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Thomas MA, Jimenez JE, Fahrenholtz SJ, Hamdani K, Erwin WD. Understanding entrance-air-kerma as a quality-control metric for dual-energy x-ray absorptiometry. J Appl Clin Med Phys 2022; 23:e13779. [PMID: 36057962 PMCID: PMC9588270 DOI: 10.1002/acm2.13779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 12/05/2022] Open
Abstract
Purpose The low exposures, unique x‐ray beam geometry, and scanning design in dual‐energy x‐ray absorptiometry (DXA) make measurement and quality‐control strategies different from traditional x‐ray equipment. This study examines the dependence of measured entrance‐air‐kerma (EAK) on both dose sensor type and scan length. The feasibility of using EAK to compare scanner output between different scan modes, individual scanners, and scanner platforms was also established. Finally, the congruence between measured and vendor‐reported EAK was analyzed. Methods Four Hologic DXA scanners at two institutions and all four available scan modes were tested. EAK was measured directly by three types of Radcal dose sensors: 60‐cc pancake ion‐chamber (IC), 180‐cc pancake IC, and solid‐state detector. The coefficient of variation (COV) was used to assess the dependence of EAK on scan length. Variations in EAK between the types of dose sensors as well as measured versus vendor‐reported values were evaluated using Bland–Altman analysis: mean ±95% prediction interval (PI): 1.96σ. Results Dose sensor variations in EAK were minimal, with a −3.5 ± 3.5% (mean ±95% PI) percent difference between the two sizes of IC's. The solid‐state detector produced highly similar measurements to the 180‐cc IC. These small differences were consistent across all scanners and all scan modes tested. Neither measured nor vendor‐reported EAK values were found to show relevant dependence on scan length, with all COV values ≤4%. Differences between measured and reported EAK were higher at −6 ± 48%. Likely errors in vendor‐reported EAK calculations were also identified. Conclusion It is feasible to quantify DXA scanner stability using EAK as a quality‐control metric with a variety of solid‐state and IC dose sensors, and the scan length used is not critical. Although vendor‐reported EAK was consistent among scanners of the same platform, measured EAK varied significantly from scanner to scanner. As a result, measured and reported EAK may not always be comparable.
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Affiliation(s)
- Matthew Allan Thomas
- Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Samuel John Fahrenholtz
- Section of Medical Physics, Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Khushnood Hamdani
- Section of Medical Physics, Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - William Daniel Erwin
- Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
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Offiah AC. Current and emerging artificial intelligence applications for pediatric musculoskeletal radiology. Pediatr Radiol 2022; 52:2149-2158. [PMID: 34272573 PMCID: PMC9537230 DOI: 10.1007/s00247-021-05130-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/28/2021] [Accepted: 06/10/2021] [Indexed: 12/03/2022]
Abstract
Artificial intelligence (AI) is playing an ever-increasing role in radiology (more so in the adult world than in pediatrics), to the extent that there are unfounded fears it will completely take over the role of the radiologist. In relation to musculoskeletal applications of AI in pediatric radiology, we are far from the time when AI will replace radiologists; even for the commonest application (bone age assessment), AI is more often employed in an AI-assist mode rather than an AI-replace or AI-extend mode. AI for bone age assessment has been in clinical use for more than a decade and is the area in which most research has been conducted. Most other potential indications in children (such as appendicular and vertebral fracture detection) remain largely in the research domain. This article reviews the areas in which AI is most prominent in relation to the pediatric musculoskeletal system, briefly summarizing the current literature and highlighting areas for future research. Pediatric radiologists are encouraged to participate as members of the research teams conducting pediatric radiology artificial intelligence research.
