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Ward LM, Ma J, Robinson ME, Scharke M, Ho J, Houghton K, Huber A, Scuccimarri R, Barsalou J, Roth J, Shenouda N, Matzinger MA, Lentle B, Jaremko JL, Koujok K, Watanabe Duffy K, Stein R, Sbrocchi AM, Rodd C, Miettunen PM, LeBlanc CMA, Larche M, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Sykes E, Konji VN, Rauch F, Siminoski K, Lang B. Osteoporotic Fractures and Vertebral Body Reshaping in Children With Glucocorticoid-treated Rheumatic Disorders. J Clin Endocrinol Metab 2021; 106:e5195-e5207. [PMID: 34232311 DOI: 10.1210/clinem/dgab494] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Osteoporotic fractures are an important cause of morbidity in children with glucocorticoid-treated rheumatic disorders. OBJECTIVE This work aims to evaluate the incidence and predictors of osteoporotic fractures and potential for recovery over six years following glucocorticoid (GC) initiation in children with rheumatic disorders. METHODS Children with GC-treated rheumatic disorders were evaluated through a prospective inception cohort study led by the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium. Clinical outcomes included lumbar spine bone mineral density (LS BMD), vertebral fractures (VF), non-VF, and vertebral body reshaping. RESULTS A total of 136 children with GC-treated rheumatic disorders were enrolled (mean age 9.9 years, SD 4.4). The 6-year cumulative fracture incidence was 16.3% for VF, and 10.1% for non-VF. GC exposure was highest in the first 6 months, and 24 of 38 VF (63%) occurred in the first 2 years. Following VF, 16 of 19 children (84%) had complete vertebral body reshaping. Increases in disease activity and body mass index z scores in the first year and declines in LS BMD z scores in the first 6 months predicted incident VF over the 6 years, while higher average daily GC doses predicted both incident VF and non-VF. LS BMD z scores were lowest at 6 months (mean -0.9, SD 1.2) and remained low by 6 years even when adjusted for height z scores (-0.6, SD 0.9). CONCLUSION VF occurred early and were more common than non-VF in children with GC-treated rheumatic disorders. Eighty-four percent of children with VF underwent complete vertebral body reshaping, whereas vertebral deformity persisted in the remainder of children. On average, LS BMD z scores remained low at 6 years, consistent with incomplete recovery.
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Affiliation(s)
- Leanne M Ward
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | - Jinhui Ma
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | - Maya Scharke
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Josephine Ho
- University of Calgary, Calgary T3B 6A8, Alberta, Canada
| | - Kristin Houghton
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | - Adam Huber
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
| | | | - Julie Barsalou
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Johannes Roth
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | | | | | - Brian Lentle
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | | | | | - Robert Stein
- University of Western Ontario, London N6A 5A5, Ontario, Canada
| | | | - Celia Rodd
- University of Manitoba, Winnipeg R3E 0Z3, Manitoba, Canada
| | | | | | - Maggie Larche
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | | | - Robert Couch
- University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - David A Cabral
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | - Nathalie Alos
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Elizabeth Sykes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Victor N Konji
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Frank Rauch
- McGill University, Montréal H4A 3J1, Quebec, Canada
| | | | - Bianca Lang
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
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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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Lentle B, Brown JP, Probyn L, Goltzman D. Vertebral Fractures: Which Radiological Criteria Are Better Associated With the Clinical Course of Osteoporosis? Can Assoc Radiol J 2020; 72:586. [PMID: 33023327 DOI: 10.1177/0846537120963692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brian Lentle
- The University of British Columbia, Victoria, British Columbia, Canada
| | | | - Linda Probyn
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Goltzman
- McGill University, McGill University and McGill University Health Centre, Montreal, Quebec, Canada
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4
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, 3710McMaster University, Hamilton, Ontario, Canada
| | | | - Brian Lentle
- Department of Radiology, 8166University of British Columbia, Vancouver, BC, Canada
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Abstract
Canadian radiology has its roots embedded in Montréal and this is no less true of the Canadian Association of Radiologists Journal, now celebrating its 70th Anniversary with the appointment of a new editor. A journal, Les Rayons-X-a monthly illustrated review published in Montréal and edited by Dr Henri Lasnier- preceded it by 40 years. Les Rayons-X was to last only 7 issues. However, Dr Lasnier clearly recognized the importance of a journal to what was then an emerging specialty. By 1950, the Canadian Association of Radiologists became the first specialty society in Canada to publish a scientific journal. We reflect on some facets of the evolution of the journal from a cottage industry to its adoption by a major publishing house and through the hands of 14 editors. In that time, radiology itself has undergone remarkable changes in its technological infrastructure leading to profound changes in the capacity of radiological practitioners and scientists to diagnose and treat disease. These changes themselves impose some constraints on a general radiology journal. The Association has at times faced substantial challenges that led to questions about its ability to sustain a journal in the face of competing priorities. Those challenges will likely recur in the future, not least in the face of other better-resourced journals. As the Canadian Association of Radiologists has evolved into a distinctive voice in Canadian medicine, we argue that a strong case can be made for preserving a platform for Canadian radiology featuring Canadian observations and perspectives, both scientific and "political."
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Affiliation(s)
- Brian Lentle
- 8166The University of British Columbia, Victoria, British Columbia, Canada
| | - D Ian Hammond
- Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Stuart Houston
- 7235University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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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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7
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Cooke-Hubley S, Gao Z, Mugford G, Kaiser SM, Goltzman D, Leslie WD, Davison KS, Brown JP, Probyn L, Lentle B, Prior JC, Kovacs CS. Parity and lactation are not associated with incident fragility fractures or radiographic vertebral fractures over 16 years of follow-up: Canadian Multicentre Osteoporosis Study (CaMos). Arch Osteoporos 2019; 14:49. [PMID: 31037359 DOI: 10.1007/s11657-019-0601-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/08/2019] [Accepted: 04/21/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Parity and lactation showed no associations with incident clinical fragility fractures or radiographic vertebral compression fractures in the 16-year CaMos prospective study. Parity was associated with slightly greater decline in femoral neck but not hip or spine areal bone mineral density (aBMD), while lactation showed no associations with aBMD change. PURPOSE Pregnancy and especially lactation cause loss of bone mass and microarchitectural changes, which temporarily increase fracture risk. After weaning, aBMD increases but skeletal microarchitecture may be incompletely restored. Most retrospective clinical studies found neutral or even protective associations of parity and lactation with fragility fractures, but prospective data are sparse. CaMos is a randomly selected observational cohort that includes ~ 6500 women followed prospectively for over 16 years. METHODS We determined whether parity or lactation were related to incident clinical fragility fractures over 16 years, radiographic (morphometric and morphologic) vertebral fractures over 10 years, and aBMD change (spine, total hip, and femoral neck) over 10 years. Parity and lactation duration were analyzed as continuous variables in predicting these outcomes using univariate and multivariate regression analyses. RESULTS Three thousand four hundred thirty-seven women completed 16 years of follow-up for incident clinical fractures, 3839 completed 10 years of morphometric vertebral fracture assessment, 3788 completed 10 years of morphologic vertebral fracture assessment, and 4464 completed 10 years of follow-up for change in aBMD. In the multivariate analyses, parity and lactation duration showed no associations with clinical fragility fractures, radiographic vertebral fractures, or change in aBMD, except that parity associated with a probable chance finding of a slightly greater decline in femoral neck aBMD. CONCLUSIONS Parity and lactation have no adverse associations with clinical fragility or radiographic vertebral fractures, or the rate of BMD decline over 10 years, in this prospective, multicenter study of a randomly selected, population-based cohort of women.
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Affiliation(s)
- Sandra Cooke-Hubley
- Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada
| | - Zhiwei Gao
- Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada
| | - Gerald Mugford
- Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada
| | - Stephanie M Kaiser
- Department of Medicine, Dalhousie University, Halifax, NS, B3H 2Y9, Canada
| | - David Goltzman
- Department of Medicine, McGill University, Montreal, QC, H4A 3J1, Canada
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, R2H 2A6, Canada
| | - K Shawn Davison
- a priori medical sciences Inc., Victoria, BC, V8R 3E3, Canada
| | - Jacques P Brown
- Department of Medicine, Division of Rheumatology, CHU de Quebec Research Centre, Laval University, Quebec City, QC, G1V 4G2, Canada
| | - Linda Probyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, M4R 1K5, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, V9A 6T5, Canada
| | - Jerilynn C Prior
- Centre for Menstrual Cycle and Ovulation Research, Medicine/Endocrinology, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Christopher S Kovacs
- Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NL, A1B 3V6, Canada.
