong Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
| | - Dean Ta
- Department of Electronic Engineering, Fudan University, Shanghai, China; Academy for Engineering & Technology, Fudan University, Shanghai, China
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The Impact of Mother-Child Dyad Dietary Intervention Using the Transtheoretical Model on Bone Mineral Density in Japanese Female Adolescents. J Pediatr Nurs 2020; 50:e39-e47. [PMID: 31669496 DOI: 10.1016/j.pedn.2019.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Peak bone mass, an important determinant of osteoporosis risk, is reached during adolescence. We evaluated the impact of mother-child dyad dietary intervention using the transtheoretical model (TTM) on bone mineral density in Japanese female adolescents. DESIGN AND METHODS The participants were dyads of female adolescents aged 15-16 years and their mothers (who are generally responsible for cooking). We enrolled 92 dyads, with 56 assigned to the intervention group and 36 to the control group. Bone mineral density was measured using quantitative ultrasound parameters (QUS). Nutrient intake and stage of behavioral change were collected via questionnaires. Evaluations were conducted at baseline and seven months later. The intervention group underwent the TTM-based dietary education program for six months. RESULTS After the intervention program, the ratio of change of the quantitative ultrasound parameter-speed of sound (SOS)-was significantly higher in the intervention than the control group (p < 0.001). Finally, we demonstrated that the intervention was found to significantly affect post-test outcomes in terms of SOS according to the result of analysis of covariance (p < 0.05). CONCLUSIONS Dietary intervention for female adolescents and their mothers using the TTM may enhance the bone mineral density in female adolescents. PRACTICE IMPLICATIONS We suggest that dietary intervention for female adolescents and their mothers using the transtheoretical model may enhance the bone mineral density in female adolescents.
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Eid MA, Aly SM. Effect of whole body vibration training on bone mineral density and functional capacity in children with thalassemia. Physiother Theory Pract 2019; 37:279-286. [PMID: 31179798 DOI: 10.1080/09593985.2019.1625089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: To investigate the effectiveness of whole body vibration (WBV) on bone mineral density (BMD) and functional capacity in children with β-thalassemia major. Methods: Thirty-nine children (23 boys and 16 girls) with β-thalassemia major, with ages ranging from 6 to 10 years, participated in a randomized controlled trial. They were selected and randomly divided, using computer-generated random numbers into two groups. The control group (n = 20) received the medical treatment and the physical therapy program whereas the study group (n = 19) received the same program as the control group in addition to WBV training (25-30 Hz, 2 mm amplitude, 10 repetitions (30-60 s) with 1 min rest, 15-20 min/day, 3 days/week/24 weeks). Bone mineral density and functional capacity were assessed before and after 24 weeks. Results: Both groups showed a significant increase in BMD and functional capacity after treatment compared with that before treatment (P ˂ 0.05). However, children in the study group demonstrated a significant increase in the functional capacity and the BMD of the lumbar spine, femoral neck and total body compared with that of the control group (P > .01). Conclusions: Whole body vibration may be an effective modality in improving BMD and functional capacity in children with β-thalassemia major.
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Affiliation(s)
- Mohamed A Eid
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University , Giza, Egypt
| | - Sobhy M Aly
- Department of Biomechanics, Faculty of Physical Therapy, Cairo University , Giza, Egypt
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Bray TJ, Karsa A, Bainbridge A, Sakai N, Punwani S, Hall‐Craggs MA, Shmueli K. Association of bone mineral density and fat fraction with magnetic susceptibility in inflamed trabecular bone. Magn Reson Med 2019; 81:3094-3107. [PMID: 30615213 PMCID: PMC6492090 DOI: 10.1002/mrm.27634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE To evaluate the relationship between bone mineral density (BMD) and magnetic susceptibility, and between proton density fat fraction and susceptibility, in inflamed trabecular bone. METHODS Two different phantoms modeling the fat fraction (FF) and BMD values of healthy bone marrow and disease states were scanned using a multiecho gradient echo acquisition at 3T. After correction for fat-water chemical shift, susceptibility mapping was performed, and susceptibility measurements were compared with BMD and FF values using linear regression. Patients with spondyloarthritis were scanned using the same protocol, and susceptibility values were calculated in areas of inflamed bone (edema) and fat metaplasia, both before and after accounting for the contribution of fat to the total susceptibility. RESULTS Susceptibility values in the phantoms were accurately described by a 2D linear function, with a negative correlation between BMD and susceptibility and a positive correlation between FF and susceptibility (adjusted R2 = 0.77; P = 3·10-5 ). In patients, significant differences in susceptibility were observed between fat metaplasia and normal marrow, but these differences were eliminated by removing the fat contribution to the total susceptibility. CONCLUSIONS BMD and proton density fat fraction both influence the total susceptibility of bone marrow and failure to account for the fat contribution could lead to errors in BMD quantification. We propose a method for removing the fat contribution from the total susceptibility, based on the observed linear relationship between susceptibility and FF. In inflamed bone, the overall increase in susceptibility in areas of fat metaplasia is at least partly due to increased fat content.
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Affiliation(s)
- Timothy J.P. Bray
- Centre for Medical ImagingUniversity College LondonUnited Kingdom
- Arthritis Research UK Centre for Adolescent RheumatologyUniversity College LondonUnited Kingdom
| | - Anita Karsa
- Department of Medical Physics and Biomedical EngineeringUniversity College LondonUnited Kingdom
| | - Alan Bainbridge
- Department of Medical PhysicsUniversity College London HospitalsUnited Kingdom
| | - Naomi Sakai
- Centre for Medical ImagingUniversity College LondonUnited Kingdom
| | - Shonit Punwani
- Centre for Medical ImagingUniversity College LondonUnited Kingdom
| | | | - Karin Shmueli
- Department of Medical Physics and Biomedical EngineeringUniversity College LondonUnited Kingdom
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Tapking C, Armenta AM, Popp D, Herndon DN, Branski LK, Lee JO, Suman OE. Relationship between lean body mass and isokinetic peak torque of knee extensors and flexors in severely burned children. Burns 2018; 45:114-119. [PMID: 30279019 DOI: 10.1016/j.burns.2018.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/11/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Severe burns cause hypermetabolic responses and prolonged hospitalization, resulting in loss of body mass and muscle strength. This study aimed to determine whether long-term gains in lean body mass (LBM) after structured exercise programs are functionally meaningful and related to greater muscle strength in severely burned children. STUDY DESIGN LBM and muscle strength were measured at discharge and at 6, 12, 24, and 36 months after burn in 349 children. Body composition, including LBM, was measured via dual-emission X-ray-absorptiometry. Peak torque was measured using Biodex dynamometer at varying angular velocities (90, 120, 150, 180°/s). Pearson correlation analysis evaluated the association between LBM and peak torque. RESULTS LBM progressively increased from discharge (32.5±11.5kg) to 36 months following injury (40.2±12.3kg). Peak torque and peak torque/LBM increased from discharge (56.4±34.0Nm and 1.7±34.0Nmkg-1) to 36 months after burn (102.3±43.8Nm and 2.5±0.7Nmkg-1, p<0.01 for both). LBM and peak torque at all angular velocities showed moderate/strong correlations, with 120°/s being the strongest (all time-points: R2≥0.57). CONCLUSION In severely burned children participating in a rehabilitative exercise program, gains in LBM over time are related to increases in muscle strength, suggesting that gained muscle mass is functional. Measurement of muscle strength at an angular velocity of 120°/s best reflects gains in LBM and should be considered for reliable measure of strength in future studies.
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Affiliation(s)
- Christian Tapking
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA; Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Andrew M Armenta
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Daniel Popp
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA; Division of Hand, Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA; Division of Hand, Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children(®)-Galveston, Galveston, TX 77550, USA.
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Mus-Peters CTR, Huisstede BMA, Noten S, Hitters MWMGC, van der Slot WMA, van den Berg-Emons RJG. Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review. Disabil Rehabil 2018; 41:2392-2402. [PMID: 29783868 DOI: 10.1080/09638288.2018.1470261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Purpose: Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Materials and methods: Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. Results: We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Conclusions: Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.