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Affiliation(s)
- Amaka C. Offiah
- grid.11835.3e0000 0004 1936 9262Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Sheffield, S10 2TH UK ,grid.419127.80000 0004 0463 9178Department of Radiology, Sheffield Children’s NHS Foundation Trust, Sheffield, UK
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3
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Martin H, Joseph S, Shepherd S, Di Marco M, Dunne J, Horrocks I, Ahmed SF, Wong SC. Observer Agreement of Vertebral Fracture Grading Using Dual Energy Absorptiometry Vertebral Fracture Assessment in Duchenne Muscular Dystrophy. J Clin Densitom 2021; 24:622-629. [PMID: 33583717 DOI: 10.1016/j.jocd.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Routine screening of the spine for vertebral fracture is recommended in the recent international standards of care for boys with Duchenne muscular dystrophy (DMD). Recent international consensus endorses the use of dual energy absorptiometry vertebral fracture assessment for identification of vertebral fractures in children, which could be used instead of spine radiographs. This study aims to evaluate the inter-observer agreement for vertebral fracture classification in boys with DMD, and the impact on clinical management. Dual energy absorptiometry vertebral fracture assessment and morphometric analysis in 39 boys was performed by a reader with no prior experience (R1) and 2 readers with experience (R2 and R3). Inter-observer concordance of vertebral fracture grading comparing R1 with R2 and R3 was substantial (Kappa 0.66, 95% CI 0.56, 0.76). Concordance between R2 and R3 was almost perfect (Kappa 0.93, 95% CI 0.89, 0.97) which did not lead to differences in clinical management. Grading by R1 in comparison to R2 and R3 would have led to change in management of 5/39 boys (13%), according to recent standards of care guidance. Structured education programme on identification of vertebral fractures should be explored to ensure consistency of reporting of this important health outcome measure in DMD.
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Affiliation(s)
- Hannah Martin
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow
| | - Shuko Joseph
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow; Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow
| | - S Shepherd
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow
| | - Marina Di Marco
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow; Scottish Muscle Network, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jennifer Dunne
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow
| | - Iain Horrocks
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow
| | - Sze Choong Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow.
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4
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Ma J, Siminoski K, Wang P, Jaremko JL, Koujok K, Matzinger MA, Shenouda N, Lentle B, Alos N, Cummings EA, Ho J, Houghton K, Miettunen PM, Scuccimarri R, Rauch F, Ward LM. The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches. J Bone Miner Res 2021; 36:1255-1268. [PMID: 33784410 DOI: 10.1002/jbmr.4294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022]
Abstract
Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <-1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging and Department of Internal Medicine, University of Alberta, Edmonton, Canada
| | - Peiyao Wang
- Faculty of Science, McMaster University, Hamilton, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Nathalie Alos
- Department of Pediatrics, Université de Montréal, Montréal, Canada
| | | | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | | | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, Canada
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Abstract
Bone mass is a key determinant of osteoporosis and fragility fractures. Epidemiologic studies have shown that a 10% increase in peak bone mass (PBM) at the population level reduces the risk of fracture later in life by 50%. Low PBM is possibly due to the bone loss caused by various conditions or processes that occur during adolescence and young adulthood. Race, gender, and family history (genetics) are responsible for the majority of PBM, but other factors, such as physical activity, calcium and vitamin D intake, weight, smoking and alcohol consumption, socioeconomic status, age at menarche, and other secondary causes (diseases and medications), play important roles in PBM gain during childhood and adolescence. Hence, the optimization of lifestyle factors that affect PBM and bone strength is an important strategy to maximize PBM among adolescents and young people, and thus to reduce the low bone mass or osteoporosis risk in later life. This review aims to summarize the available evidence for the common but important factors that influence bone mass gain during growth and development and discuss the advances of developing high PBM.
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Affiliation(s)
- Xiaowei Zhu
- Disease & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, Hangzhou, 310024, China
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Westlake University, Hangzhou, 310024, China
- School of Life Sciences, Fudan University, Shanghai, 200433, China
| | - Houfeng Zheng
- Disease & Population (DaP) Geninfo Lab, School of Life Sciences, Westlake University, Hangzhou, 310024, China.