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Lentle B, Koromani F, Brown JP, Oei L, Ward L, Goltzman D, Rivadeneira F, Leslie WD, Probyn L, Prior J, Hammond I, Cheung AM, Oei EH. The Radiology of Osteoporotic Vertebral Fractures Revisited. J Bone Miner Res 2019; 34:409-418. [PMID: 30645770 DOI: 10.1002/jbmr.3669] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [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: 11/05/2018] [Revised: 12/17/2018] [Accepted: 01/05/2019] [Indexed: 01/31/2023]
Abstract
Until recently there has been little evidence available to validate any method by which to make an accurate diagnosis of an osteoporotic vertebral fractures (OVFs) from plain radiographs. In part this reflects a lack of a completely satisfactory "gold standard," but primarily it relates to the absence of well-designed prospective studies in this context. Historically, OVFs were recognized by evidence of macroscopic structural failure in vertebrae using the criteria applied elsewhere in the skeleton. This comprised altered alignment, fragmentation, cortical disruptions, and breaks, among other changes. However, these morphological criteria were replaced by vertebral morphometry, referring to the use of quantitative or quasi-quantitative measurement tools for fracture diagnosis. Vertebral morphometry emerged as an understanding of and treatment for osteoporosis evolved, mainly in response to the need for expeditious assessments of large numbers of spine images for epidemiological and pharmaceutical purposes. Although most of the descriptions of such morphometric tools have stressed that they were not to be applied to clinical diagnosis with respect to individual patients, this constraint has been widely disregarded. Here we review the major attempts to develop a diagnostic strategy for OVF and describe their characteristics in adults and children. Recent evidence suggests that morphometric (quantitative; ie, based on measurement of dimensions and shape description) criteria are inferior to morphologic (qualitative; ie, based on structural integrity) vertebral damage assessment in identifying people with low bone density and at an increased risk of future fracture. Thus there is now an evidentiary basis for suggesting that morphological assessment is the preferred strategy for use in diagnosing OVF from radiographs. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Fjorda Koromani
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Jacques P Brown
- Department of Medicine, Division of Rheumatology, CHU de Québec Research Centre, Laval University, Québec City, QC, Canada
| | - Ling Oei
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Leanne Ward
- Division of Bone Health, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - David Goltzman
- Department of Medicine, McGill University and McGill University Health Centre, Montréal, QC, Canada
| | - Fernando Rivadeneira
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Linda Probyn
- Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jerilynn Prior
- Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Ian Hammond
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, Centre of Excellence in Skeletal Health Assessment, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Edwin H Oei
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
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Ma J, Siminoski K, Alos N, Halton J, Ho J, Cummings EA, Shenouda N, Matzinger MA, Lentle B, Jaremko JL, Wilson B, Stephure D, Stein R, Sbrocchi AM, Rodd C, Lewis VA, Laverdière C, Israels S, Grant RM, Fernandez CV, Dix DB, Couch R, Cairney E, Barr R, Atkinson S, Abish S, Moher D, Rauch F, Ward LM. Impact of Vertebral Fractures and Glucocorticoid Exposure on Height Deficits in Children During Treatment of Leukemia. J Clin Endocrinol Metab 2019; 104:213-222. [PMID: 30247635 PMCID: PMC6291659 DOI: 10.1210/jc.2018-01083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/17/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the effect of vertebral fractures (VF) and glucocorticoid (GC) exposure on height deficits in children during treatment of acute lymphoblastic leukemia (ALL). METHODS Children with ALL treated without cranial radiation therapy (n = 160; median age, 5.1 years; 58.1% male) were followed prospectively for 6 years. Spinal deformity index (SDI) was used to quantify VF status. RESULTS Baseline height z score ± SD was 0.3 ± 1.2. It fell by 0.5 ± 0.4 in the first 6 months for boys and by 0.4 ± 0.4 in the first 12 months for girls (P < 0.01 for both) and then subsequently recovered. The prevalence of VF peaked at 1 year (17.6%). Among those with VF, median SDI rose from 2 [interquartile range (IQR): 1, 7] at baseline to 8 (IQR: 1, 8) at 1 year. A mixed model for repeated measures showed that height z score declined by 0.13 (95% CI: 0.02 to 0.24; P = 0.02) for each 5-unit increase in SDI during the previous 12 months. Every 10 mg/m2 increase in average daily GC dose (prednisone equivalent) in the previous 12 months was associated with a height z score decrement of 0.26 (95% CI: 0.20 to 0.32; P < 0.01). CONCLUSIONS GC likely plays a major role in the observed height decline during therapy for ALL. Because only a minority of children had VF, fractures could not have contributed significantly to the height deficit in the entire cohort but may have been important among the subset with VF.
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Affiliation(s)
- Jinhui Ma
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | - Brian Lentle
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Robert Stein
- University of Western Ontario, London, Ontario, Canada
| | | | - Celia Rodd
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Sara Israels
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - David B Dix
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Couch
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Ronald Barr
- McMaster University, Hamilton, Ontario, Canada
| | | | | | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Leanne M Ward
- University of Ottawa, Ottawa, Ontario, Canada
- Correspondence and Reprint Requests: Leanne M. Ward, MD, University of Ottawa, Room 250H, Research Institute, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada. E-mail:
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Ward LM, Ma J, Lang B, Ho J, Alos N, Matzinger MA, Shenouda N, Lentle B, Jaremko JL, Wilson B, Stephure D, Stein R, Sbrocchi AM, Rodd C, Lewis V, Israels S, Grant RM, Fernandez CV, Dix DB, Cummings EA, Couch R, Cairney E, Barr R, Abish S, Atkinson SA, Hay J, Rauch F, Moher D, Siminoski K, Halton J. Bone Morbidity and Recovery in Children With Acute Lymphoblastic Leukemia: Results of a Six-Year Prospective Cohort Study. J Bone Miner Res 2018; 33:1435-1443. [PMID: 29786884 DOI: 10.1002/jbmr.3447] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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: 01/05/2018] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 11/07/2022]
Abstract
Osteoporotic fractures are a significant cause of morbidity in acute lymphoblastic leukemia (ALL). Our objective was to determine the incidence and predictors of fractures and recovery from osteoporosis in pediatric ALL over 6 years following glucocorticoid initiation. Vertebral fractures (VF) and vertebral body reshaping were assessed on annual spine radiographs, low-trauma non-VF were recorded at regular intervals and spine bone mineral density (BMD) was captured every 6 months for 4 years and then annually. A total of 186 children with ALL were enrolled (median age 5.3 years; range, 1.3 to 17.0 years). The cumulative fracture incidence was 32.5% for VF and 23.0% for non-VF; 39.0% of children with VF were asymptomatic. No fractures occurred in the sixth year and 71.3% of incident fractures occurred in the first 2 years. Baseline VF, cumulative glucocorticoid dose, and baseline lumbar spine (LS) BMD Z-score predicted both VF and non-VF. Vertebral body reshaping following VF was incomplete or absent in 22.7% of children. Those with residual vertebral deformity following VF were older compared to those without (median age 8.0 years at baseline [interquartile range {IQR}, 5.5 to 9.4] versus 4.8 years [IQR, 3.6 to 6.2], p = 0.04) and had more severe vertebral collapse (median maximum spinal deformity index 3.5 [IQR, 1.0 to 8.0] versus 0.5 [IQR, 0.0 to 1.0], p = 0.01). VF and low LS BMD Z-score at baseline as well as glucocorticoid exposure predicted incident VF and non-VF. Nearly 25% of children had persistent vertebral deformity following VF, more frequent in older children, and in those with more severe collapse. These results suggest the need for trials addressing interventions in the first 2 years of chemotherapy, targeting older children and children with more severe vertebral collapse, because these children are at greatest risk for incident VF and subsequent residual vertebral deformity. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Nathalie Alos
- Département de Pédiatrie, Université de Montréal, Montréal, QC, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Jacob L Jaremko
- Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Beverly Wilson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - David Stephure
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Robert Stein
- Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | | | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Victor Lewis
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sara Israels
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Ronald M Grant
- Department of Pediatics, University of Toronto, Toronto, ON, Canada
| | | | - David B Dix
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Robert Couch
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Elizabeth Cairney
- Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Sharon Abish
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - John Hay
- Department of Health Sciences, Brock University, St, Catharines, ON, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, and Department of Medicine, University of Alberta, Edmonton, AB, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, ON, Canada
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11
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Ward LM, Ma J, Rauch F, Benchimol EI, Hay J, Leonard MB, Matzinger MA, Shenouda N, Lentle B, Cosgrove H, Scharke M, Konji VN, Mack DR. Musculoskeletal health in newly diagnosed children with Crohn's disease. Osteoporos Int 2017; 28:3169-3177. [PMID: 28791436 DOI: 10.1007/s00198-017-4159-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/11/2017] [Indexed: 12/15/2022]
Abstract
UNLABELLED We evaluated the impact of Crohn's disease on muscle and bone strength, mass, density, and geometry in children with newly diagnosed CD and found profound muscle and bone deficits; nevertheless, the prevalence of vertebral fractures at this time point was low. INTRODUCTION Crohn's disease (CD) is an inflammatory condition of the gastrointestinal tract that can affect the musculoskeletal system. The objective of this study was to determine the prevalence of vertebral fractures and the impact of CD on muscle and bone mass, strength, density, and geometry in children with newly diagnosed CD. METHODS Seventy-three children (26 girls) aged 7.0 to 17.7 years were examined within 35 days following CD diagnosis by lateral spine radiograph for vertebral fractures and by jumping mechanography for muscle strength. Bone and muscle mass, density, and geometry were assessed by dual-energy x-ray absorptiometry and peripheral quantitative computed tomography (pQCT). RESULTS Disease activity was moderate to severe in 66 (90%) patients. Mean height (Z-score -0.3, standard deviation (SD) 1.1, p = 0.02), weight (Z-score -0.8, SD 1.3, p < 0.01), body mass index (Z-score -1.0, SD 1.3, p < 0.01), lumbar spine areal bone mineral density (BMD; Z-score -1.1, SD 1.0, p < 0.01), total body bone mineral content (Z-score -1.5, SD 1.0, p < 0.01), and total body lean mass (Z-score -2.5, SD 1.1, p < 0.01) were all low for age and gender. pQCT showed reduced trabecular volumetric BMD at the tibial metaphysis, expansion of the bone marrow cavity and thin cortices at the diaphysis, and low calf muscle cross-sectional area. Jumping mechanography demonstrated low muscle power. Only one patient had a vertebral fracture. CONCLUSIONS Children with newly diagnosed CD have profound muscle and bone deficits; nevertheless, the prevalence of vertebral fractures at this time point was low.