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Affiliation(s)
| | - Bionka M A Huisstede
- b Department of Rehabilitation, Physical Therapy Science & Sports, Rudolf Magnus Institute of Neurosciences , University Medical Centre Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Suzie Noten
- c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | | | - Wilma M A van der Slot
- c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands.,d Rijndam Rehabilitation , Rotterdam , The Netherlands
| | - Rita J G van den Berg-Emons
- a Libra Rehabilitation & Audiology , Eindhoven/Tilburg , The Netherlands.,c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands
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Abstract
OBJECTIVES Prolonged hospitalization due to burn injury results in physical inactivity and muscle weakness. However, how these changes are distributed among body parts is unknown. The aim of this study was to evaluate the degree of body composition changes in different anatomical regions during ICU hospitalization. DESIGN Retrospective chart review. SETTING Children's burn hospital. PATIENTS Twenty-four severely burned children admitted to our institution between 2000 and 2015. INTERVENTIONS All patients underwent a dual-energy x-ray absorptiometry within 2 weeks after injury and 2 weeks before discharge to determine body composition changes. No subject underwent anabolic intervention. We analyzed changes of bone mineral content, bone mineral density, total fat mass, total mass, and total lean mass of the entire body and specifically analyzed the changes between the upper and lower limbs. MEASUREMENTS AND MAIN RESULTS In the 24 patients, age was 10 ± 5 years, total body surface area burned was 59% ± 17%, time between dual-energy x-ray absorptiometries was 34 ± 21 days, and length of stay was 39 ± 24 days. We found a significant (p < 0.001) average loss of 3% of lean mass in the whole body; this loss was significantly greater (p < 0.001) in the upper extremities (17%) than in the lower extremities (7%). We also observed a remodeling of the fat compartments, with a significant whole-body increase in fat mass (p < 0.001) that was greater in the truncal region (p < 0.0001) and in the lower limbs (p < 0.05). CONCLUSIONS ICU hospitalization is associated with greater lean mass loss in the upper limbs of burned children. Mobilization programs should include early mobilization of upper limbs to restore upper extremity function.
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Le Rouzic MA, Fouquet C, Leblanc T, Touati M, Fouyssac F, Vermylen C, Jäkel N, Guichard JF, Maloum K, Toutain F, Lutz P, Perel Y, Manceau H, Kannengiesser C, Vannier JP. Non syndromic childhood onset congenital sideroblastic anemia: A report of 13 patients identified with an ALAS2 or SLC25A38 mutation. Blood Cells Mol Dis 2017; 66:11-18. [PMID: 28772256 DOI: 10.1016/j.bcmd.2017.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/18/2017] [Accepted: 07/25/2017] [Indexed: 01/19/2023]
Abstract
The most frequent germline mutations responsible for non syndromic congenital sideroblastic anemia are identified in ALAS2 and SLC25A38 genes. Iron overload is a key issue and optimal chelation therapy should be used to limit its adverse effects on the development of children. Our multicentre retrospective descriptive study compared the strategies for diagnosis and management of congenital sideroblastic anemia during the follow-up of six patients with an ALAS2 mutation and seven patients with an SLC25A38 mutation. We described in depth the clinical, biological and radiological phenotype of these patients at diagnosis and during follow-up and highlighted our results with a review of available evidence and data on the management strategies for congenital sideroblastic anemia. This report confirms the considerable variability in manifestations among patients with ALAS2 or SLC25A38 mutations and draws attention to differences in the assessment and the monitoring of iron overload and its complications. The use of an international registry would certainly help defining recommendations for the management of these rare disorders to improve patient outcome.
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Affiliation(s)
| | | | | | | | | | - Christiane Vermylen
- Université Catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium.
| | - Nadja Jäkel
- Department für Hämatologie, Onkologie und Hämostaseologie, Leipzig, Germany.
| | | | - Karim Maloum
- Assistance Publique des Hôpitaux de Paris/Hôpital de la Pitié-Salpêtrière, Paris, France.
| | | | - Patrick Lutz
- CHU de Strasbourg/Hôpital de Hautepierre, Strasbourg, France.
| | - Yves Perel
- CHU de Bordeaux/Hôpital Pellegrin, Bordeaux, France.
| | - Hana Manceau
- INSERM U1149, Centre de Recherche sur l'inflammation CRI, Paris, France.
| | - Caroline Kannengiesser
- INSERM U1149, Centre de Recherche sur l'inflammation CRI, Paris, France; Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, DHU UNITY, Paris, France; Laboratory of Excellence, GR-Ex, Paris, France; Assistance Publique des Hôpitaux de Paris, Département de Génétique, Hôpital Bichat, Paris, France.
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14
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Abstract
PURPOSE OF REVIEW In this paper, we review the pathogenesis and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD), especially as it relates to pediatric CKD patients. RECENT FINDINGS Disordered regulation of bone and mineral metabolism in CKD may result in fractures, skeletal deformities, and poor growth, which is especially relevant for pediatric CKD patients. Moreover, CKD-MBD may result in extra-skeletal calcification and cardiovascular morbidity. Early increases in fibroblast growth factor 23 (FGF23) levels play a key, primary role in CKD-MBD pathogenesis. Therapeutic approaches in pediatric CKD-MBD aim to minimize complications to the growing skeleton and prevent extra-skeletal calcifications, mainly by addressing hyperphosphatemia and secondary hyperparathyroidism. Ongoing clinical trials are focused on assessing the benefit of FGF23 reduction in CKD. CKD-MBD is a systemic disorder that has significant clinical implications. Treatment of CKD-MBD in children requires special consideration in order to maximize growth, optimize skeletal health, and prevent cardiovascular disease.
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Affiliation(s)
- Mark R Hanudel
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
- Division of Pediatric Nephrology, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, MDCC A2-383, Los Angeles, CA, 90095-1752, USA.
| | - Isidro B Salusky
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Shepherd JA, Sommer MJ, Fan B, Powers C, Stranix-Chibanda L, Zadzilka A, Basar M, George K, Mukwasi-Kahari C, Siberry G. Advanced Analysis Techniques Improve Infant Bone and Body Composition Measures by Dual-Energy X-Ray Absorptiometry. J Pediatr 2017; 181:248-253.e3. [PMID: 27866821 PMCID: PMC5274603 DOI: 10.1016/j.jpeds.2016.10.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/29/2016] [Accepted: 10/12/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate a novel technique designed to reduce the negative impact of motion artifacts in infant dual-energy X-ray absorptiometry (DXA) scans. STUDY DESIGN Using cross-sectional data from a large multicenter study, we developed and tested advanced methods for infant scan analysis. Newborns (n = 750) received spine and whole-body DXA scans with up to 3 attempts to acquire a motion free scan. Precision of infant DXA was estimated from visits with multiple valid scans. Accuracy of regional reflection, fusion, and omission techniques was estimated by comparing modified scans to unmodified valid scans. The effectiveness of the acquisition and analysis protocol was represented by the reduction in rate of failure to acquire valid results from infant visits. RESULTS For infant whole-body DXA, arm reflection and all fusion techniques caused no significant changes to bone mineral content, bone mineral density, bone area, total mass, fat mass, lean mass, and percentage fat. Leg reflection and arm/leg dual-reflection caused significant changes to total mass, but the percentage change remained small. For infant spine DXA, fusion and omission caused no significant changes. Advanced analysis techniques reduced the failure rate of whole-body scanning from 20.8% to 9.3% and the failure rate of spine scanning from 8.9% to 2.4%. CONCLUSIONS Advanced analysis techniques significantly reduced the impact of motion artifacts on infant DXA scans. We suggest this protocol be used in future infant DXA research and clinical practice.