- Institute of Basic Medical Sciences, Westlake Institute for Advanced Study, Westlake University, Hangzhou, 310024, China.
- School of Life Sciences, Fudan University, Shanghai, 200433, China.
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Abstract
The last 2 decades have seen tremendous growth in understanding the clinical characteristics of various childhood bone disorders, their mechanisms and natural histories, and their responses to treatment. In this review, the authors describe advances in bone assessment techniques for children. In addition, they provide their skeletal site-specific applications, underscore the principles that are relevant to the biology of the growing child, show how these methods assist in the diagnosis and management of pediatric bone diseases, and highlight how these techniques have shed light on bone development and underlying disease mechanisms.
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Affiliation(s)
- Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada.
| | - Victor N Konji
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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Michels KB, Keller K, Pereira A, Kim CE, Santos JL, Shepherd J, Corvalan C, Binder AM. Association between indicators of systemic inflammation biomarkers during puberty with breast density and onset of menarche. Breast Cancer Res 2020; 22:104. [PMID: 33004039 PMCID: PMC7531086 DOI: 10.1186/s13058-020-01338-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background Systemic inflammation may play a role in shaping breast composition, one of the strongest risk factors for breast cancer. Pubertal development presents a critical window of breast tissue susceptibility to exogenous and endogenous factors, including pro-inflammatory markers. However, little is known about the role of systemic inflammation on adolescent breast composition and pubertal development among girls. Methods We investigated associations between circulating levels of inflammatory markers (e.g., interleukin-6 (IL-6), tumor necrosis factor receptor 2 (TNFR2), and C-reactive protein (CRP)) at Tanner stages 2 and 4 and breast composition at Tanner stage 4 in a cohort of 397 adolescent girls in Santiago, Chile (Growth and Obesity Cohort Study, 2006–2018). Multivariable linear models were used to examine the association between breast composition and each inflammatory marker, stratifying by Tanner stage at inflammatory marker measurement. Accelerated failure time models were used to evaluate the association between inflammatory markers concentrations at each Tanner stage and time to menarche. Results In age-adjusted linear regression models, a doubling of TNFR2 at Tanner 2 was associated with a 26% (95% CI 7–48%) increase in total breast volume at Tanner 4 and a 22% (95% CI 10–32%) decrease of fibroglandular volume at Tanner 4. In multivariable models further adjusted for body fatness and other covariates, these associations were attenuated to the null. The time to menarche was 3% (95% CI 1–5%) shorter among those in the highest quartile of IL-6 at Tanner 2 relative to those in the lowest quartile in fully adjusted models. Compared to those in the lowest quartile of CRP at Tanner 4, those in the highest quartile experienced 2% (95% CI 0–3%) longer time to menarche in multivariable models. Conclusions Systemic inflammation during puberty was not associated with breast volume or breast density at the conclusion of breast development among pubertal girls after adjusting for body fatness; however, these circulating inflammation biomarkers, specifically CRP and IL-6, may affect the timing of menarche onset.