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Affiliation(s)
- L M Ward
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
| | - J Ma
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - F Rauch
- Shriners Hospital for Children, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - E I Benchimol
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - J Hay
- Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - M B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - M A Matzinger
- Department of Medical Imaging, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - N Shenouda
- Department of Medical Imaging, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - B Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - H Cosgrove
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - M Scharke
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - V N Konji
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - D R Mack
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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12
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Hammond I, Lentle B, van den Berg L, Vitols-McKay M. Gender Identity and Bone Densitometry. Can Assoc Radiol J 2017; 68:267-269. [DOI: 10.1016/j.carj.2016.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/16/2016] [Accepted: 10/27/2016] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ian Hammond
- Department of Radiology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lucretia van den Berg
- Division of Endocrinology, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Megan Vitols-McKay
- Division of Nuclear Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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13
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Ma J, McMillan HJ, Karagüzel G, Goodin C, Wasson J, Matzinger MA, DesClouds P, Cram D, Page M, Konji VN, Lentle B, Ward LM. The time to and determinants of first fractures in boys with Duchenne muscular dystrophy. Osteoporos Int 2017; 28:597-608. [PMID: 27774565 DOI: 10.1007/s00198-016-3774-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/12/2016] [Indexed: 11/24/2022]
Abstract
UNLABELLED Boys with vertebral fractures (VF) identified through routine spine radiographs had milder, less symptomatic, and fewer VF compared to those diagnosed with VF following consultation for back pain. Spontaneous (i.e., medication-unassisted) reshaping of fractured vertebral bodies was absent. Long bone fractures were present even before Duchenne muscular dystrophy (DMD) diagnosis in some boys. INTRODUCTION The objective of the study was to determine the time to and characteristics of first fractures in Duchenne muscular dystrophy. METHODS This study was a retrospective longitudinal study of 30 boys with DMD <18 years. Boys were classified into four groups according to their first fracture: those with VF identified on routine lateral spine radiographs, those with VF diagnosed following consultation for back pain, those with long bone fractures, and those without fractures. RESULTS Compared to boys diagnosed with VF as their initial fracture following consultation for back pain, those with VF surveillance radiographs had shorter durations of glucocorticoid (GC) therapy at the time of VF diagnosis (median 1.6 versus 5.3 years, p < 0.01), higher areal (mean ± standard deviation -1.4 ± 0.7 versus -3.1 ± 0.8, p = 0.01), and volumetric (-0.3 ± 0.5 versus -2.6 ± 0.8, p < 0.01) lumbar spine bone mineral density Z-scores, as well as fewer VF (median 1.4 versus 5.2 per person, p < 0.01) and a lower median spinal deformity index (median 1.5 versus 9.5, p < 0.01). Vertebral body reshaping following VF was not observed. Ten boys sustained a long bone fracture as their first fracture at a mean age of 8.9 ± 4.0 years; four of these boys later sustained a total of 27 incident VF. CONCLUSIONS Routine lateral spine radiographs led to detection of VF in their earlier stages, vertebral body reshaping following VF was absent, and VF were frequent after the first long bone fracture. These results support the inclusion of a lateral spine radiograph starting at the time of GC initiation as part of routine bone health monitoring in DMD.
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Affiliation(s)
- J Ma
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - H J McMillan
- Department of Pediatrics, and Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - G Karagüzel
- Department of Pediatric Endocrinology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - C Goodin
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - J Wasson
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - M A Matzinger
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - P DesClouds
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - D Cram
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - M Page
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - V N Konji
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - B Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - L M Ward
- Pediatric Bone Health Clinical Research Program, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
- Department of Pediatrics, and Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Rd, Ottawa, ON, K1H 8L1, Canada.
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14
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Lentle B, Hammond I, Worsley D, Colquhoun A, Grochowski C, Leggett J, Gill S. A Qualitative Examination of the Ward Region of Interest as Imaged on Dual-Energy X-ray Absorptiometry Examinations: The "Wandering Ward Sign". J Clin Densitom 2016; 19:515-521. [PMID: 27102659 DOI: 10.1016/j.jocd.2016.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/14/2016] [Accepted: 03/21/2016] [Indexed: 11/18/2022]
Abstract
While analyzing dual-energy X-ray absorptiometry (DXA) examinations, we observed that, on occasion, the Ward region of interest (ROI) was positioned either unexpectedly or differently between successive examinations. When this occurred, it appeared to be either a marker of a compromised examination or of incident disease. This prompted a systematic inquiry. It became apparent that, while in general seeking the region of least areal density, the Ward ROI is positioned differently by the machines available to us from 2 particular manufacturers (General Electric Co. and Hologic Inc.). Three reviews were thus undertaken: (1) a prospective systematic examination of 200 unselected consecutive DXA examinations made with a General Electric Co. machine, 80 having had follow-up examinations and 245 made with a Hologic Inc. device; (2) a prospective systematic examination of 625 consecutive, unselected DXA examinations that were repeat examinations; and (3) a retrospective examination of a file of 86 cases collected for pedagogical purposes, predominantly made with a Hologic Inc. device. The commonest cause of an unusual position of the Ward area was compromised patient positioning or change in body habitus. Changes between examinations were, in addition if less often, apt to reflect physiological change or disease. Unusual positioning or a change in position of the Ward ROI is easily observed. It does not occur frequently, but, when it does, it may be useful in directing attention to either technical factors or incidental diseases. Observation of the position of the Ward ROI may thus be a quality assurance, and occasionally a diagnostic, tool.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
| | - Ian Hammond
- Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Dan Worsley
- Division of Nuclear Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Anita Colquhoun
- Centre for Osteoporosis & Bone Health, Women's College Hospital, Toronto, ON, Canada
| | - Christa Grochowski
- Division of Nuclear Medicine and Bone Density, BC Children's Hospital, Vancouver, BC, Canada
| | - Jan Leggett
- Division of Nuclear Medicine and Bone Density, BC Children's Hospital, Vancouver, BC, Canada
| | - Sabrina Gill
- Division of Endocrinology, St. Paul's Hospital, Vancouver BC, Canada
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15
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Lian K, Trollip J, Sandhu S, Moosavi M, Gill A, Kendler D, Dian L, Lentle B. Audit of Atypical Femoral Fractures and a Description of Some of Their Features. Can Assoc Radiol J 2016; 67:69-75. [PMID: 26800621 DOI: 10.1016/j.carj.2015.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Atypical femoral fractures (AFF) are recently described events related to osteoporosis and, potentially, a rare result of antiresorptive treatment. METHODS We set out to audit the diagnosis of AFF in an acute hospital. Charts and radiographs were reviewed retrospectively from patients diagnosed with subtrochanteric femoral fractures according to hospital discharge coding at Vancouver General Hospital (VGH), Canada, from January 2005 to March 2013. RESULTS A total of 3084 patients were discharged from the hospital with a diagnosis of hip fracture between 2005 and 2013. Of these, 204 were coded as having had subtrochanteric fractures; 178 of the patients thus coded had radiographic evidence of other fracture types-usually intertrochanteric fractures. Eleven patients did not have available radiographs. Of the remaining 193 patients whose radiographs were reviewed, 24 (12.4%) fulfilled the published criteria for AFF. OUR OBSERVATIONS WERE 1) laterality: 13 of 24 AFF (54.2%) were right-sided; 2) there was only one incomplete AFF in this series: a completed fracture was an inclusion criterion, but 1 patient with an AFF had both that fracture and an incomplete fracture and further foci of periosteal or endosteal foci of new bone (PENB) involving the contralateral femur; 3) radiologists had only diagnosed AFF in only 1 of the 24 patients with characteristic radiographic signs of AFF; 4) all but 1 patient had a focus of periosteal and/or endosteal new bone (PENB) through which the fracture line invariably passed, and in the 1 exception the radiography was too poor to be sure of this but there was a symmetrical contralateral focus of PENB; 5) in 19 of 24 patients there was an adequate image of part of the contralateral femur and of these 12 (63%) had a contralateral focus of PENB situated ±2.5 cm from the index lesion site when measured from the upper aspect of the greater trochanter, and in another patient a prior fracture of the contralateral femur had been treated surgically and it was at a symmetrical contralateral location from the index fracture.; 6) in 3 of the 19 patients multiple foci of PENB were detected on the lateral aspect of the contralateral femur even though the examination was of limited extent; and 7) AFFs were associated with bisphosphonate medication in 75% of the patients studied. CONCLUSIONS Hospital discharge coding misclassified a great majority of femoral fractures as subtrochanteric. As an essential criteria for diagnosing AFF is their subtrochanteric location, this misclassification impaired our ability to retrospectively search for AFF patients. Radiologists tended not to report AFF when typical radiographic characteristics were present. Bilateral and multifocal disease is of interest in pointing to the diagnosis and in suggesting that the mechanism of injury in respect of these unusual fractures is more complex than simple low-energy trauma.
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Affiliation(s)
- Kevin Lian
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacques Trollip
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Supna Sandhu
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mandana Moosavi
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amninder Gill
- BC Women's Health Centre, Vancouver, British Columbia, Canada
| | - David Kendler
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry Dian
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada; Private Consultant, The Project Management Institute, Canadian West Coast Chapter, Vancouver, British Columbia, Canada.
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16
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Affiliation(s)
- Brian Lentle
- Department of Radiology, BC Women's Hospital and Health Centre, University of British Columbia, Vancouver, BC, Canada.
| | - Ian Hammond
- Department of Radiology, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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17
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Abstract
Some 30 years ago the diagnosis of osteoporosis relied primarily on the measurement of bone mineral density by DXA. More recently, however, it was recognized that vertebral fractures are an important predictor of future fractures and that they reflect some aspect of bone fragility not captured by BMD measurement. In response to that, DXA manufacturers developed VFA, spine imaging on the densitometer, which allowed integration of BMD with information on vertebral fractures obtained at the same visit. ISCD has been instrumental in several aspects of VFA use such as developing and teaching courses for VFA or more broadly, for recognition of vertebral fractures; in developing guidelines for performance, interpretation and reporting of the VFA; and in advocating for reimbursement for VFA tests performed in the clinical practice. ISCD is poised to continue as a leader in vertebral fracture recognition and application of VFA to clinical practice and research.