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Affiliation(s)
- John A Shepherd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA.
| | - Markus J Sommer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Bo Fan
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Cassidy Powers
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | | | - Amanda Zadzilka
- Frontier Science and Technology Research Foundation, Amherst, NY
| | - Michael Basar
- Frontier Science and Technology Research Foundation, Amherst, NY
| | - Kathy George
- Frontier Science and Technology Research Foundation, Amherst, NY
| | | | - George Siberry
- Maternal and Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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16
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Allen B, Migliorati C, Rowland C, An Q, Shintaku W, Donaldson M, Wells M, Kaste S. Comparison of mandibular cortical thickness and QCT-derived bone mineral density (BMD) in survivors of childhood acute lymphoblastic leukemia: a retrospective study. Int J Paediatr Dent 2016; 26:330-5. [PMID: 26370921 PMCID: PMC4792795 DOI: 10.1111/ipd.12203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To examine whether panoramic radiograph-determined mandibular cortical thickness correlated with quantitative computed tomography-derived bone mineral density (BMD) in survivors of childhood acute lymphoblastic leukemia (ALL). METHODS We identified patients treated for ALL at St. Jude Children's Research Hospital, seen in the After Completion of Therapy (ACT) Clinic between January of 2006 and January of 2014 who had QCT-derived BMD and panoramic radiographs obtained within 1 month of each other. Panoramic radiographs were independently scored by a pediatric radiologist, two pediatric dentists, and a general dentist using the Klemetti technique. We used the Spearman's rank correlation test and the multivariate regression model to investigate the effect of evaluator experience on results. RESULTS The study cohort comprised 181 patients with 320 paired studies: 112 (62%) male, 112 (71%) were white. Median age at ALL diagnosis was 6.4 (range, 0-18.8) years. Median age at study was 11.9 (range, 3.3 to 29.4) years. The median average BMD was 154.6 (range, 0.73-256) mg/cc; median QCT Z-score (age and gender adjusted) was -0.875 (range, -5.04 to 3.2). We found very weak association between panoramic radiograph score and both QCT-BMD average (P = 0.53) and QCT Z-score (P = 0.39). Results were not influenced by level of reader experience. CONCLUSIONS The Klemetti technique of estimating BMD does not predict BMD deficits in children and young adult survivors of ALL, regardless of reviewer expertise. Alternative methods are needed whereby dental healthcare providers can identify and refer patients at risk for BMD deficits for detailed assessment and intervention.
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Affiliation(s)
- Brandice Allen
- Department of Pediatric Dentistry, University of Tennessee Health Science Center, College of Dentistry
| | - Cesar Migliorati
- Department of Diagnostic Sciences and Oral Medicine, University of Tennessee Health Science Center, College of Dentistry
| | - Chris Rowland
- Department of Surgery, Dental Clinic St. Jude Children’s Research Hospital
| | - Qi An
- Department of Biostatistics, St. Jude Children’s Research Hospital
| | - Werner Shintaku
- Department of Diagnostic Sciences and Oral Medicine, University of Tennessee Health Science Center, College of Dentistry
| | - Martin Donaldson
- Department of Pediatric Dentistry, University of Tennessee Health Science Center, College of Dentistry
| | - Martha Wells
- Department of Pediatric Dentistry, University of Tennessee Health Science Center, College of Dentistry
| | - Sue Kaste
- Departments of Radiological Sciences and Oncology, St. Jude Children’s Research Hospital and Department of Radiology, University of Tennessee Health Science Center College of Medicine
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Gervais-André L, Vija L, Franchi-Abella S, Gonzales E, Linglart A, Adamsbaum C. Quantitative computed tomography in pediatric patients. Diagn Interv Imaging 2016; 97:499-502. [DOI: 10.1016/j.diii.2015.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 08/10/2015] [Accepted: 08/26/2015] [Indexed: 10/22/2022]
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Weaver CM, Gordon CM, Janz KF, Kalkwarf HJ, Lappe JM, Lewis R, O'Karma M, Wallace TC, Zemel BS. The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporos Int 2016; 27:1281-1386. [PMID: 26856587 PMCID: PMC4791473 DOI: 10.1007/s00198-015-3440-3] [Citation(s) in RCA: 722] [Impact Index Per Article: 90.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/10/2015] [Indexed: 12/21/2022]
Abstract
Lifestyle choices influence 20-40 % of adult peak bone mass. Therefore, optimization of lifestyle factors known to influence peak bone mass and strength is an important strategy aimed at reducing risk of osteoporosis or low bone mass later in life. The National Osteoporosis Foundation has issued this scientific statement to provide evidence-based guidance and a national implementation strategy for the purpose of helping individuals achieve maximal peak bone mass early in life. In this scientific statement, we (1) report the results of an evidence-based review of the literature since 2000 on factors that influence achieving the full genetic potential for skeletal mass; (2) recommend lifestyle choices that promote maximal bone health throughout the lifespan; (3) outline a research agenda to address current gaps; and (4) identify implementation strategies. We conducted a systematic review of the role of individual nutrients, food patterns, special issues, contraceptives, and physical activity on bone mass and strength development in youth. An evidence grading system was applied to describe the strength of available evidence on these individual modifiable lifestyle factors that may (or may not) influence the development of peak bone mass (Table 1). A summary of the grades for each of these factors is given below. We describe the underpinning biology of these relationships as well as other factors for which a systematic review approach was not possible. Articles published since 2000, all of which followed the report by Heaney et al. [1] published in that year, were considered for this scientific statement. This current review is a systematic update of the previous review conducted by the National Osteoporosis Foundation [1]. [Table: see text] Considering the evidence-based literature review, we recommend lifestyle choices that promote maximal bone health from childhood through young to late adolescence and outline a research agenda to address current gaps in knowledge. The best evidence (grade A) is available for positive effects of calcium intake and physical activity, especially during the late childhood and peripubertal years-a critical period for bone accretion. Good evidence is also available for a role of vitamin D and dairy consumption and a detriment of DMPA injections. However, more rigorous trial data on many other lifestyle choices are needed and this need is outlined in our research agenda. Implementation strategies for lifestyle modifications to promote development of peak bone mass and strength within one's genetic potential require a multisectored (i.e., family, schools, healthcare systems) approach.
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Affiliation(s)
- C M Weaver
- Department of Nutritional Sciences, Women's Global Health Institute, Purdue University, 700 W. State Street, West Lafayette, IN, 47907, USA
| | - C M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital, 3333 Burnet Avenue, MLC 4000, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - K F Janz
- Departments of Health and Human Physiology and Epidemiology, University of Iowa, 130 E FH, Iowa City, IA, 52242, USA
| | - H J Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7035, Cincinnati, OH, 45229, USA
| | - J M Lappe
- Schools of Nursing and Medicine, Creighton University, 601 N. 30th Street, Omaha, NE, 68131, USA
| | - R Lewis
- Department of Foods and Nutrition, University of Georgia, Dawson Hall, Athens, GA, 30602, USA
| | - M O'Karma
- The Children's Hospital of Philadelphia Research Institute, 3535 Market Street, Room 1560, Philadelphia, PA, 19104, USA
| | - T C Wallace
- Department of Nutrition and Food Studies, George Mason University, MS 1 F8, 10340 Democracy Lane, Fairfax, VA, 22030, USA.
- National Osteoporosis Foundation, 1150 17th Street NW, Suite 850, Washington, DC, 20036, USA.
- National Osteoporosis Foundation, 251 18th Street South, Suite 630, Arlington, VA, 22202, USA.
| | - B S Zemel
- University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Room 1560, Philadelphia, PA, 19104, USA
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, 3535 Market Street, Room 1560, Philadelphia, PA, 19104, USA
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Grover K, Lin L, Hu M, Muir J, Qin YX. Spatial distribution and remodeling of elastic modulus of bone in micro-regime as prediction of early stage osteoporosis. J Biomech 2016; 49:161-6. [PMID: 26705110 PMCID: PMC4761497 DOI: 10.1016/j.jbiomech.2015.11.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 11/17/2015] [Accepted: 11/21/2015] [Indexed: 11/24/2022]
Abstract
We assessed the local distribution of bone mechanical properties on a micro-nano-scale and its correlation to strain distribution. Left tibia samples were obtained from 5-month old female Sprague Dawley rats, including baseline control (n=9) and hindlimb suspended (n=9) groups. Elastic modulus was measured by nanoindentation at the dedicated locations. Three additional tibias from control rats were loaded axially to measure bone strain, with 6-10N at 1Hz on a Bose machine for strain measurements. In the control group, the difference of the elastic modulus between periosteum and endosteum was much higher at the anterior and posterior regions (2.6GPa), where higher strain differences were observed (45μɛ). Minimal elastic modulus difference between periosteum and endosteum was observed at the medial region (0.2GPa), where neutral axis of the strain distribution was oriented with lower strain difference (5μɛ). In the disuse group, however, the elastic modulus differences in the anterior posterior regions reduced to 1.2GPa from 2.6GPa in the control group, and increased in the medial region to 2.7GPa from 0.2GPa. It is suggested that the remodeling rate in a region of bone is possibly influenced by the strain gradient from periosteum to endosteum. Such pattern of moduli gradients was compromised in disuse osteopenia, suggesting that the remodeling in distribution of micro-nano-elastic moduli among different regions may serve as a predictor for early stage of osteoporosis.