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Affiliation(s)
- Karin B Michels
- Department of Epidemiology, Fielding School of Public Health, University of California, 650 Charles Young Drive South, Room 71-264 CHS, Los Angeles, CA, 90095, USA. .,Institute for Prevention and Cancer Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Kristen Keller
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Ana Pereira
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | - Claire E Kim
- Department of Epidemiology, Fielding School of Public Health, University of California, 650 Charles Young Drive South, Room 71-264 CHS, Los Angeles, CA, 90095, USA
| | - José L Santos
- Department of Nutrition, Diabetes and Metabolism, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - John Shepherd
- Population Sciences in the Pacific Program (Cancer Epidemiology), University of Hawai'i Cancer Center, University of Hawai'i, Honolulu, HI, USA
| | - Camila Corvalan
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | - Alexandra M Binder
- Department of Epidemiology, Fielding School of Public Health, University of California, 650 Charles Young Drive South, Room 71-264 CHS, Los Angeles, CA, 90095, USA.,Population Sciences in the Pacific Program (Cancer Epidemiology), University of Hawai'i Cancer Center, University of Hawai'i, Honolulu, HI, USA
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8
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Alqahtani FF, Crabtree NJ, Bromiley PA, Cootes T, Broadley P, Lang I, Offiah AC. Diagnostic performance of morphometric vertebral fracture analysis (MXA) in children using a 33-point software program. Bone 2020; 133:115249. [PMID: 31978618 DOI: 10.1016/j.bone.2020.115249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is significant inter and intraobserver variability in diagnosing vertebral fractures in children. PURPOSE We aimed to evaluate the diagnostic accuracy of morphometric vertebral fracture analysis (MXA) using a 33-point software program designed for adults, on dual-energy x-ray absorptiometry (DXA) images of children. MATERIALS AND METHODS Lateral spine DXA images of 420 children aged between 5 and 18 years were retrospectively reviewed. Vertebral fracture assessment (VFA) by an expert pediatric radiologist using Genant's semiquantitative scoring system served as the gold standard. All 420 DXA scans were analyzed by a trained radiographer, using semi-automated software (33-point morphometry). VFA of a random sample of 100 DXA was performed by an experienced pediatric clinical scientist. MXA of a random sample of 30 DXA images were analyzed by three pediatric radiologists and the pediatric clinical scientist. Diagnostic accuracy and inter and intraobserver agreement (kappa statistics) were calculated. RESULTS Overall sensitivity, specificity, false positive (FP) and false negative (FN) rates for the radiographer using the MXA software were 80%, 90%, 10%, and 20% respectively and for mild fractures alone were 46%, 92%, 8%, and 54% respectively. Overall sensitivity, specificity, FP, and FN rates for the four additional observers using MXA were 89%, 79%, 21%, and 11% respectively and for mild fractures alone were 36%, 86%, 14%, and 64% respectively. Agreement between two expert observers was fair to good for VFA and MXA [kappa = 0·29 to 0·76 (95% CI: 0·17-0·88) and 0·29 to 0·69 (95% CI: 0·17-0·83)] respectively. CONCLUSION MXA using a 33-point technique developed for adults is not a reliable method for the identification of mild vertebral fractures in children. A pediatric standard is required which not only incorporates specific vertebral body height ratios but also the age-related physiological changes in vertebral shape that occur throughout childhood.
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Affiliation(s)
- Fawaz F Alqahtani
- Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - Nicola J Crabtree
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Paul A Bromiley
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Timothy Cootes
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Penny Broadley
- Radiology Department, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Isla Lang
- Radiology Department, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Sheffield, UK; Radiology Department, Sheffield Children's NHS Foundation Trust, Sheffield, UK.
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Ma J, Siminoski K, Wang P, Alos N, Cummings EA, Feber J, Halton J, Ho J, Houghton K, Lang B, Miettunen PM, Scuccimarri R, Jaremko JL, Koujok K, Lentle B, Matzinger MA, Shenouda N, Rauch F, Ward LM. The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches. J Bone Miner Res 2020; 35:460-468. [PMID: 31742768 DOI: 10.1002/jbmr.3922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 01/06/2023]
Abstract