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Affiliation(s)
- Tamara Vokes
- Department of Medicine and Biological Sciences, University of Chicago, Chicago, IL, USA.
| | - Brian Lentle
- Department of Medicine and Biological Sciences, University of Chicago, Chicago, IL, USA
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18
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Abstract
When a low-energy fracture occurs, then osteoporosis has progressed to the point of bony structural failure. Because vertebral fractures are the commonest type of osteoporotic fracture, the correct identification of them becomes important for diagnosis, risk estimation, and management. However, there are no uniformly agreed criteria for their diagnosis. The purpose of this review was to examine the diagnostic radiological strategies available and suggest a coherent approach to diagnosis. Diagnosis had come to focus on comparative changes in vertebral dimensions. However, it has become apparent that mild reductions in vertebral height are of uncertain implication. The importance of structural damage in diagnosis has become recognized in parallel. Relative reductions in vertebral height may not be a necessary nor sufficient criterion by which to diagnose a fracture.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
| | - Jacques Trollip
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Kevin Lian
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
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19
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Lentle B, Ma J, Jaremko JL, Siminoski K, Matzinger MA, Shenouda N, Konji VN, Ward LM. The Radiology of Vertebral Fractures in Childhood Osteoporosis Related to Glucocorticoid Administration. J Clin Densitom 2016; 19:81-8. [PMID: 26653615 DOI: 10.1016/j.jocd.2015.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 10/21/2015] [Accepted: 10/21/2015] [Indexed: 12/29/2022]
Abstract
A number of unusual conditions cause decreased bone mass and density in children and these may be associated with low-trauma fractures. However, a series of reports have more recently identified that children with chronic disease sustain vertebral fractures (VFs) much more often than had been suspected. The common denominator involved is glucocorticoid (GC) administration, although other factors such as disease activity come into play. This review will focus on the imaging findings in this form of secondary osteoporosis. Spinal fractures in children have been found to correlate with back pain. At the same time, up to 2/3 of children with VFs in the GC-treated setting are asymptomatic, underscoring the importance of routine surveillance in at-risk children. Other predictors of prevalent and incident VFs include GC exposure (average daily and cumulative dose), declines in lumbar spine bone mineral density Z-scores and increases in body mass index Z-scores, as well as increases in disease activity scores. The imaging diagnosis of osteoporotic VFs in children is made differently from that in adults because immature vertebral bodies continue to ossify during growth. Thus, it is not possible to assess the vertebral end plates or periphery until late, as enchondral ossification extends centripetally within the centrum. Diagnosis, therefore, is much more dependent upon changes in shape than on loss of structural integrity, which may have a more prominent diagnostic role in adults. However, children have a unique ability to model (a growth-dependent process) and thereby reshape previously fractured vertebral bodies. If the underlying disease is successfully treated and the child has sufficient residual growth potential, this means that, on one hand, treatment of the bone disease may be of more limited duration, and, as a last recourse, the diagnosis may be apparent retrospectively.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
| | - Jinhui Ma
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jacob L Jaremko
- Department of Radiology & Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging and Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Victor N Konji
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Leanne M Ward
- Department of Pediatrics and Department of Surgery, University of Ottawa, Ottawa, ON, Canada
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20
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LeBlanc CMA, Ma J, Taljaard M, Roth J, Scuccimarri R, Miettunen P, Lang B, Huber AM, Houghton K, Jaremko JL, Ho J, Shenouda N, Matzinger MA, Lentle B, Stein R, Sbrocchi AM, Oen K, Rodd C, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Rauch F, Siminoski K, Ward LM. Incident Vertebral Fractures and Risk Factors in the First Three Years Following Glucocorticoid Initiation Among Pediatric Patients With Rheumatic Disorders. J Bone Miner Res 2015; 30:1667-75. [PMID: 25801315 PMCID: PMC4556451 DOI: 10.1002/jbmr.2511] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [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: 01/28/2015] [Revised: 03/10/2015] [Accepted: 03/13/2015] [Indexed: 12/21/2022]
Abstract
Vertebral fractures are an important yet underrecognized manifestation of osteoporosis in children with chronic, glucocorticoid-treated illnesses. Our goal was to determine the incidence and clinical predictors of vertebral fractures in the 3 years following glucocorticoid initiation among pediatric patients with rheumatic disorders. Incident vertebral fractures were evaluated according to the Genant semiquantitative method on lateral radiographs at baseline and then annually in the 3 years following glucocorticoid initiation. Extended Cox models were used to assess the association between vertebral fractures and clinical risk predictors. A total of 134 children with rheumatic disorders were enrolled in the study (mean ± standard deviation (SD) age 9.9 ± 4.4 years; 65% girls). The unadjusted vertebral fracture incidence rate was 4.4 per 100 person-years, with a 3-year incidence proportion of 12.4%. The highest annual incidence occurred in the first year (6.0%; 95% confidence interval (CI) 2.9% to 11.7%). Almost one-half of the patients with fractures were asymptomatic. Every 0.5 mg/kg increase in average daily glucocorticoid (prednisone equivalents) dose was associated with a twofold increased fracture risk (hazard ratio (HR) 2.0; 95% CI 1.1 to 3.5). Other predictors of increased vertebral fracture risk included: (1) increases in disease severity scores between baseline and 12 months; (2) increases in body mass index Z-scores in the first 6 months of each 12-month period preceding the annual fracture assessment; and (3) decreases in lumbar spine bone mineral density Z-scores in the first 6 months of glucocorticoid therapy. As such, we observed that a clinically significant number of children with rheumatic disorders developed incident vertebral fractures in the 3 years following glucocorticoid initiation. Almost one-half of the children were asymptomatic and thereby would have been undiagnosed in the absence of radiographic monitoring. In addition, discrete clinical predictors of incident vertebral fractures were evident early in the course of glucocorticoid therapy.
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Affiliation(s)
| | - Jinhui Ma
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Johannes Roth
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Adam M Huber
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | | | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Stein
- Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | | | - Kiem Oen
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Roman Jurencak
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Robert Couch
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Nathalie Alos
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, and Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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Cummings EA, Ma J, Fernandez CV, Halton J, Alos N, Miettunen PM, Jaremko JL, Ho J, Shenouda N, Matzinger MA, Lentle B, Stephure D, Stein R, Sbrocchi AM, Rodd C, Lang B, Israels S, Grant RM, Couch R, Barr R, Hay J, Rauch F, Siminoski K, Ward LM. Incident Vertebral Fractures in Children With Leukemia During the Four Years Following Diagnosis. J Clin Endocrinol Metab 2015; 100:3408-17. [PMID: 26171800 PMCID: PMC4909472 DOI: 10.1210/jc.2015-2176] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [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] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The purpose of this article was to determine the incidence and predictors of vertebral fractures (VF) during the 4 years after diagnosis in pediatric acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS Children were enrolled within 30 days of chemotherapy initiation, with incident VF assessed annually on lateral spine radiographs according to the Genant method. Extended Cox models were used to assess the association between incident VF and clinical predictors. RESULTS A total of 186 children with ALL completed the baseline evaluation (median age, 5.3 years; interquartile range, 3.4-9.7 years; 58% boys). The VF incidence rate was 8.7 per 100 person-years, with a 4-year cumulative incidence of 26.4%. The highest annual incidence occurred at 12 months (16.1%; 95% confidence interval [CI], 11.2-22.7), falling to 2.9% at 4 years (95% CI, 1.1-7.3). Half of the children with incident VF had a moderate or severe VF, and 39% of those with incident VF were asymptomatic. Every 10 mg/m(2) increase in average daily glucocorticoid dose (prednisone equivalents) was associated with a 5.9-fold increased VF risk (95% CI, 3.0-11.8; P < .01). Other predictors of increased VF risk included VF at diagnosis, younger age, and lower spine bone mineral density Z-scores at baseline and each annual assessment. CONCLUSIONS One quarter of children with ALL developed incident VF in the 4 years after diagnosis; most of the VF burden was in the first year. Over one third of children with incident VF were asymptomatic. Discrete clinical predictors of a VF were evident early in the patient's clinical course, including a VF at diagnosis.
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Affiliation(s)
- Elizabeth A Cummings
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Jinhui Ma
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Conrad V Fernandez
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Jacqueline Halton
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Nathalie Alos
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Paivi M Miettunen
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Jacob L Jaremko
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Josephine Ho
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Nazih Shenouda
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Mary Ann Matzinger
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Brian Lentle
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - David Stephure
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Robert Stein
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Ann Marie Sbrocchi
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Celia Rodd
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Bianca Lang
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Sara Israels
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Ronald M Grant
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Robert Couch
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Ronald Barr
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - John Hay
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Frank Rauch
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Kerry Siminoski
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
| | - Leanne M Ward
- Dalhousie University (E.A.C., C.V.F., B.La.), Halifax, Nova Scotia B3H 4R2, Canada; University of Ottawa (H.M., J.Ha., N.S., M.A.M., L.M.W.), Ottawa, Ontario K1N 6N5, Canada; Université de Montréal (N.A.), Montreal, Quebec H3T 1J4, Canada; University of Calgary (P.M.M., J.Ho., D.S.), Calgary, Alberta T2N 1N4, Canada; University of Alberta (J.L.J., R.C., K.S.), Edmonton, Alberta T6G 2R3, Canada; University of British Columbia (B.Le.), Vancouver, British Columbia V6T 1Z4, Canada; University of Western Ontario (R.S.), London, Ontario N6A 3K7, Canada; McGill University (A.M.S., F.R.), Montréal, Quebec H3A 0G4, Canada; University of Manitoba (C.R., S.I.), Winnipeg, Manitoba R3T 2N2, Canada; University of Toronto (R.M.G.), Toronto, Ontario M5S 2J7, Canada; McMaster University (R.B.), Hamilton, Ontario L8S 4L8, Canada; and Brock University (J.H.), St. Catharines, Ontario L2S 3A1, Canada
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Naylor KL, Garg AX, Zou G, Langsetmo L, Leslie WD, Fraser LA, Adachi JD, Morin S, Goltzman D, Lentle B, Jackson SA, Josse RG, Jamal SA. Comparison of fracture risk prediction among individuals with reduced and normal kidney function. Clin J Am Soc Nephrol 2015; 10:646-53. [PMID: 25655423 PMCID: PMC4386249 DOI: 10.2215/cjn.06040614] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 01/05/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The Fracture Risk Assessment Tool (FRAX) is widely used to predict the 10-year probability of fracture; however, the clinical utility of FRAX in CKD is unknown. This study assessed the predictive ability of FRAX in individuals with reduced kidney function compared with individuals with normal kidney function. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The discrimination and calibration (defined as the agreement between observed and predicted values) of FRAX were examined using data from the Canadian Multicentre Osteoporosis Study (CaMos). This study included individuals aged ≥40 years with an eGFR value at year 10 of CaMos (defined as baseline). The cohort was stratified by kidney function at baseline (eGFR<60 ml/min per 1.73 m(2) [72.2% stage 3a, 23.8% stage 3b, and 4.0% stage 4/5] versus ≥60 ml/min per 1.73 m(2)) and followed individuals for a mean of 4.8 years for an incident major osteoporotic fracture (clinical spine, hip, forearm/wrist, or humerus). RESULTS There were 320 individuals with an eGFR<60 ml/min per 1.73 m(2) and 1787 with an eGFR≥60 ml/min per 1.73 m(2). The mean age was 67±10 years and 71% were women. The 5-year observed major osteoporotic fracture risk was 5.3% (95% confidence interval [95% CI], 3.3% to 8.6%) in individuals with an eGFR<60 ml/min per 1.73 m(2), which was comparable to the FRAX-predicted fracture risk (6.4% with bone mineral density; 8.2% without bone mineral density). A statistically significant difference was not observed in the area under the curve values for FRAX in individuals with an eGFR<60 ml/min per 1.73 m(2) versus ≥60 ml/min per 1.73 m(2) (0.69 [95% CI, 0.54 to 0.83] versus 0.76 [95% CI, 0.70 to 0.82]; P=0.38). CONCLUSIONS This study showed that FRAX was able to predict major osteoporotic fractures in individuals with reduced kidney function; further study is needed before FRAX should be routinely used in individuals with reduced kidney function.