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Affiliation(s)
- Kartikey Grover
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Liangjun Lin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Minyi Hu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Jesse Muir
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Yi-Xian Qin
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.
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Bone health of patients with juvenile idiopathic arthritis: a comparison between dual-energy X-ray absorptiometry and digital X-ray radiogrammetry. Eur J Radiol 2015; 84:1999-2003. [DOI: 10.1016/j.ejrad.2015.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 06/03/2015] [Accepted: 06/16/2015] [Indexed: 01/01/2023]
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21
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Williams KD, Blangero J, Mahaney MC, Subedi J, Jha B, Williams-Blangero S, Towne B. Axial quantitative ultrasound assessment of pediatric bone quality in eastern Nepal. Osteoporos Int 2015; 26:2319-28. [PMID: 25862355 DOI: 10.1007/s00198-015-3115-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 03/18/2015] [Indexed: 12/29/2022]
Abstract
UNLABELLED This study presents quantitative ultrasonography (QUS) bone quality data for an underrepresented, south Asian pediatric population from Nepal. Data were collected as part of a longitudinal study of growth and development. This study offers normative data and documents the effect of stunting, wasting, and underweight on the bone properties measured by QUS. INTRODUCTION The purpose of this study was to (1) examine the bone quality of a rural, non-Western pediatric population using QUS, (2) explore variation in the trajectory of bone quality development between males and females, and (3) examine the impact of growth disruption(s) on bone quality. METHODS A cross-sectional study of 860 children and adolescents aged 5-18 years from the Jirel ethnic group in eastern Nepal was performed. The Sunlight Omnisense 7000P was used to assess bone quality of the distal 1/3 radius and midshaft tibia. WHO reference standards were used to assess growth disruptions of height, weight, and BMI. RESULTS QUS bone quality data for an underrepresented, non-Western pediatric population are presented for the radius and tibia. A sizable portion of the study participants were classified as stunted, wasted, and/or underweight. Despite this prevalence of growth disruption in the study sample, bone quality data conform to other documented populations with less growth disruption. Thus, this study offers normative data and documents the minimal effect of stunting, wasting, and underweight on the bone properties measured by QUS. CONCLUSIONS Non-Western pediatric populations are significantly underserved with regard to simple, non-invasive screening tools that may help identify developmental disorders and assess bone health. The children and adolescents examined here represent normal growth and development for an underrepresented south Asian population. While this work demonstrates that stunting, wasting, or underweight status at time of QUS assessment is not associated with poor bone quality, we do suggest that further study is needed to examine possible cumulative effects of persistent disruptions that may lead to compromised bone quality in later adolescence.
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Affiliation(s)
- K D Williams
- Department of Anthropology, Temple University, 1115 Polett Walk, 210 Gladfelter Hall, Philadelphia, PA, 19120, USA,
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Abstract
In this review, we will first discuss the concept of bone strength and introduce how fat at different locations, including the bone marrow, directly or indirectly regulates bone turnover. We will then review the current literature supporting the mechanistic relationship between marrow fat and bone and our understanding of the relationship between body fat, body weight, and bone with emphasis on its hormonal regulation. Finally, we will briefly discuss the importance and challenges of accurately measuring the fat compartments using non-invasive methods. This review highlights the complex relationship between fat and bone and how these new concepts will impact our diagnostic and therapeutic approaches in the very near future.
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Affiliation(s)
- Richard Kremer
- McGill University, Montreal, QC, Canada
- *Correspondence: Richard Kremer,
| | - Vicente Gilsanz
- Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Jang JH, Jee YS, Oh HW. Frequency-effect of playing screen golf on body composition and golf performance in middle-aged men. J Exerc Rehabil 2014; 10:271-8. [PMID: 25426463 PMCID: PMC4237841 DOI: 10.12965/jer.140140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 08/11/2014] [Indexed: 11/22/2022] Open
Abstract
There are many studies showing that physical training improves body composition including bone mineral density (BMD) in almost all subjects. However, the frequency-dependent effect of playing golf on body composition is still not clearly comprehended. Moreover, the effect of screen golf in relations with exercise-frequency on body composition and golf performance has not been documented. Forty year old men participated and were classified into 4 groups: Control group (n= 10), BMD1 group (n= 10) played screen golf less than 1 day per a week, BMD2–3 group (n= 10) played screen golf 2–3 days per a week, and BMD5 group (n= 10) played screen golf 5 days per week. Dual-energy X-ray absorptiometry (DXA) was performed on 30 male recreational golfers and 10 sedentary individuals. The data gained through DXA were fat mass, lean mass, regional (head, rib, arm, leg, pelvis, spine and trunk) BMD level, and total BMD level summed by regional scores. The club speeds were measured using the Golfzon Vision machine and the handicap points were measured using a simple questionnaire. The present results suggest that the long-frequency of playing screen golf does not improve bone mineral density, lean mass, and handicap point yet improves fat mass and club speed in the middle-aged men.
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Affiliation(s)
- Jung-Hoon Jang
- School of Sports and Leisure Studies, Korea University, Sejong, Korea
| | - Yong-Seok Jee
- Department of Physical Activity Design, Hanseo University, Seosan, Korea
| | - Hye-Won Oh
- Department of Occupational Therapy, Woosuk University, Wanju, Jeollabuk-do, Korea
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Abstract
PURPOSE OF REVIEW Abnormalities in bone health are increasingly recognized in the pediatric population. Although the methodologies for assessing bone mineral density were originally developed for adults, great strides have been made in recent years, improving their applicability to children. Understanding these technologies, their interpretation, utility, and limitations is critical when assessing a child or adolescent with a suspected abnormality in bone mineral density. RECENT FINDINGS Improved normative databases that address some of the confounding variables in the growing and maturing child have solidified dual-energy X-ray absorptiometry as the preferred method for the assessment of bone mineral density in children. Consensus statements by expert panels now provide specific guidance to clinicians seeking to evaluate children with fractures or at risk for fractures. Although still primarily a research tool, continued development of quantitative computed tomography applications in pediatrics suggests there may be a complementary role for clinical use in the future. SUMMARY In the child or adolescent with a significant fracture history or a potential for fractures because of an underlying cause, clinicians now have guidelines and normative data to better focus their evaluation. Likewise, researchers can use this information to improve clinical trial design and interpretation of results.
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Bone Mineral Density in Children From Anthropological and Clinical Sciences: A Review. ANTHROPOLOGICAL REVIEW 2014. [DOI: 10.2478/anre-2014-0011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
Bone mineral density (BMD) is a frequent topic of discussion in the clinical literature in relation to the bone health of both adults and children. However, in archaeological and/ or anthropological studies the role of BMD is often cited as a possible factor in the poor skeletal preservation which can lead to an under-representation of juvenile skeletal remains. During skeletal development and growth throughout childhood and adolescence changes take place in both the size and shape of bones and these changes also result in the increasing of mineral content. BMD can be affected by many factors, which include, age, genetics, sexual maturation, amount of physical activity and dietary calcium. This paper aims to review the clinical and anthropological literature on BMD and discuss the numerous methods of measurement and how the availability of certain methods such as Dual-energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT) can influence the study of bone density in archaeological skeletal collections and also the future potential for forensic anthropological studies.
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Adams JE, Engelke K, Zemel BS, Ward KA. Quantitative computer tomography in children and adolescents: the 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014; 17:258-74. [PMID: 24792821 DOI: 10.1016/j.jocd.2014.01.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 12/24/2022]
Abstract
In 2007, International Society of Clinical Densitometry Pediatric Positions Task Forces reviewed the evidence for the clinical application of peripheral quantitative computed tomography (pQCT) in children and adolescents. At that time, numerous limitations regarding the clinical application of pQCT were identified, although its use as a research modality for investigation of bone strength was highlighted. The present report provides an updated review of evidence for the clinical application of pQCT, as well as additional reviews of whole body QCT scans of the central and peripheral skeletons, and high-resolution pQCT in children. Although these techniques remain in the domain of research, this report summarizes the recent literature and evidence of the clinical applicability and offers general recommendations regarding the use of these modalities in pediatric bone health assessment.