Due to concerns about cumulative radiation exposure in the pediatric population, it is not standard practice to perform spine radiographs in most conditions that predispose to vertebral fracture (VF). In this study we examined the accuracy of two clinical predictors, back pain and lumbar spine bone mineral density (LS BMD), to derive four case-finding paradigms for detection of prevalent VF (PVF). Subjects were 400 children at risk for PVF (leukemia 186, rheumatic disorders 135, nephrotic syndrome 79). Back pain was assessed by patient report, LS BMD was measured by dual-energy X-ray absorptiometry, and PVF were quantified on spine radiographs using the modified Genant semiquantitative method. Forty-four patients (11.0%) had PVF. Logistic regression analysis between LS BMD and PVF produced an odds ratio (OR) of 1.9 (95% confidence interval [CI], 1.5 to 2.5) per reduction in Z-score unit, an area under the receiver operating characteristic curve of 0.70 (95% CI, 0.60 to 0.79), and an optimal BMD Z-score cutoff of -1.6. Case identification using either low BMD alone (Z-score < -1.6) or back pain alone gave similar results for sensitivity (55%, 52%, respectively), specificity (78%, 81%, respectively), positive predictive value (PPV; 24%, 25%, respectively), and negative predictive value (NPV; 93%, 93%, respectively). The paradigm using low BMD plus back pain produced lower sensitivity (32%), higher specificity (96%), higher PPV (47%), and similar NPV (92%). The approach using low BMD or back pain had the highest sensitivity (75%), lowest specificity (64%), lowest PPV (20%), and highest NPV (95%). All paradigms had increased sensitivities for higher fracture grades. Our results show that BMD and back pain history can be used to identify children with the highest risk of PVF so that radiography can be used judiciously. The specific paradigm to be applied will depend on the expected PVF rate and the clinical approach to the use of radiography. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging and Department of Internal Medicine, University of Alberta, Edmonton, AB, Canada
| | - Peiyao Wang
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Nathalie Alos
- Department of Pediatrics, Universite de Montreal, Montreal, QC, Canada
| | | | - Janusz Feber
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Paivi M Miettunen
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | | | - Jacob L Jaremko
- Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, ON, Canada
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10
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Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
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Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
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11
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Abstract
The measurement of bone density is a frequent request in the assessment of children with concerns about bone health due to chronic disease or recurrent fractures. Dual energy X-ray absorptiometry (DXA) remains the recommended modality and is widely available. However, the interpretation and reporting of results in growing individuals needs to be undertaken by individuals who are familiar with scanning children and the potential pitfalls.
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Affiliation(s)
- Nick Shaw
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, West Midlands, UK
| | - Nicola Crabtree
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, West Midlands, UK
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12
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Weber DR, Boyce A, Gordon C, Högler W, Kecskemethy HH, Misra M, Swolin-Eide D, Tebben P, Ward LM, Wasserman H, Shuhart C, Zemel BS. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. J Clin Densitom 2019; 22:567-589. [PMID: 31421951 PMCID: PMC7010480 DOI: 10.1016/j.jocd.2019.07.002] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 11/20/2022]
Abstract
Dual-energy X-ray absorptiometry (DXA) is widely used in the evaluation of bone fragility in children. Previous recommendations emphasized total body less head and lumbar spine DXA scans for clinical bone health assessment. However, these scan sites may not be possible or optimal for all groups of children with conditions that threaten bone health. The utility of DXA scans of the proximal femur, forearm, and radius were evaluated for adequacy of reference data, precision, ability of predict fracture, and applicability to all, or select groups of children. In addition, the strengths and limitations of vertebral fracture assessment by DXA were evaluated. The new Pediatric Positions provide guidelines on the use of these additional measures in the assessment of skeletal health in children.