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Affiliation(s)
- Kyla L Naylor
- Division of Nephrology, Departments of Epidemiology and Biostatistics and
| | - Amit X Garg
- Division of Nephrology, Departments of Epidemiology and Biostatistics and Institute for Clinical Evaluative Sciences, Ontario, Canada
| | | | | | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Jonathan D Adachi
- Division of Rheumatology, McMaster University, Hamilton, Ontario, Canada
| | - Suzanne Morin
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - David Goltzman
- Bone and Calcium Research Laboratories, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart A Jackson
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Robert G Josse
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Sophie A Jamal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Women's College Hospital and Women's College Research Institute, Toronto, Ontario, Canada
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23
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Ma J, Siminoski K, Alos N, Halton J, Ho J, Lentle B, Matzinger M, Shenouda N, Atkinson S, Barr R, Cabral DA, Couch R, Cummings EA, Fernandez CV, Grant RM, Rodd C, Sbrocchi AM, Scharke M, Rauch F, Ward LM. The choice of normative pediatric reference database changes spine bone mineral density Z-scores but not the relationship between bone mineral density and prevalent vertebral fractures. J Clin Endocrinol Metab 2015; 100:1018-27. [PMID: 25494661 PMCID: PMC4519277 DOI: 10.1210/jc.2014-3096] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [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] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Our objectives were to assess the magnitude of the disparity in lumbar spine bone mineral density (LSBMD) Z-scores generated by different reference databases and to evaluate whether the relationship between LSBMD Z-scores and vertebral fractures (VF) varies by choice of database. PATIENTS AND DESIGN Children with leukemia underwent LSBMD by cross-calibrated dual-energy x-ray absorptiometry, with Z-scores generated according to Hologic and Lunar databases. VF were assessed by the Genant method on spine radiographs. Logistic regression was used to assess the association between fractures and LSBMD Z-scores. Net reclassification improvement and area under the receiver operating characteristic curve were calculated to assess the predictive accuracy of LSBMD Z-scores for VF. RESULTS For the 186 children from 0 to 18 years of age, 6 different age ranges were studied. The Z-scores generated for the 0 to 18 group were highly correlated (r ≥ 0.90), but the proportion of children with LSBMD Z-scores ≤-2.0 among those with VF varied substantially (from 38-66%). Odds ratios (OR) for the association between LSBMD Z-score and VF were similar regardless of database (OR = 1.92, 95% confidence interval 1.44, 2.56 to OR = 2.70, 95% confidence interval 1.70, 4.28). Area under the receiver operating characteristic curve and net reclassification improvement ranged from 0.71 to 0.75 and -0.15 to 0.07, respectively. CONCLUSIONS Although the use of a LSBMD Z-score threshold as part of the definition of osteoporosis in a child with VF does not appear valid, the study of relationships between BMD and VF is valid regardless of the BMD database that is used.
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Affiliation(s)
- Jinhui Ma
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Maya Scharke
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON
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24
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Palomo T, Al-Jallad H, Moffatt P, Glorieux FH, Lentle B, Roschger P, Klaushofer K, Rauch F. Skeletal characteristics associated with homozygous and heterozygous WNT1 mutations. Bone 2014; 67:63-70. [PMID: 25010833 DOI: 10.1016/j.bone.2014.06.041] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 02/05/2023]
Abstract
Recent reports have shown that homozygous or compound heterozygous mutations in WNT1 can give rise to severe bone fragility resembling osteogenesis imperfecta, whereas heterozygous WNT1 mutations have been found in adults with dominant early-onset osteoporosis. Here we assessed the effects of WNT1 mutations in four children with recessive severe bone fragility and in heterozygous family members. In vitro studies using the Topflash luciferase reporter system showed that two WNT1 missense mutations that were observed in these families, p.Cys143Phe and p.Val355Phe, decreased the ability of WNT1 to stimulate WNT signaling by >90%. Analyses of iliac bone samples revealed no major abnormalities in bone mineralization density distribution, an indicator of material bone properties, whereas a shift towards higher bone mineralization density is characteristic of classical osteogenesis imperfecta caused by mutations in COL1A1/COL1A2. Intravenous bisphosphonate treatment of four children with homozygous or compound heterozygous WNT1 mutations was associated with increasing lumbar spine areal bone mineral density z-scores, as measured by dual energy X-ray absorptiometry, but the effect was smaller than what had previously been reported for children with classical osteogenesis imperfecta. Family members with heterozygous WNT1 mutation tended to have low bone mass. Three of these heterozygous individuals had radiographic signs of vertebral fractures. These observations suggest that more effective treatment approaches are needed for children with recessive WNT1-related bone fragility and that a systematic work-up for osteoporosis is warranted for WNT1 mutation carriers in these families.
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Affiliation(s)
- Telma Palomo
- Shriners Hospital for Children and McGill University, Montreal, Quebec, Canada
| | - Hadil Al-Jallad
- Shriners Hospital for Children and McGill University, Montreal, Quebec, Canada
| | - Pierre Moffatt
- Shriners Hospital for Children and McGill University, Montreal, Quebec, Canada
| | - Francis H Glorieux
- Shriners Hospital for Children and McGill University, Montreal, Quebec, Canada
| | - Brian Lentle
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Roschger
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Center Meidling, 1st Med. Dept., Hanusch Hospital, Vienna, Austria
| | - Klaus Klaushofer
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK, AUVA Trauma Center Meidling, 1st Med. Dept., Hanusch Hospital, Vienna, Austria
| | - Frank Rauch
- Shriners Hospital for Children and McGill University, Montreal, Quebec, Canada.
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25
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Khan A, Cheung A, Khan O, Rahman Z, Pritzker K, Lentle B. Atypical Femoral Fractures: Radiographic and Histomorphometric Features in 19 Patients. J Clin Densitom 2014. [DOI: 10.1016/j.jocd.2014.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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LeBlanc CMA, Ma J, Scuccimarri R, Cabral DA, Dent PB, Ellsworth JE, Houghton K, Huber AM, Jurencak R, Lang BA, Larche M, Lentle B, Matzinger MA, Miettunen PM, Oen K, Roth J, Saint-Cyr C, Shenouda N, Taljaard M, Ward LM. A154: Glucocorticoid Therapy and the Risk of Incident Vertebral Fracture in Children with Rheumatic Disorders. Arthritis Rheumatol 2014. [DOI: 10.1002/art.38580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Kiem Oen
- University of Manitoba; Winnipeg MB
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27
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Leslie WD, Langsetmo L, Zhou W, Goltzman D, Kovacs CS, Prior J, Josse R, Olszynski WP, Davison KS, Anastassiades T, Towheed T, Hanley DA, Kaiser SM, Lentle B, Kreiger N. Choice of lumbar spine bone density reference database for fracture prediction in men and women: a population-based analysis. J Clin Densitom 2014; 17:295-300. [PMID: 24613388 PMCID: PMC5094882 DOI: 10.1016/j.jocd.2013.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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: 07/12/2013] [Accepted: 09/05/2013] [Indexed: 10/25/2022]
Abstract
The diagnosis of osteoporosis in men is controversial, although most studies demonstrate similar fracture rates for men and women with the same level of hip bone mineral density (BMD). Whether this applies to the lumbar spine is currently uncertain and has important implications with respect to choice of reference population for T-score calculation and osteoporosis diagnosis. This question was specifically addressed in the population-based Canadian Multicentre Osteoporosis Study cohort of 4745 women and 1887 men ages 50+ yr at the time of baseline lumbar spine dual energy x-ray absorptiometry. In up to 10 yr of observation, incident clinical major osteoporotic fractures occurred in 110 men (5.8%) vs 543 women (11.4%) (p < 0.001). Mean lumbar spine BMD in men was greater than in women, both among those with and those without incident major osteoporotic fracture (p < 0.001). Men were at slightly lower risk for incident major osteoporotic fracture than women for an equivalent lumbar spine BMD (age- and BMD-adjusted rate ratio 0.75, 95% confidence interval 0.60-0.93, p = 0.008) with similar findings after adjustment for the World Health Organization fracture risk assessment clinical risk factors or competing mortality. No significant sex difference in the BMD relationship was seen for vertebral fractures (clinical or radiographic) or for all fractures. In summary, this large population-based longitudinal cohort study found similar or lower fracture risk for men vs women after adjustment for absolute lumbar spine BMD and additional covariates. The least complicated model for describing fracture risk is therefore to use the same reference lumbar spine data for generating T-scores in men and women.