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Affiliation(s)
- Judith E Adams
- Department of Clinical Radiology, The Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, England, UK.
| | - Klaus Engelke
- Institute of Medical Physics, University of Erlangen, Erlangen, Germany and Synarc A/S, Germany
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kate A Ward
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
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Xu Y, Guo B, Gong J, Xu H, Bai Z. The correlation between calcaneus stiffness index calculated by QUS and total body BMD assessed by DXA in Chinese children and adolescents. J Bone Miner Metab 2014; 32:159-66. [PMID: 23695447 DOI: 10.1007/s00774-013-0474-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/14/2013] [Indexed: 12/31/2022]
Abstract
Few studies have shown comparison data between calcaneus stiffness index (SI) calculated by quantitative ultrasound (QUS) and bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) in the Chinese population. This study was aimed to examine the correlations between calcaneus SI calculated by QUS and total body BMD and bone mineral content (BMC) measured by DXA in Chinese children and adolescents. We measured the total body BMD and BMC using Lunar Prodigy (GE Healthcare), and speed of sound (SOS), broadband ultrasound attenuation (BUA), and a calculated SI of the left os calcis using Lunar Achilles Express (GE Healthcare) in 392 healthy Chinese schoolchildren and adolescents aged 5-19 years. The short-term precision for DXA was 0.5 % for total body BMD. The precision for QUS was 1.8 % for SI, 2.9 % for BUA, and 0.4 % for SOS. Pearson's correlation coefficients (r) were calculated to assess the possible correlations between the total body BMC by DXA and SI calculated by QUS. There were significantly positive correlations between SI of the left os calcis and total body BMD (r = 0.693, p < 0.001, n = 392) and BMC (r = 0.690, p < 0.001, n = 392). For all the subjects, significant positive correlations were observed between the calcaneal SI and the age, weight, height, BMI, total body BMD, total body BMC, total body lean mass, and total body fat mass, with r ranging from 0.310 (total body fat mass) to 0.693 (total body BMD) (p < 0.001, n = 392). In conclusion, QUS bone densitometry is a useful measuring method showing the physiological bone development in childhood and adolescence.
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Affiliation(s)
- Yi Xu
- Department of Clinical Medicine, Medical College, Jinan University, No. 601 West Huangpu Road, Guangzhou, 510632, China
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Basha N. KP, Shetty B, Shenoy U. Prevalence of Hypoparathyroidism (HPT) in Beta Thalassemia Major. J Clin Diagn Res 2014; 8:24-6. [PMID: 24701472 PMCID: PMC3972574 DOI: 10.7860/jcdr/2014/6672.3997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 12/19/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim of this study was to assess the parathyroid functions and bone mineral density (BMD) in patients with beta thalassemia and to correlate them with serum ferritin, calcium, phosphorus and alkaline phosphatase levels. MATERIALS AND METHODS This is a case control study which was done on 55 subjects (40 cases and 15 controls) in the age group of 2-18 years. The cases included were with confirmed diagnosis of beta thalassemia major, more than ten blood transfusions and serum ferritin levels >2000 μg/L irrespective of chelation therapy. RESULTS Significant Hypoparathyroidism (HPT) observed along with low BMD levels in beta thalassemia patients (p < 0.01). A significant decrease in serum calcium level was seen in cases when compared to controls, where as the levels of both serum phosphorus and alkaline phosphatase levels increased in cases when compared to controls. CONCLUSION BMD and PTH levels are very useful tools for diagnosing HPT. As a routine, in beta thalassemia major, screening for vitamin D deficiency and hypocalcemia should be done in second decade of life and as a preventive measure they should be supplemented with calcium and vitamin D to prevent hypocalcemic tetany, to facilitate bone growth and to prevent fractures.
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Affiliation(s)
- Khalida Parveen Basha N.
- Consultant Biochemist and Section Head, Triesta Reference Laboratory, A Unit of Health Care Global Enterprises, Bangalore, India
| | - Beena Shetty
- Professor, Department of Biochemistry, Kasturba Medical College, Manipal University, Mangalore, India
| | - U.V. Shenoy
- Professor, Department of Paediatrics, Kasturba Medical College, Manipal University, Mangalore, India
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Wu J. Bone mass and density in preadolescent boys with and without Down syndrome. Osteoporos Int 2013; 24:2847-54. [PMID: 23681086 DOI: 10.1007/s00198-013-2393-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/29/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED Preadolescent boys with Down syndrome at 7-10 years of age have lower bone mass and density in the pelvis than age-matched children without Down syndrome. However, bone mass and density of total body less head and lumbar spine are not different between these two groups. INTRODUCTION This study aimed to assess bone mineral content (BMC) and density (BMD) in preadolescent boys with and without Down syndrome (DS) at 7-10 years of age. METHODS Eleven preadolescent boys with DS and eleven age-matched children without DS participated in this study. Dual-energy X-ray absorptiometry was used to measure BMC and BMD in whole body and lumbar spine. Both BMC and BMD of total body less head (TBLH) and lumbar spine (vertebrae L2-L4) were compared between the two groups, with and without adjusting for physical characteristics such as bone area, body height, and total lean mass. Two bone mineral apparent density (BMAD) variables were calculated to estimate volumetric BMD in the lumbar spine. RESULTS Both BMC and BMD in the pelvis were lower in the DS group, after adjusting for physical characteristics. However, with and without adjusting for physical characteristics, the two groups were not different in BMC and BMD of the arms, legs, and TBLH from the whole body scan and in BMC, BMD, and BMAD of the lumbar spine from the lumbar spine scan. CONCLUSIONS These findings indicate that the pelvis may be the first site to show the significant difference in BMC and BMD between preadolescent boys with and without DS. It also suggests that significantly lower BMC and BMD in whole body and lumbar spine, which is usually observed in young adults with DS, may not occur before adolescence.
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Affiliation(s)
- J Wu
- Department of Kinesiology and Health, Georgia State University, Atlanta, GA, 30302, USA,
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Zhang R, Ta D, Liu C, Chen C. Feasibility of bone assessment with ultrasonic backscatter signals in neonates. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1751-1759. [PMID: 23932274 DOI: 10.1016/j.ultrasmedbio.2013.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 01/26/2013] [Accepted: 03/20/2013] [Indexed: 06/02/2023]
Abstract
The objective of this study was to assess the value of ultrasonic backscatter signals and the backscatter coefficient (BSC) in the analysis of bone status in neonates and to analyze the relationships between the BSC and gestational age, birth weight, length, head circumference and gender. A total of 122 neonates participated in the study, including 83 premature infants and 39 full-term infants. Their BSCs were measured by ultrasound after birth. The results revealed a significant correlation between the BSC and gestational age (R = 0.47, p < 0.001), birth weight (R = 0.47, p < 0.0001) and length at birth (R = 0.43, p < 0.001) at a frequency of 5.0 MHz. This study suggests that the use of ultrasonic backscattering and the BSC is feasible for assessment of the bone status of neonates.
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Affiliation(s)
- Rong Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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Khan KM, Sarafoglou K, Somani A, Frohnert B, Miller BS. Can ultrasound be used to estimate bone mineral density in children with growth problems? Acta Paediatr 2013; 102:e407-12. [PMID: 23750846 DOI: 10.1111/apa.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/26/2013] [Accepted: 06/05/2013] [Indexed: 01/22/2023]
Abstract
AIM To assess predictability of bone mineral density (BMD) of the lumbar spine (LS) determined by dual-energy x-ray absorptiometry (DXA) using by ultrasound speed of sound of the right and left radii (SOS-R and SOS-L) in patients with growth problems. METHODS Ultrasound and DXA were compared in patients with advanced, normal and delayed bone ages assessed by Greulich and Pyle (GP) and Tanner and Whitehouse (TW3) methods. RESULTS There was a strong correlation (r), of raw scores, between SOS-R and SOS-L, r = 0.81, p = 0.000 and their respective Z-scores, r = 0.78, p = 0.000. Z-score correlations were poor between SOS-R or SOS-L and LS-BMD. Sensitivity, specificity, positive and negative predictive values of SOS-R and Z-scores for predicting normal (>-1 to <1) and low (<-1) LS-BMD were poor. For high (>1) LS-BMD, Z-scores were 22%, 93%, 29% and 90%, respectively, for SOS-R and for SOS-L, 25%, 89%, 20% and 91%. For very low (<-2) LS-BMD, SOS-R and SOS-L were the same, respectively, 29%, 91%, 40% and 86%. CONCLUSION Ultrasound of the radius is a poor predictor of radiologically assessed BMD at the LS, especially with delayed bone age.