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Affiliation(s)
- David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Alison Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Catherine Gordon
- Divisions of Adolescent/Young Adult Medicine and Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, Birmingham Women's and Children's NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, UK
| | - Heidi H Kecskemethy
- Departments of Biomedical Research & Medical Imaging, Nemours/Alfred I. duPont Hospital for Children Wilmington, DE, USA
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Diana Swolin-Eide
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Region Västra Götaland, Sahlgrenska University Hospital, The Queen Silvia Children's Hospital, Department of Pediatrics, Gothenburg, Sweden
| | - Peter Tebben
- Division of Pediatric Endocrinology, Department of Pediatrics and Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism; Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Halley Wasserman
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Babette S Zemel
- Division of GI, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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13
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Alqahtani FF, Messina F, Offiah AC. Are semi-automated software program designed for adults accurate for the identification of vertebral fractures in children? Eur Radiol 2019; 29:6780-6789. [PMID: 31119416 PMCID: PMC6828619 DOI: 10.1007/s00330-019-06250-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/12/2019] [Accepted: 04/24/2019] [Indexed: 11/05/2022]
Abstract
Objectives To assess whether diagnostic accuracy of morphometric vertebral fracture (VF) diagnosis in children can be improved using AVERT™ (a 33-point semi-automated program developed for VF diagnosis in adults) compared with SpineAnalyzer™ (a 6-point program), which has previously been shown to be of insufficient accuracy. Materials and methods Lateral spine radiographs (XR) and dual-energy X-ray absorptiometry (DXA) scans of 50 children and young people were analysed by two observers using two different programs (AVERT™ and SpineAnalyzer™). Diagnostic accuracy (sensitivity, specificity, false-negative (FN) and false-positive rates (FP)) was calculated by comparing with a previously established consensus arrived at by three experienced paediatric musculoskeletal radiologists, using a simplified algorithm-based qualitative scoring system. Observer agreement was calculated using Cohen’s kappa. Results For XR, overall sensitivity, specificity, FP and FN rates using AVERT™ were 36%, 95%, 5% and 64% respectively and 26%, 98%, 2% and 75% respectively, using SpineAnalyzer™. For DXA, overall sensitivity, specificity, FP and FN rates using AVERT™ were 41%, 91%, 9% and 59% respectively and 31%, 96%, 4% and 69% respectively, using SpineAnalyzer. Reliability (kappa) ranged from 0.34 to 0.37 (95%CI, 0.26–0.46) for AVERT™ and from 0.26 to 0.31 (95%CI, 0.16–0.44) for SpineAnalyzer™. Inter- and intra-observer agreement ranged from 0.41 to 0.47 for AVERT™ and from 0.50 to 0.79 for SpineAnalyzer™. Conclusion AVERT™ has slightly higher accuracy but lower observer reliability for the representation of vertebral morphometry in children when compared with SpineAnalyzer™. However, neither software program is satisfactorily reliable for VF diagnosis in children. Key Points • SpineAnalyzer™ and AVERT™ have low diagnostic accuracy and observer agreement when compared to three paediatric radiologists’ readings for the diagnosis of vertebral fractures (VF) in children. • Neither AVERT™ nor SpineAnalyzer™ is satisfactorily reliable for VF diagnosis in children. • Development of specific paediatric software and normative values (incorporating age-related physiological variation in children) is required.
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Affiliation(s)
- Fawaz F Alqahtani
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Medical School, University of Sheffield, Street Building, Western Bank, Sheffield, S10 2TH, UK. .,Department of Radiological Sciences, College of Applied Medical Sciences, Najran University, Najran, Kingdom of Saudi Arabia.
| | - Fabrizio Messina
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Medical School, University of Sheffield, Street Building, Western Bank, Sheffield, S10 2TH, UK.,Radiology Department, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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14
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Abstract
Osteoporosis is a generalised disorder of the skeleton with reduced bone density and abnormal bone architecture. It increases bone fragility and renders the individual susceptible to fractures. Fractures of the vertebrae are common osteoporotic fractures. Vertebral fractures may result in scoliosis or kyphosis and, because they may be clinically silent, it is imperative that vertebral fractures are diagnosed in children accurately and at an early stage, so the necessary medical care can be implemented. Traditionally, diagnosis of osteoporotic vertebral fractures has been from lateral spine radiographs; however, a small number of studies have shown that dual energy x-ray absorptiometry is comparable to radiographs for identifying vertebral fractures in children, while allowing reduced radiation exposure. The diagnosis of vertebral fractures from dual energy x-ray absorptiometry is termed vertebral fracture assessment. Existing scoring systems for vertebral fracture assessment in adults have been assessed for use in children, but there is no standardisation and observer reliability is variable. This literature review suggests the need for a semiautomated tool that (compared to the subjective and semiquantitative methods available) will allow more reliable and precise detection of vertebral fractures in children.