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Affiliation(s)
- William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Lisa Langsetmo
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Wei Zhou
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - David Goltzman
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Jerilynn Prior
- Department of Medicine, University British Columbia, Vancouver, BC, Canada
| | - Robert Josse
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - K Shawn Davison
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Tanveer Towheed
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - David A Hanley
- Departments of Medicine, Oncology, and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Stephanie M Kaiser
- Division of Endocrinology and Metabolism, Dalhousie University, Halifax, NS, Canada
| | - Brian Lentle
- Department of Radiology, University British Columbia, Vancouver, BC, Canada
| | - Nancy Kreiger
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Cancer Care Ontario, Toronto, ON, Canada
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28
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Siminoski K, Lentle B, Matzinger MA, Shenouda N, Ward LM. Observer agreement in pediatric semiquantitative vertebral fracture diagnosis. Pediatr Radiol 2014; 44:457-66. [PMID: 24323185 PMCID: PMC3900460 DOI: 10.1007/s00247-013-2837-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 07/12/2013] [Revised: 10/20/2013] [Accepted: 11/06/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Genant semiquantitative (GSQ) method has been a standard procedure for diagnosis of vertebral fractures in adults but has only recently been shown to be of clinical utility in children. Observer agreement using the GSQ method in this age group has not been described. OBJECTIVE To evaluate observer agreement on vertebral readability and vertebral fracture diagnosis using the GSQ method in pediatric vertebral morphometry. MATERIALS AND METHODS Spine radiographs of 186 children with acute lymphoblastic leukemia were evaluated independently by three radiologists using the same GSQ methodology as in adults. A subset of 100 radiographs was evaluated on two occasions. RESULTS An average of 4.7% of vertebrae were unreadable for the three radiologists. Intraobserver Cohen's kappa (κ) on readability ranged from 0.434 to 0.648 at the vertebral level and from 0.416 to 0.611 at the patient level, while interobserver κ for readability had a range of 0.330 to 0.504 at the vertebral level and 0.295 to 0.467 at the patient level. Intraobserver κ for the presence of vertebral fracture had a range of 0.529 to 0.726 at the vertebral level and was 0.528 to 0.767 at the patient level. Interobserver κ for fracture at the vertebral level ranged from 0.455 to 0.548 and from 0.433 to 0.486 at the patient level. CONCLUSION Most κ values for both intra- and interobserver agreement in applying the GSQ method to pediatric spine radiographs were in the moderate to substantial range, comparable to the performance of the technique in adult studies. The GSQ method should be considered for use in pediatric research and clinical practice.
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Affiliation(s)
- Kerry Siminoski
- Department of Radiology and Diagnostic Imaging and Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, 6628-123 St., Edmonton, Canada, T6H 3T6,
| | - Brian Lentle
- Department of Radiology, BC Children’s Hospital, University of British Columbia 4500 Oak St, Vancouver, British Columbia, Canada V6H 3N1
| | - Mary-Ann Matzinger
- Department of Diagnostic Imaging, Children’s Hospital of Eastern Ontario, University of Ottawa 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1
| | - Nazih Shenouda
- Department of Diagnostic Imaging, Children’s Hospital of Eastern Ontario, University of Ottawa 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1
| | - Leanne M. Ward
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1
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Phan V, Blydt-Hansen T, Feber J, Alos N, Arora S, Atkinson S, Bell L, Clarson C, Couch R, Cummings EA, Filler G, Grant RM, Grimmer J, Hebert D, Lentle B, Ma J, Matzinger M, Midgley J, Pinsk M, Rodd C, Shenouda N, Stein R, Stephure D, Taback S, Williams K, Rauch F, Siminoski K, Ward LM. Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome. Osteoporos Int 2014; 25:627-37. [PMID: 23948876 PMCID: PMC4100956 DOI: 10.1007/s00198-013-2466-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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: 05/01/2013] [Accepted: 07/16/2013] [Indexed: 02/08/2023]
Abstract
UNLABELLED Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point. INTRODUCTION Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome. METHODS VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry. RESULTS Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3-17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2-15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), -0.5 ± 1.1; p = 0.001) and at 3 months (-0.6 ± 1.1; p < 0.001), but not at 6 months (-0.3 ± 1.3; p = 0.066) or 12 months (-0.3 ± 1.2; p = 0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p = 0.003). A subgroup (N = 16; 25 %) had LS BMD Z-scores that were ≤-1.0 at 12 months. In these children, each additional 1,000 mg/m(2) of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, -0.71 to -0.07; p = 0.017). CONCLUSIONS The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤-1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.
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Affiliation(s)
- V Phan
- Université de Montréal, Montréal, QC, Canada
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Langsetmo L, Berger C, Kreiger N, Kovacs CS, Hanley DA, Jamal SA, Whiting SJ, Genest J, Morin SN, Hodsman A, Prior JC, Lentle B, Patel MS, Brown JP, Anastasiades T, Towheed T, Josse RG, Papaioannou A, Adachi JD, Leslie WD, Davison KS, Goltzman D. Calcium and vitamin D intake and mortality: results from the Canadian Multicentre Osteoporosis Study (CaMos). J Clin Endocrinol Metab 2013; 98:3010-8. [PMID: 23703722 PMCID: PMC5096927 DOI: 10.1210/jc.2013-1516] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
CONTEXT Calcium and vitamin D are recommended for bone health, but there are concerns about adverse risks. Some clinical studies suggest that calcium intake may be cardioprotective, whereas others report increased risk associated with calcium supplements. Both low and high serum levels of 25-hydroxyvitamin D have been associated with increased mortality. OBJECTIVE The purpose of this study was to determine the association between total calcium and vitamin D intake and mortality and heterogeneity by source of intake. DESIGN The Canadian Multicentre Osteoporosis Study cohort is a population-based longitudinal cohort with a 10-year follow-up (1995-2007). SETTING This study included randomly selected community-dwelling men and women. PARTICIPANTS A total of 9033 participants with nonmissing calcium and vitamin D intake data and follow-up were studied. EXPOSURE Total calcium intake (dairy, nondairy food, and supplements) and total vitamin D intake (milk, yogurt, and supplements) were recorded. OUTCOME The outcome variable was all-cause mortality. RESULTS There were 1160 deaths during the 10-year period. For women only, we found a possible benefit of higher total calcium intake, with a hazard ratio of 0.95 (95% confidence interval, 0.89-1.01) per 500-mg increase in daily calcium intake and no evidence of heterogeneity by source; use of calcium supplements was also associated with reduced mortality, with hazard ratio of 0.78 (95% confidence interval, 0.66-0.92) for users vs nonusers with statistically significant reductions remaining among those with doses up to 1000 mg/d. These associations were not modified by levels of concurrent vitamin D intake. No definitive associations were found among men. CONCLUSIONS Calcium supplements, up to 1000 mg/d, and increased dietary intake of calcium may be associated with reduced risk of mortality in women. We found no evidence of mortality benefit or harm associated with vitamin D intake.
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Zhang C, Gordon PB, Sutton R, Lentle B. Proximal femoral changes related to bisphosphonate use and looser zones in hypophosphatemic osteomalacia: dual-energy X-ray absorptiometry findings. J Clin Densitom 2013; 16:380-383. [PMID: 23473957 DOI: 10.1016/j.jocd.2013.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 01/31/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Charlie Zhang
- Osteoporosis Program, British Columbia Women's Hospital & Health Center, Vancouver, British Columbia, Canada.
| | - Paula B Gordon
- Osteoporosis Program, British Columbia Women's Hospital & Health Center, Vancouver, British Columbia, Canada
| | - Roger Sutton
- Osteoporosis Program, British Columbia Women's Hospital & Health Center, Vancouver, British Columbia, Canada
| | - Brian Lentle
- Osteoporosis Program, British Columbia Women's Hospital & Health Center, Vancouver, British Columbia, Canada
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Siminoski K, Lee KC, Jen H, Warshawski R, Matzinger MA, Shenouda N, Charron M, Coblentz C, Dubois J, Kloiber R, Nadel H, O'Brien K, Reed M, Sparrow K, Webber C, Lentle B, Ward LM. Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines. Osteoporos Int 2012; 23:1999-2008. [PMID: 22109742 PMCID: PMC4067402 DOI: 10.1007/s00198-011-1837-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [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: 06/25/2011] [Accepted: 08/19/2011] [Indexed: 11/25/2022]
Abstract
SUMMARY We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine. INTRODUCTION We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults. METHODS We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N = 221; 545 fractures) and in children early in the course of glucocorticoid therapy (N = 44; 94 fractures). RESULTS The average age in the adult cohort was 62.9 years (standard deviation (SD), 13.4 years), 26% was male, the mean lumbar spine Z-score was -1.0 (SD, 1.5), and the corresponding T-score was -2.4 (SD, 1.4). The pediatric cohort median age was 7.7 years (range, 2.1-16.6 years), the mean lumbar spine Z-score was -1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10 years. CONCLUSIONS These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.
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Affiliation(s)
- K Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, 6628-123 Street, Edmonton, AB, Canada, T6H 3T6.