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Affiliation(s)
- Khalid M Khan
- Medstar Georgetown University Hospital; Washington DC USA
| | | | - Arif Somani
- Department of Pediatrics; McMaster University; Hamilton Ontario Canada
| | - Brigitte Frohnert
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
| | - Bradley S Miller
- Department of Pediatrics; University of Minnesota; Minneapolis MN USA
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Winzenberg TM, Shaw KA, van der Mei IAF, Jones G. Vitamin D supplementation in infancy for improving bone density. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Tania M Winzenberg
- University of Tasmania; Menzies Research Institute Tasmania; Private Bag 23 Hobart TAS Australia 7000
| | - Kelly A Shaw
- Tasmanian Government; Department of Health and Human Services; 3/25 Argyle Street Hobart Tasmania Australia 7000
| | - Ingrid AF van der Mei
- University of Tasmania; Menzies Research Institute Tasmania; Private Bag 23 Hobart TAS Australia 7000
| | - Graeme Jones
- University of Tasmania; Menzies Research Institute Tasmania; Private Bag 23 Hobart TAS Australia 7000
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Shivaprasad C, Marwaha RK, Tandon N, Kanwar R, Mani K, Narang A, Bhadra K, Singh S. Correlation between bone mineral density measured by peripheral and central dual energy X-ray absorptiometry in healthy Indian children and adolescents aged 10-18 years. J Pediatr Endocrinol Metab 2013; 26:695-702. [PMID: 23612636 DOI: 10.1515/jpem-2012-0359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 03/07/2013] [Indexed: 11/15/2022]
Abstract
There are few large-scale studies on the utility of peripheral dual energy X-ray absorptiometry (pDXA) in children. As central dual energy X-ray absorptiometry (cDXA) equipment is not commonly available in the developing world, we assessed the correlation of bone mineral density (BMD) with cDXA and pDXA in children to determine the optimal Z-score thresholds of pDXA for predicting two predefined Z-score cutoffs (≤-1, ≤-2) of cDXA in 844 subjects (441 boys, 403 girls) aged 10-18 years. The BMD of antero-posterior lumbar spine (L1-L4), proximal femur and forearm was measured by cDXA, while the peripheral BMD of forearm and calcaneus was estimated using pDXA. The correlation was statistically significant at all sites (p<0.01). The coefficients ranged from 0.56 to 0.79 in boys and 0.17 to 0.32 in girls. A significant positive correlation was observed between BMD by pDXA and cDXA in Indian children, with a strong gender difference in both the extent of correlation and the ability of peripheral BMD to predict central BMD.
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Pirker-Frühauf UM, Friesenbichler J, Urban EC, Obermayer-Pietsch B, Leithner A. Osteoporosis in children and young adults: a late effect after chemotherapy for bone sarcoma. Clin Orthop Relat Res 2012; 470:2874-85. [PMID: 22806259 PMCID: PMC3441998 DOI: 10.1007/s11999-012-2448-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 06/12/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Premature bone loss after childhood chemotherapy may be underestimated in patients with bone sarcoma. Methotrexate (MTX), a standard agent in osteosarcoma protocols, reportedly reduces bone mineral density (BMD). The literature, however, has reported cases of BMD reduction in patients with Ewing's sarcoma treated without MTX. Thus, it is unclear whether osteoporosis after chemotherapy relates to MTX or to other factors. QUESTIONS/PURPOSES We therefore asked whether (1) young patients with a bone sarcoma had BMD reduction, (2) patients treated with MTX had lower BMD, and (3) other factors (eg, lactose intolerance or vitamin D deficiency) posed additional risks for low BMD. METHODS We retrospectively reviewed 43 patients with malignancies who had dual-energy x-ray absorptiometry (DEXA) (lumbar, femoral); 18 with Ewing's sarcoma (mean age, 26 ± 8 years), and 25 with an osteosarcoma (mean age, 27 ± 10 years). The mean time since diagnosis was 8 ± 4 years in the group with Ewing's sarcoma and 7 ± 5 years in the group with osteosarcoma. At last followup we determined BMD (computing z-scores), fracture rate, and lifestyle, and performed serum analysis. RESULTS BMD reduction was present in 58% of patients (37% had a z-score between -1 and -2 SD, 21% had a z-score less than -2 SD) in at least one measured site. Seven of the 43 patients (16%) had nontrauma or tumor-associated fractures after chemotherapy. Findings were similar in the Ewing and osteosarcoma subgroups. We found vitamin D deficiency in 38 patients (88%) and borderline elevated bone metabolism; lactose intolerance was present in 16 patients (37%). CONCLUSION Doctors should be aware of the possibility of major bone loss after chemotherapy with a risk of pathologic fracture. Vitamin D deficiency, calcium malnutrition, and lactose intolerance may potentiate the negative effects of chemotherapy, and should be considered in long-term patient management. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Jörg Friesenbichler
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Ernst-Christian Urban
- Division of Paediatric Haemato-Oncology, Department of Paediatrics, Medical University of Graz, Graz, Austria
| | - Barbara Obermayer-Pietsch
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Dalén Y, Sääf M, Nyrén S, Mattsson E, Haglund-Åkerlind Y, Klefbeck B. Observations of four children with severe cerebral palsy using a novel dynamic platform. A case report. ACTA ACUST UNITED AC 2012. [DOI: 10.3109/14038196.2012.693948] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE As 80% of intrauterine bone mineralization takes place during the last trimester of pregnancy, preterm infants should be supplemented postnatally with optimal doses of calcium, phosphate and vitamin D. Calcium and phosphate excretion in the urine may be used to monitor individual mineral requirements, but are sometimes difficult to interpret. The objective of this study was to assess the value of quantitative ultrasound (QUS) for the analysis of bone status in neonates. STUDY DESIGN All admissions to three independent tertiary neonatal intensive care units were studied. In 172 preterm and term infants with a gestational age between 23 and 42 weeks (mean 33.8±5.0) and a birth weight from 405 to 5130 g (mean 2132±1091 g) bone status was evaluated prospectively by quantitative ultrasound velocity using a standardized protocol. Infants were followed in regular intervals up to their first discharge home. While measurements were conducted in weekly intervals initially (n=55), 2-week intervals were regarded as sufficient thereafter due to limited changes in QUS values within the shorter period. Infants with a birth weight below 1500 g were followed during outpatient visits until up to 17 months of age. RESULT The intra-individual day-to-day reproducibility was 0.62%. QUS-values from the first week of life correlated significantly with gestational age and birth weight (r=0.5 and r=0.6; P<0.001). Small-for-gestational-age infants showed lower values for QUS than appropriate-for-gestational-age infants allowing for their gestational age. Follow-up measurements correlated positively with age and weight during the week of measurement (r=0.2 and r=0.4; P=0.001). Comparing bone quality at 40 weeks of age in infants born at term versus infants born at 24 to 28 weeks, preterm infants showed significantly lower QUS than term infants (P<.0001).There was a significant correlation of QUS with serum alkaline phosphatase (P=0.003), the supplementation with calcium, phosphate and vitamin D (P< 0.001 each), as well as risk factors for a reduced bone mineralization. No correlation was found between QUS and calcium or phosphate concentration in serum or urine. CONCLUSION QUS is a highly reproducible, easily applicable and radiation-free technique that can be used to monitor bone quality in individual newborns. Further prospective randomized-trials are necessary to evaluate, if therapeutic interventions based on QUS are able to prevent osteopenia of prematurity.