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15
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Binder AM, Stiemsma LT, Keller K, van Otterdijk SD, Mericq V, Pereira A, Santos JL, Shepherd J, Michels KB. Inverse association between estrogen receptor-α DNA methylation and breast composition in adolescent Chilean girls. Clin Epigenetics 2018; 10:122. [PMID: 30286806 PMCID: PMC6172836 DOI: 10.1186/s13148-018-0553-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/14/2018] [Indexed: 12/21/2022] Open
Abstract
Background Estrogen receptor-α (ER-α) is a transcriptional regulator, which mediates estrogen-dependent breast development, as well as breast tumorigenesis. The influence of epigenetic regulation of ER-α on adolescent breast composition has not been previously studied and could serve as a marker of pubertal health and susceptibility to breast cancer. We investigated the association between ER-α DNA methylation in leukocytes and breast composition in adolescent Chilean girls enrolled in the Growth and Obesity Cohort Study (GOCS) in Santiago, Chile. Breast composition (total breast volume (BV; cm3), fibroglandular volume (FGV; cm3), and percent fibroglandular volume (%FGV)) was measured at breast Tanner stage 4 (B4). ER-α promoter DNA methylation was assessed by pyrosequencing in blood samples collected at breast Tanner stages 2 (B2; n = 256) and B4 (n = 338). Results After adjusting for fat percentage at breast density measurement, ER-α methylation at B2, and cellular heterogeneity, we observed an inverse association between B4 average ER-α DNA methylation and BV and FGV. Geometric mean BV was 15% lower (95% CI: − 28%, − 1%) among girls in the highest quartile of B4 ER-α methylation (6.96–23.60%) relative to the lowest (0.78–3.37%). Similarly, FGV was 19% lower (95% CI: − 33%, − 2%) among girls in the highest quartile of B4 ER-α methylation relative to the lowest. The association between ER-α methylation and breast composition was not significantly modified by body fat percentage and was not influenced by pubertal timing. Conclusions These findings suggest that the methylation profile of ER-α may modulate adolescent response to estrogen and breast composition, which may influence breast cancer risk in adulthood. Electronic supplementary material The online version of this article (10.1186/s13148-018-0553-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexandra M Binder
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 90095, USA
| | - Leah T Stiemsma
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 90095, USA
| | - Kristen Keller
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, 90095, USA
| | - Sanne D van Otterdijk
- Institute for Prevention and Cancer Epidemiology, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Verónica Mericq
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | - Ana Pereira
- Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile
| | - José L Santos
- Department of Nutrition, Diabetes and Metabolism, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - John Shepherd
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, HI, 96813, USA
| | - Karin B Michels
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, 90095, USA.
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16
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Abstract
Following the increased awareness about the central role of the pediatric age in building bone for life, clinicians face more than ever the necessity of assessing bone health in pediatric subjects at risk for early bone mass derangements or in healthy children, in order to optimize their bone mass accrual and prevent osteoporosis. Although the diagnosis of osteoporosis is not made solely upon bone mineral density measurements during growth, such determination can be very useful in the follow-up of pediatric patients with primary and secondary osteoporosis. The ideal instrument would give information on the mineral content and density of the bone, and on its architecture. It should be able to perform the measurements on the skeletal sites where fractures are more frequent, and it should be minimally invasive, accurate, precise and rapid. Unfortunately, none of the techniques currently utilized fulfills all requirements. In the present review, we focus on the pediatric use of dual-energy X-ray absorptiometry (DXA), quantitative computed tomography (QCT), peripheral QCT (pQCT), and magnetic resonance imaging (MRI), highlighting advantages and limits for their use and providing indications for bone densitometry interpretation and of vertebral fractures diagnosis in pediatric subjects.
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Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
| | - Katia Maruca
- Pediatric Bone Densitormetry Service and Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Institute, Milano, Italy
| | - Giuseppa Patti
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Stefano Mora
- Pediatric Bone Densitormetry Service and Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Institute, Milano, Italy.
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