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Lang BA, Rodd C, Ramsay T, Cabral DA, Dent PB, Ellsworth JE, Houghton KM, Huber A, Jurencak R, Larché M, LeBlanc CMA, Lentle B, Matzinger M, Miettunen PM, Oen K, Roth J, Saint-Cyr C, Scuccimarri R, Shenouda N, Ward LM. Incident vertebral fractures 12 months following glucocorticoid initiation in children with rheumatic disorders. Pediatr Rheumatol Online J 2012. [PMCID: PMC3403113 DOI: 10.1186/1546-0096-10-s1-a75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Alos N, Grant RM, Ramsay T, Halton J, Cummings EA, Miettunen PM, Abish S, Atkinson S, Barr R, Cabral DA, Cairney E, Couch R, Dix DB, Fernandez CV, Hay J, Israels S, Laverdière C, Lentle B, Lewis V, Matzinger M, Rodd C, Shenouda N, Stein R, Stephure D, Taback S, Wilson B, Williams K, Rauch F, Siminoski K, Ward LM. High incidence of vertebral fractures in children with acute lymphoblastic leukemia 12 months after the initiation of therapy. J Clin Oncol 2012; 30:2760-7. [PMID: 22734031 DOI: 10.1200/jco.2011.40.4830] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (ALL). To date, the incidence of vertebral fractures during ALL treatment has not been reported. PATIENT AND METHODS We prospectively evaluated 155 children with ALL during the first 12 months of leukemia therapy. Lateral thoracolumbar spine radiographs were obtained at baseline and 12 months. Vertebral bodies were assessed for incident vertebral fractures using the Genant semiquantitative method, and relevant clinical indices such as spine bone mineral density (BMD), back pain, and the presence of vertebral fractures at baseline were analyzed for association with incident vertebral fractures. RESULTS Of the 155 children, 25 (16%; 95% CI, 11% to 23%) had a total of 61 incident vertebral fractures, of which 32 (52%) were moderate or severe. Thirteen (52%) of the 25 children with incident vertebral fractures also had fractures at baseline. Vertebral fractures at baseline increased the odds of an incident fracture at 12 months by an odds ratio of 7.3 (95% CI, 2.3 to 23.1; P = .001). In addition, for every one standard deviation reduction in spine BMD Z-score at baseline, there was 1.8-fold increased odds of incident vertebral fracture at 12 months (95% CI, 1.2 to 2.7; P = .006). CONCLUSION Children with ALL have a high incidence of vertebral fractures after 12 months of chemotherapy, and the presence of vertebral fractures and reductions in spine BMD Z-scores at baseline are highly associated clinical features.
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Lentle B, Cheung AM, Hanley DA, Leslie WD, Lyons D, Papaioannou A, Atkinson S, Brown JP, Feldman S, Hodsman AB, Jamal AS, Josse RG, Kaiser SM, Kvern B, Morin S, Siminoski K. Osteoporosis Canada 2010 guidelines for the assessment of fracture risk. Can Assoc Radiol J 2012; 62:243-50. [PMID: 21852066 DOI: 10.1016/j.carj.2011.05.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 05/04/2011] [Indexed: 10/17/2022] Open
Abstract
Osteoporosis Canada's 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada focus on the clinical impact of fragility fractures, and on the assessment and management of women and men at high risk for fragility fracture. These guidelines now integrate a 10-year absolute fracture risk prediction into an overall management approach by using validated risk assessment tools. There currently is a large gap between optimal practices and those that are now being provided to Canadians with osteoporosis. These guidelines are part of a concerted effort to close this gap. Key changes from the 2002 guidelines of interest and relevance to radiologists are highlighted in this report.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
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Rodd C, Lang B, Ramsay T, Alos N, Huber AM, Cabral DA, Scuccimarri R, Miettunen PM, Roth J, Atkinson SA, Couch R, Cummings EA, Dent PB, Ellsworth J, Hay J, Houghton K, Jurencak R, Larché M, LeBlanc C, Oen K, Saint-Cyr C, Stein R, Stephure D, Taback S, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Incident vertebral fractures among children with rheumatic disorders 12 months after glucocorticoid initiation: a national observational study. Arthritis Care Res (Hoboken) 2012; 64:122-31. [PMID: 22213727 DOI: 10.1002/acr.20589] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. METHODS Children with rheumatic diseases initiating GC were enrolled in a prospective observational study. Annual spine radiographs were evaluated using the Genant semiquantitative method. Spine areal bone mineral density (aBMD) was measured every 6 months. Clinical features, including cumulative GC dose, back pain, disease and physical activity, calcium and vitamin D intake, and spine aBMD Z scores, were analyzed for association with IVF. RESULTS Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than -2.0 at 12 months compared to 16% of children without IVF (P = 0.011). CONCLUSION The incidence of VF 12 months following GC initiation was 6%; most children were asymptomatic. Children with IVF received more GC, had greater increases in BMI, and had greater declines in spine aBMD Z scores in the first 6 months.
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Affiliation(s)
- Celia Rodd
- McGill University, Montreal, Quebec, Canada
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37
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Feber J, Gaboury I, Ni A, Alos N, Arora S, Bell L, Blydt-Hansen T, Clarson C, Filler G, Hay J, Hebert D, Lentle B, Matzinger M, Midgley J, Moher D, Pinsk M, Rauch F, Rodd C, Shenouda N, Siminoski K, Ward LM. Skeletal findings in children recently initiating glucocorticoids for the treatment of nephrotic syndrome. Osteoporos Int 2012; 23:751-60. [PMID: 21494860 PMCID: PMC4000256 DOI: 10.1007/s00198-011-1621-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [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: 10/19/2010] [Accepted: 03/02/2011] [Indexed: 01/27/2023]
Abstract
SUMMARY Eighty children with nephrotic syndrome underwent lumbar spine densitometry and vertebral morphometry soon after glucocorticoid initiation. We found an inverse relationship between glucocorticoid exposure and spine areal bone mineral density (BMD) Z-score and a low rate of vertebral deformities (8%). INTRODUCTION Vertebral fractures are an under-recognized complication of childhood glucocorticoid-treated illnesses. Our goal was to study the relationships among glucocorticoid exposure, lumbar spine areal BMD (LS BMD), and vertebral shape in glucocorticoid-treated children with new-onset nephrotic syndrome. METHODS Lateral thoracolumbar spine radiography and LS BMD were performed in 80 children with nephrotic syndrome (median age 4.4 years; 46 boys) within the first 37 days of glucocorticoid therapy. Genant semiquantitative grading was used as the primary method for vertebral morphometry; the algorithm-based qualitative (ABQ) method was used for secondary vertebral deformity analysis. RESULTS Six of the 78 children with usable radiographs (8%; 95% confidence interval 4 to 16%) manifested a single Genant grade 1 deformity each. All deformities were mild anterior wedging (two at each of T6, T7, and T8). Four of the 78 children (5%; 95% confidence interval 2 to 13%) showed one ABQ sign of fracture each (loss of endplate parallelism; two children at T6 and two at T8). Two of the children with ABQ signs also had a Genant grade 1 deformity in the same vertebral body. None of the children with a Genant or ABQ deformity reported back pain. An inverse relationship was identified between LS BMD Z-score and glucocorticoid exposure. CONCLUSIONS Although we identified an inverse relationship between steroid exposure and LS BMD soon after glucocorticoid initiation for childhood nephrotic syndrome, there was only a low rate of vertebral deformities. The clinical significance of these findings requires further study.
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Affiliation(s)
- J Feber
- University of Ottawa, Ottawa, ON, Canada
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38
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Huber AM, Gaboury I, Cabral DA, Lang B, Ni A, Stephure D, Taback S, Dent P, Ellsworth J, LeBlanc C, Saint-Cyr C, Scuccimarri R, Hay J, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders. Arthritis Care Res (Hoboken) 2010; 62:516-26. [PMID: 20391507 DOI: 10.1002/acr.20171] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Vertebral fractures are an under-recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy. METHODS Children were categorized as follows: juvenile dermatomyositis (n = 30), juvenile idiopathic arthritis (n = 28), systemic lupus erythematosus and related conditions (n = 26), systemic arthritis (n = 22), systemic vasculitis (n = 16), and other conditions (n = 12). Thoracolumbar spine radiograph and dual x-ray absorptiometry for lumbar spine (L-spine) areal bone mineral density (BMD) were performed within 30 days of glucocorticoid initiation. Genant semiquantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative glucocorticoid dose, underlying diagnosis, L-spine BMD Z score, and back pain were analyzed for association with vertebral fracture. RESULTS Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2-3 fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean +/- SD L-spine BMD Z score was significantly different from zero (-0.55 +/- 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 +/- 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1-53.8], P = 0.004). CONCLUSION In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged glucocorticoid exposure.
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Affiliation(s)
- A M Huber
- Dalhousie University, Halifax, Nova Scotia, Canada
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39
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Khan AA, Colquhoun A, Hanley DA, Jankowski LG, Josse RG, Kendler DL, Lentle B, Leslie WD, Lewiecki EM, O'neill E, Robertson S, Syed ZA, Tanner SB, Webster D. Standards and guidelines for technologists performing central dual-energy X-ray absorptiometry. J Clin Densitom 2007; 10:189-95. [PMID: 17485038 DOI: 10.1016/j.jocd.2007.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 01/10/2007] [Accepted: 01/12/2007] [Indexed: 11/25/2022]
Affiliation(s)
- Aliya A Khan
- Division of Endocrinology, McMaster University, Hamilton, Ontario, Canada.
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40
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Lentle B, Worsley D. Osteoporosis redux. J Nucl Med 2006; 47:1945-59. [PMID: 17138737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Affiliation(s)
- Brian Lentle
- Division of Nuclear Medicine, Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada.
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41
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Leslie WD, Lentle B. Race/ethnicity and fracture risk assessment: an issue that is more than skin deep. J Clin Densitom 2006; 9:406-12. [PMID: 17097525 DOI: 10.1016/j.jocd.2006.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 07/08/2006] [Accepted: 07/14/2006] [Indexed: 11/16/2022]
Abstract
The study of race/ethnicity in relation to health outcomes and health disparities is of great importance in medicine. This is as true in the field of osteoporosis as it is in others, and it comes into sharp focus when the question of population-specific reference data for bone densitometry arises. Race/ethnicity can be viewed as both an ecosocial construct and as a biomedical concept. Whether or not, and how, to use race/ethnicity in fracture assessment potentially places these two paradigms in opposition. In this article, some of the issues that need to be considered to develop a rational approach to reference data selection and a globally acceptable measure of fracture risk are reviewed. Race/ethnicity is often a proxy for other disease-related risk factors. Understanding fundamental risk factors goes beyond the language of race/ethnicity.