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Winzenberg TM, Powell S, Shaw KA, Jones G. Cochrane Review: Vitamin D supplementation for improving bone mineral density in children. ACTA ACUST UNITED AC 2012. [DOI: 10.1002/ebch.1822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Skalsky AJ, Han JJ, Abresch RT, McDonald CM. Regional and whole-body dual-energy X-ray absorptiometry to guide treatment and monitor disease progression in neuromuscular disease. Phys Med Rehabil Clin N Am 2011; 23:67-73, x. [PMID: 22239875 DOI: 10.1016/j.pmr.2011.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Dual-energy x-ray absorptiometry (DEXA) is a safe, noninvasive, inexpensive tool for managing patients with neuromuscular diseases. Regional and whole-body DEXA can be used to guide clinical treatments, such as determining body composition to guide nutritional recommendations, as well as to monitor disease progression by assessing regional and whole-body lean tissue mass. DEXA can also be used as an outcome measure for clinical trials.
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Affiliation(s)
- Andrew J Skalsky
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital and Health Center, San Diego, CA 92123, USA.
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Abstract
PURPOSE OF REVIEW This study reviews recent insights into racial differences in bone from 2010 to 2011. RECENT FINDINGS Recent studies have focused on expanding our current understanding of responsible mechanisms for racial differences in osteoporotic fracture risk. Using newer, three-dimensional imaging techniques, these studies demonstrated that racial differences in bone mass and structure are apparent early in adolescence, even when accounting for differences in bone size and muscle mass by race. In addition, recent studies using genetic admixture analysis showed that greater percentage of African admixture was independently associated with higher bone mass and more favorable parameters of bone strength in children and adults. Furthermore, recent studies showed that the relationships between 25-hydoxyvitamin D and bone outcomes differed by race, with lower 25-hydroxyvitamin D levels being associated with lower bone quality and higher fracture risk in whites but not blacks. SUMMARY Racial differences in bone mass and strength are apparent early in life, are independently associated with genetic ancestry, and may be partly explained by differences in the relationships between vitamin D and bone metabolism. Further studies are needed to explore these findings, with the ultimate goal of better defining molecular and cellular mechanisms underlying racial differences in bone quality.
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Affiliation(s)
- Orlando M Gutiérrez
- Division of Nephrology, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-0006, USA.
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Shepherd JA, Wang L, Fan B, Gilsanz V, Kalkwarf HJ, Lappe J, Lu Y, Hangartner T, Zemel BS, Fredrick M, Oberfield S, Winer KK. Optimal monitoring time interval between DXA measures in children. J Bone Miner Res 2011; 26:2745-52. [PMID: 21773995 PMCID: PMC3200454 DOI: 10.1002/jbmr.473] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The monitoring time interval (MTI) is the expected time in years necessary to identify a change between two measures that exceeds the measurement error. Our purpose was to determine MTI values for dual-energy X-ray absorptiometry (DXA) scans in normal healthy children, according to age, sex, and skeletal site. 2014 children were enrolled in the Bone Mineral Density in Childhood Study and had DXA scans of the lumbar spine, total hip, nondominant forearm, and whole body. Measurements were obtained annually for seven visits from 2002 to 2010. Annualized rates of change were calculated by age and sex for all bone regions. A subgroup of 155 children ages 6 to 16 years (85 boys) had duplicate scans for calculation of scan precision. The bone mineral density (BMD) regions of interest included the spine, total body less head (TBLH), total hip, femoral neck, and one-third radius. Bone mineral content (BMC) was also evaluated for the spine and TBLH. The percent coefficient of variation (%CV) and MTI were calculated for each measure as a function of age and sex. The MTI values were substantially less than 1 year for the TBLH and spine BMD and BMC for boys ≤ 17 years and girls ≤ 15 years. The hip and one-third radius MTIs were generally 1 year in the same group. MTI values as low as 3 months were found during the peak growth years. However, the MTI values in late adolescence for all regions were substantially longer and became nonsensical as each region neared the age for peak bone density. All four DXA measurement sites had reasonable (< 1 year) MTI values for boys ≤ 17 years and girls ≤ 15 years. MTI was neither useful nor stable in late adolescence and young adulthood. Alternative criteria to determine scan intervals must be used in this age range.
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Affiliation(s)
- John A Shepherd
- Department of Radiology, Bone and Breast Density Research Group, University of California, San Francisco, San Francisco, CA, USA.
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Lee M, Nahhas RW, Choh AC, Demerath EW, Duren DL, Chumlea WC, Sherwood RJ, Towne B, Siervogel RM, Czerwinski SA. Longitudinal changes in calcaneal quantitative ultrasound measures during childhood. Osteoporos Int 2011; 22:2295-305. [PMID: 20976593 PMCID: PMC3988661 DOI: 10.1007/s00198-010-1458-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 10/07/2010] [Indexed: 12/21/2022]
Abstract
UNLABELLED This longitudinal study examined how calcaneal quantitative ultrasound (QUS) measures change during childhood while taking into account skeletal maturation, body mass index (BMI), and physical activity. The study reported sex differences in QUS growth curves and an inverse relationship between BMI and speed of sound (SOS) measures. INTRODUCTION The aim of this study was to examine how calcaneal QUS parameters change over time during childhood and to determine what factors influence these changes. METHODS The study sample consisted of a total of 192 Caucasian children participating in the Fels Longitudinal Study. A total of 548 calcaneal broadband ultrasound attenuation (BUA) and SOS observations were obtained between the ages of 7.6 and 18 years. The best fitting growth curves were determined using statistical methods for linear mixed effect models. RESULTS There are significant sex differences in the pattern of change in QUS parameters (p < 0.05). The relationship between QUS measures and skeletal age is best described by a cubic growth curve in boys and a linear pattern among girls. Boys experience their most rapid growth in BUA and SOS in early and late adolescence, while girls experience constant growth throughout childhood. Adiposity levels were significantly associated with the changes in SOS among boys (p < 0.001) and girls (p < 0.01), indicating that children with higher BMI are likely to have lower SOS over time compared to children with lower BMI. For girls, physical activity levels showed positive associations with changes in QUS measures (p < 0.05). CONCLUSION This study documents significant sex differences in the pattern of change in QUS measures over childhood and adolescence. Our study also shows significant influences of adiposity and physical activity on the pattern of change in QUS measures during childhood.
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Affiliation(s)
- M Lee
- Lifespan Health Research Center, Department of Community Health, Wright State University Boonshoft School of Medicine, 3171 Research Blvd., Dayton, OH 45420, USA.
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Mascarenhas MR, Thayu M. Pediatric inflammatory bowel disease and bone health. Nutr Clin Pract 2011; 25:347-52. [PMID: 20702839 DOI: 10.1177/0884533610374962] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Childhood and adolescence are important periods for bone development. Any disease that affects bone health has the potential to affect the bones not only in the short term but also later in life. Bone health abnormalities in patients with inflammatory bowel disease are being increasingly recognized. Screening the at-risk patient is important so that appropriate treatments can be instituted. Treatment options are limited to vitamin D and calcium supplementation, control of underlying disease activity, and appropriate physical activity. The role of bisphosphonates in these patients needs to be better studied, and treatment with bisphosphonates may be considered for some patients in consultation with a bone health expert.
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Affiliation(s)
- Maria R Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19014, USA
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Ay L, Jaddoe VWV, Hofman A, Moll HA, Raat H, Steegers EAP, Hokken-Koelega ACS. Foetal and postnatal growth and bone mass at 6 months: the Generation R Study. Clin Endocrinol (Oxf) 2011; 74:181-90. [PMID: 21050252 DOI: 10.1111/j.1365-2265.2010.03918.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To examine whether parental, foetal and postnatal characteristics and growth patterns in foetal life and infancy are associated with bone mass at 6 months, as bone acquisition seems to be associated with genetic and environmental factors. DESIGN This study was embedded in the Generation R Study, a prospective cohort from early foetal life onwards. PATIENTS AND MEASUREMENTS Bone mineral density (BMD) and bone mineral content (BMC) total body (TB) and BMD lumbar spine (LS) were measured by dual-energy X-ray absorptiometry in 252 infants at 6 months. Parental, foetal and postnatal data were collected by physical and foetal ultrasound examinations and questionnaires. RESULTS Maternal, foetal and postnatal anthropometrics were positively associated with BMD(TB) and BMC(TB) at 6 months, but only postnatal anthropometrics were associated with BMD(LS) . A gain in weight-SD-score during foetal life and prenatal catch-up in weight were positively associated with BMD(TB) . After birth, a gain in weight-SD-score was positively associated with BMD(LS) and bone mineral apparent density (BMAD(LS) ). The effect was strongest between 6 weeks and 6 months. Catch-up in weight was associated with a lower probability of low (lowest quartile of) BMD(TB) and BMD(LS) . Children remaining in the first tertile of weight from birth to 6 months had a much higher risk of low BMD(TB) at 6 months [OR (95% CI): 15 (2, 88)]. CONCLUSIONS Our findings suggest that growth patterns in foetal and postnatal life are associated with bone mass in infancy and may have consequences for bone mass in later life. Follow-up studies are needed to assess whether and to what extent maternal anthropometrics, foetal and postnatal growth patterns have an effect on bone status in adulthood.