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Affiliation(s)
- William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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42
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Liu-Ambrose TYL, Khan KM, Eng JJ, Lord SR, Lentle B, McKay HA. Both resistance and agility training reduce back pain and improve health-related quality of life in older women with low bone mass. Osteoporos Int 2005; 16:1321-9. [PMID: 15702262 DOI: 10.1007/s00198-005-1842-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2004] [Accepted: 12/16/2004] [Indexed: 10/25/2022]
Abstract
The purpose of the study was to compare the effects of three different types of group-based exercise programs (resistance training, agility training and general stretching) on back pain and health-related quality of life in older (aged 75-85 years) community-dwelling women with low bone mass (i.e., osteopenia or osteoporosis). The design was a 25-week randomized controlled trial. Participating were 98 community-dwelling women with low bone mass between the ages of 75 to 85 years old. We assessed back pain and its related disability and health-related quality of life. All three types of group-based exercise programs significantly reduced back pain and its related disabilities, but only resistance and agility training significantly improved health-related quality of life in community-dwelling older women with low bone mass. Baseline physical activity level and class attendance were significant predictors of change in health-related quality of life. Change in back pain and its related disabilities after 25 weeks of exercise intervention was significantly correlated with change in health-related quality of life and changes in the domains of pain and physical function. Resistance and agility training significantly enhanced health-related quality of life and may have done so by increasing social interactions and support, enhancing self-efficacy of physical abilities and modifying the experience of back pain. These data provide valuable insight into the specifics of exercise prescription for older women with low bone mass. Future studies may wish to use individualized quality of life measures to further delineate the effects of different types of exercise on quality of life in older adults with low bone mass.
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Affiliation(s)
- Teresa Y L Liu-Ambrose
- UBC Bone Health Research Group, BC Women's Hospital and Health Centre, Osteoporosis Program, University of British Columbia, Vancouver, BC, Canada
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43
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Khan AA, Brown J, Faulkner K, Kendler D, Lentle B, Leslie W, Miller PD, Nicholson L, Olszynski WP, Watts NB, Hanley D, Hodsman A, Josse R, Murray TM, Yuen K. Standards and guidelines for performing central dual X-ray densitometry from the Canadian panel of International Society for Clinical Densitometry. J Clin Densitom 2002; 5:247-57. [PMID: 12357062 DOI: 10.1385/jcd:5:3:247] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2002] [Accepted: 03/04/2002] [Indexed: 11/11/2022]
Abstract
The International Society for Clinical Densitometry (ISCD) is a multidisciplinary nonprofit global organization formed to ensure excellence in densitometry imaging, interpretation, and application. The Canadian panel of the ISCD represents ISCD in Canada and oversees Canadian bone densitometry certification programs. The standards of care from the Canadian panel of the ISCD have been developed in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. A variety of techniques are available for skeletal assessment of bone mineral density, which vary in accuracy, precision, and clinical utility as well as availability. This article focuses on central dual X-ray absorptiometry in adults and does not address densitometry in the pediatric population. Other technologies will be addressed in a subsequent article.
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Affiliation(s)
- A A Khan
- McMaster University, Oakville, Ontario, Canada
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44
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Khan AA, Brown J, Faulkner K, Kendler D, Lentle B, Leslie W, Miller PD, Nicholson L, Olszynski WP, Watts NB. Standards and guidelines for performing central dual X-ray densitometry from the Canadian Panel of International Society for Clinical Densitometry. J Clin Densitom 2002; 5:435-45. [PMID: 12665644 DOI: 10.1385/jcd:5:4:435] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2002] [Accepted: 03/04/2002] [Indexed: 11/11/2022]
Abstract
The International Society for Clinical Densitometry (ISCD) is a multidisciplinary nonprofit global organization formed to ensure excellence in densitometry imaging, interpretation, and application. The Canadian panel of the ISCD represents ISCD in Canada and oversees Canadian bone densitometry certification programs. The standards of care from the Canadian panel of the ISCD have been developed in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. A variety of techniques are available for skeletal assessment of bone mineral density, which vary in accuracy, precision, and clinical utility as well as availability. This article focuses on central dual X-ray absorptiometry in adults and does not address densitometry in the pediatric population. Other technologies will be addressed in a subsequent article.
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Affiliation(s)
- A A Khan
- McMaster University, Oakville, Ontario, Canada
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45
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Harriman M, Morrison M, Hay J, Revonta M, Eisen A, Lentle B. Use of radiotherapy for control of sialorrhea in patients with amyotrophic lateral sclerosis. J Otolaryngol 2001; 30:242-5. [PMID: 11771037 DOI: 10.2310/7070.2001.19779] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Many patients with amyotrophic lateral sclerosis (ALS) develop progressive difficulty with swallowing secretions, and drooling becomes a significant problem. The production of saliva can be reduced with radiation of the submandibular and sublingual salivary gland tissue. This method has been used successfully in Europe and had limited use at Vancouver Hospital. This study was undertaken to determine the lowest effective dose of radiation necessary to control salivary production. Over a 3-year period, patients with ALS who developed significant problems with drooling were identified and treated with a predetermined dose of radiation. The first group received a single dose of 8 Gy in one fraction and the second received a total of 12.5 Gy in two fractions. They were followed over the next 6 months and were evaluated for effectiveness and side effects. Their saliva was measured pre- and postradiation treatment, and they were also asked to evaluate the change subjectively, using a questionnaire. The preliminary findings suggest that 8 Gy of radiation was effective in controlling drooling, and increasing the dose did not improve initial control. Long-term control was difficult to evaluate as the patients entered in the study were very ill and their life expectancy was very short. Radiation at this low dose resulted in very few side effects. Low-dose radiation can safely help control secretions in selected patients with ALS.
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Affiliation(s)
- M Harriman
- Division of Otolaryngology, University of British Columbia, Vancouver
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Brown JP, Olszynski WP, Hodsman A, Bensen WG, Tenenhouse A, Anastassiades TP, Ste-Marie LG, Kendler DL, Hanley DA, Josse R, Hanly JG, Lentle B, Jovaisas A, Ioannidis G, Stephenson GF, Barton I, Pack S, Chines A, Dias R, Adachi JD. Positive effect of etidronate therapy is maintained after drug is terminated in patients using corticosteroids. J Clin Densitom 2001; 4:363-71. [PMID: 11748341 DOI: 10.1385/jcd:4:4:363] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2001] [Revised: 05/03/2001] [Accepted: 05/07/2001] [Indexed: 11/11/2022]
Abstract
Following a 52-wk randomized controlled trial of intermittent cyclic etidronate therapy in patients using corticosteroids, we performed a 52-wk open-label trial of calcium alone in 114 corticosteroid-treated patients to determine whether the beneficial effect of etidronate is maintained after the drug is discontinued. All patients were given 500 mg/d of elemental calcium. Sixty-one and 53 patients made up the former placebo and etidronate groups, respectively. A total of 89 (98%) of patients in the former placebo and etidronate groups remained on corticosteroids throughout the second year. The mean (SE) percentage change in bone mineral density of the lumbar spine, femoral neck, and trochanter were compared between groups. The difference between groups in mean percentage change from baseline (wk 0, initiation of etidronate or placebo therapy) in the bone density of the lumbar spine, femoral neck, and trochanter, following 104 wk, was 3.8 (0.9), 3.0 (1.1), and 4.3 (1.1), respectively (p < 0.05, all sites), in favor of the former etidronate group. While not significant, the former placebo group demonstrated a slightly larger rate of decline in bone density over the second year than the former etidronate group at all three sites. Following the discontinuation of etidronate therapy, there was no accelerated bone loss and there was evidence of a residual protective effect in both the lumbar spine and femoral neck for up to 1 yr posttreatment.
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Affiliation(s)
- J P Brown
- Centre de Recherche du CHUL, Centre Hospitalier Universitaire de Quebec, 2705 boul Laurier #S-784, Ste-Foy, Québec, G1V 4G2 Canada.
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Affiliation(s)
- T McLoud
- Radiological Society of North America, Oak Brook, IL 60523, USA
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Lentle B. X-rays and technology as metaphor. CMAJ 2000; 162:512-4. [PMID: 10701386 PMCID: PMC1231170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- B Lentle
- Department of Radiology, University of British Columbia, Vancouver.
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Lentle B. The magnetic resonance imperative. Can Assoc Radiol J 1999; 50:79-82. [PMID: 10226628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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Adachi JD, Bensen WG, Brown J, Hanley D, Hodsman A, Josse R, Kendler DL, Lentle B, Olszynski W, Ste-Marie LG, Tenenhouse A, Chines AA. Intermittent etidronate therapy to prevent corticosteroid-induced osteoporosis. N Engl J Med 1997; 337:382-7. [PMID: 9241127 DOI: 10.1056/nejm199708073370603] [Citation(s) in RCA: 515] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND METHODS Osteoporosis is a recognized complication of corticosteroid therapy. Whether it can be prevented is not known. We conducted a 12-month, randomized, placebo-controlled study of intermittent etidronate (400 mg per day for 14 days) followed by calcium (500 mg per day for 76 days), given for four cycles, in 141 men and women (age, 19 to 87 years) who had recently begun high-dose corticosteroid therapy. The primary outcome measure was the difference in the change in the bone density of the lumbar spine between the groups from base line to week 52. Secondary measures included changes in the bone density of the femoral neck, trochanter, and radius and the rate of new vertebral fractures. RESULTS The mean (+/-SE) bone density of the lumbar spine and trochanter in the etidronate group increased 0.61 +/- 0.54 and 1.46 +/- 0.67 percent, respectively, as compared with decreases of 3.23 +/- 0.60 and 2.74 +/- 0.66 percent, respectively, in the placebo group. The mean differences between the groups after one year were 3.72 +/- 0.88 percentage points for the lumbar spine (P = 0.02) and 4.14 +/- 0.94 percentage points for the trochanter (P = 0.02). The changes in the femoral neck and the radius were not significantly different between the groups. There was an 85 percent reduction in the proportion of postmenopausal woman with new vertebral fractures in the etidronate group as compared with the placebo group (1 of 31 patients vs. 7 of 32 patients, P = 0.05), and the etidronate-treated postmenopausal women also had significantly fewer vertebral fractures per patient (P = 0.04). CONCLUSIONS Intermittent etidronate therapy prevents the loss of vertebral and trochanteric bone in corticosteroid-treated patients.
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Affiliation(s)
- J D Adachi
- Department of Medicine, St. Joseph's Hospital, McMaster University, Hamilton, ON, Canada
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