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Affiliation(s)
- Lamise Ay
- The Generation R Study Group, Department of Pediatrics, Erasmus Medical Center, Rotterdam, The Netherlands.
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Winzenberg T, Powell S, Shaw KA, Jones G. Effects of vitamin D supplementation on bone density in healthy children: systematic review and meta-analysis. BMJ 2011; 342:c7254. [PMID: 21266418 PMCID: PMC3026600 DOI: 10.1136/bmj.c7254] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the effectiveness of vitamin D supplementation for improving bone mineral density in children and adolescents and if effects vary with factors such as vitamin D dose and vitamin D status. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline (1966 to present), Embase (1980 to present), CINAHL (1982 to present), AMED (1985 to present), and ISI Web of Science (1945 to present), last updated on 9 August 2009, and hand searching of conference abstracts from key journals. Study selection Placebo controlled randomised controlled trials of vitamin D supplementation for at least three months in healthy children and adolescents (aged 1 month to <20 years) with bone density outcomes. Two authors independently assessed references for inclusion and study quality and extracted data. DATA SYNTHESIS Standardised mean differences of the percentage change from baseline in bone mineral density of the forearm, hip, and lumbar spine and total body bone mineral content in treatment and control groups. Subgroup analyses were carried out by sex, pubertal stage, dose of vitamin D, and baseline serum vitamin D concentration. Compliance and allocation concealment were also considered as possible sources of heterogeneity. RESULTS From 1653 potential references, six studies, totalling 343 participants receiving placebo and 541 receiving vitamin D, contributed data to meta-analyses. Vitamin D supplementation had no statistically significant effects on total body bone mineral content or on bone mineral density of the hip or forearm. There was a trend to a small effect on lumbar spine bone mineral density (standardised mean difference 0.15, 95% confidence interval -0.01 to 0.31; P=0.07). Effects were similar in studies of participants with high compared with low serum vitamin D levels, although there was a trend towards a larger effect with low vitamin D for total body bone mineral content (P=0.09 for difference). In studies with low serum vitamin D, significant effects on total body bone mineral content and lumbar spine bone mineral density were roughly equivalent to a 2.6% and 1.7% percentage point greater change from baseline in the supplemented group. CONCLUSIONS It is unlikely that vitamin D supplements are beneficial in children and adolescents with normal vitamin D levels. The planned subgroup analyses by baseline serum vitamin D level suggest that vitamin D supplementation of deficient children and adolescents could result in clinically useful improvements, particularly in lumbar spine bone mineral density and total body bone mineral content, but this requires confirmation.
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Affiliation(s)
- Tania Winzenberg
- Menzies Research Institute, University of Tasmania, Hobart, TAS, Australia.
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Winzenberg TM, Powell S, Shaw KA, Jones G. Vitamin D supplementation for improving bone mineral density in children. Cochrane Database Syst Rev 2010:CD006944. [PMID: 20927753 DOI: 10.1002/14651858.cd006944.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Results of randomised controlled trials (RCTs) of vitamin D supplementation to improve bone density in children are inconsistent. OBJECTIVES To determine the effectiveness of vitamin D supplementation for improving bone mineral density in children, whether any effect varies by sex, age or pubertal stage, the type or dose of vitamin D given or baseline vitamin D status, and if effects persist after cessation of supplementation. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL Issue 3, 2009), MEDLINE (1966 to present), EMBASE (1980 to present), CINAHL (1982 to present), AMED (1985 to present) and ISI Web of Science (1945 to present) on 9 August 2009, and we handsearched key journal conference abstracts. SELECTION CRITERIA Placebo-controlled RCTs of vitamin D supplementation for at least three months in healthy children and adolescents (aged from one month to < 20 years) with bone density outcomes. DATA COLLECTION AND ANALYSIS Two authors screened references for inclusion, assessed risk of bias, and extracted data. We conducted meta-analyses and calculated standardised mean differences (SMD) of the percent change from baseline in outcomes in treatment and control groups. We performed subgroup analyses by sex, pubertal stage, dose of vitamin D and baseline serum vitamin D and considered these as well as compliance and allocation concealment as possible sources of heterogeneity. MAIN RESULTS We included six RCTs (343 participants receiving placebo and 541 receiving vitamin D) for meta-analyses. Vitamin D supplementation had no statistically significant effects on total body bone mineral content (BMC), hip bone mineral density (BMD) or forearm BMD. There was a trend to a small effect on lumbar spine BMD (SMD 0.15, 95% CI -0.01 to 0.31, P = 0.07). There were no differences in effects between high and low serum vitamin D studies at any site though there was a trend towards a larger effect with low vitamin D for total body BMC (P = 0.09 for difference). In low serum vitamin D studies, significant effects on total body BMC and lumbar spine BMD were approximately equivalent to a 2.6% and 1.7 % percentage point greater change from baseline in the supplemented group. AUTHORS' CONCLUSIONS These results do not support vitamin D supplementation to improve bone density in healthy children with normal vitamin D levels, but suggest that supplementation of deficient children may be clinically useful. Further RCTs in deficient children are needed to confirm this.
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Affiliation(s)
- Tania M Winzenberg
- Menzies Research Institute, University of Tasmania, Private Bag 23, Hobart, TAS, Australia, 7001
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Kocks J, Ward K, Mughal Z, Moncayo R, Adams J, Högler W. Z-score comparability of bone mineral density reference databases for children. J Clin Endocrinol Metab 2010; 95:4652-9. [PMID: 20668038 DOI: 10.1210/jc.2010-0677] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The diversity of pediatric dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) reference databases raises questions as to whether they are interchangeable in their application. This study examined the comparability of BMD Z-scores generated from the largest available Hologic DXA databases, applied on BMD results of a large series of unselected pediatric patients. METHODS A total of 2027 BMD scans were extracted from Hologic QDR-4500A machines. Age- and sex-specific BMD Z-scores of children aged 8-17 yr, calculated from six Hologic databases, were compared for lumbar spine (LS) and total body (TB). The final dataset included 708 scans (307 of girls). RESULTS BMD Z-scores calculated from the six databases were highly correlated but differed significantly (P < 0.001) in both scan regions. Interdatabase Z-score differences (boys/girls, respectively) were up to 0.54/0.55 for LS and 1.0/0.83 for TB. These differences also varied significantly among age groups. In girls, the percentage of LS BMD Z-scores of -2 or below ("low BMD for age") varied between 15.4 and 27.9% (P < 0.012). The percentage of TB BMD Z-scores of -2 or below varied similarly in boys (P < 0.009). CONCLUSIONS Clinically relevant differences in BMD Z-scores exist between the Hologic databases, revealing a significant potential for misdiagnosis. Ideally, Z-scores should be calculated using model-, brand-, and software-specific reference curves for age, sex, and ethnic group. However, our results can be used to estimate converted values. There are other differences in children's bone mass, shape, strength, and body size that are not detected by DXA.
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Affiliation(s)
- J Kocks
- Department of Pediatrics, Medical University Innsbruck, Innsbruck, Austria
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Abstract
Late effects of therapy for childhood cancer are frequent and serious. Fortunately, many late effects are also modifiable. Proactive and anticipatory risk-based care can reduce the frequency and severity of treatment-related morbidity. The primary care clinician should be an integral component in risk-based care of survivors. Continued communication between the "late effects" staff at the cancer center and the primary care clinician is essential for optimum care of this high-risk population.
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Affiliation(s)
- Kevin C Oeffinger
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Alonso Franch M, Redondo Del Río M, Suárez Cortina L. Nutrición infantil y salud ósea. An Pediatr (Barc) 2010; 72:80.e1-11. [DOI: 10.1016/j.anpedi.2009.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 07/31/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022] Open
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