The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

and the Canadian Steroid-Induced Osteoporosis in the Pediatric Population (STOPP) Consortium

doi:10.1002/jbmr.3922

The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

and the Canadian Steroid-Induced Osteoporosis in the Pediatric Population (STOPP) Consortium

Medicine

Producción científica: Contribución a una revista › Artículo › revisión exhaustiva

7 Citas (Scopus)

Resumen

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.

Idioma original	English
Páginas (desde-hasta)	460-468
Número de páginas	9
Publicación	Journal of Bone and Mineral Research
Volumen	35
N.º	3
DOI	https://doi.org/10.1002/jbmr.3922
Estado	Published - mar. 1 2020

Nota bibliográfica

Funding Information:
This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers.

Funding Information:
This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers. The Canadian STOPP Consortium (a Pan‐Canadian, Pediatric Bone Health Working Group): Principal Investigator: Leanne M. Ward (Children's Hospital of Eastern Ontario, Ottawa); Alberta Children's Hospital, Calgary: Josephine Ho, Reinhard Kloiber, Victor Lewis, Julian Midgley, Paivi Miettunen, David Stephure; British Columbia Women's Hospital and Health Sciences, Vancouver: Brian C. Lentle; British Columbia Children's Hospital, Vancouver: Tom Blydt‐Hansen, David Cabral, David B. Dix, Kristin Houghton, Helen R. Nadel; Brock University, St. Catharines: John Hay; Children's Hospital of Eastern Ontario, Ottawa: Janusz Feber, Jacqueline Halton, Roman Jurencak, Jinhui Ma, MaryAnn Matzinger, Johannes Roth, Nazih Shenouda, Karen Watanabe‐Duffy; Children's Hospital, London Health Sciences Centre, University of Western Ontario, London: Elizabeth Cairney, Cheril Clarson, Guido Filler, Joanne Grimmer, Scott McKillop, Keith Sparrow, Robert Stein; IWK Health Center, Halifax: Elizabeth Cummings, Conrad Fernandez, Adam M. Huber, Bianca Lang, Kathy O'Brien: McMaster Children's Hospital, Hamilton: Steve Arora, Stephanie Atkinson, Ronald Barr, Craig Coblentz, Peter B. Dent, Maggie Larche; Montreal Children's Hospital, Montreal: Sharon Abish, Lorraine Bell, Claire LeBlanc, Anne Marie Sbrocchi, Rosie Scuccimarri; Ottawa Hospital Research Institute, Ottawa: David Moher, Monica Taljaard; Shriners Hospital for Children, Montreal: Frank Rauch; Ste. Justine Hospital, Montreal: Nathalie Alos, Josee Dubois, Caroline Laverdiere, Veronique Phan, Claire Saint‐Cyr, Julie Barsalou; Stollery Children's Hospital, Edmonton: Robert Couch, Janet Ellsworth, Jacob Jaremko, Kerry Siminoski, Beverly Wilson; Toronto Hospital for Sick Children, Toronto: Ronald Grant, Martin Charron, Diane Hebert; Universite de Sherbrooke, Sherbrooke: Isabelle Gaboury; Winnipeg Children's Hospital, Winnipeg, Manitoba: Shayne Taback, Sara Israels, Kiem Oen, Maury Pinsk, Martin Reed, Celia Rodd. Authors’ roles: Study design: JM, KS, and LMW. Study conduct: JM, KS, and LMW, and the STOPP Consortium. Data collection: LMW and the STOPP Consortium. Data analysis: JM, PW, and KS. Data interpretation: JM, KS, and LMW. Drafting manuscript: JM and KS. Revising manuscript content: LMW, EC, JF, JH, KH, PM, RS, and FR. Approving final version of the manuscript: All authors and the STOPP Consortium. LMW takes responsibility for the integrity of the raw data, and JM takes responsibility for the integrity of the data analysis.

Publisher Copyright:
© 2019 American Society for Bone and Mineral Research

ASJC Scopus Subject Areas

Endocrinology, Diabetes and Metabolism
Orthopedics and Sports Medicine

ODS de las Naciones Unidas

Este resultado contribuye a los siguientes Objetivos de Desarrollo Sostenible

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10.1002/jbmr.3922

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The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches. / and the Canadian Steroid-Induced Osteoporosis in the Pediatric Population (STOPP) Consortium.
En: Journal of Bone and Mineral Research, Vol. 35, N.º 3, 01.03.2020, p. 460-468.

Producción científica: Contribución a una revista › Artículo › revisión exhaustiva

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title = "The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches",

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.",

author = "{and the Canadian Steroid-Induced Osteoporosis in the Pediatric Population (STOPP) Consortium} and Jinhui Ma and Kerry Siminoski and Peiyao Wang and Nathalie Alos and Cummings, {Elizabeth A.} and Janusz Feber and Jacqueline Halton and Josephine Ho and Kristin Houghton and Bianca Lang and Miettunen, {Paivi M.} and Rosie Scuccimarri and Jaremko, {Jacob L.} and Khaldoun Koujok and Brian Lentle and Matzinger, {Mary Ann} and Nazih Shenouda and Frank Rauch and Ward, {Leanne M.}",

note = "Funding Information: This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers. Funding Information: This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers. The Canadian STOPP Consortium (a Pan‐Canadian, Pediatric Bone Health Working Group): Principal Investigator: Leanne M. Ward (Children's Hospital of Eastern Ontario, Ottawa); Alberta Children's Hospital, Calgary: Josephine Ho, Reinhard Kloiber, Victor Lewis, Julian Midgley, Paivi Miettunen, David Stephure; British Columbia Women's Hospital and Health Sciences, Vancouver: Brian C. Lentle; British Columbia Children's Hospital, Vancouver: Tom Blydt‐Hansen, David Cabral, David B. Dix, Kristin Houghton, Helen R. Nadel; Brock University, St. Catharines: John Hay; Children's Hospital of Eastern Ontario, Ottawa: Janusz Feber, Jacqueline Halton, Roman Jurencak, Jinhui Ma, MaryAnn Matzinger, Johannes Roth, Nazih Shenouda, Karen Watanabe‐Duffy; Children's Hospital, London Health Sciences Centre, University of Western Ontario, London: Elizabeth Cairney, Cheril Clarson, Guido Filler, Joanne Grimmer, Scott McKillop, Keith Sparrow, Robert Stein; IWK Health Center, Halifax: Elizabeth Cummings, Conrad Fernandez, Adam M. Huber, Bianca Lang, Kathy O'Brien: McMaster Children's Hospital, Hamilton: Steve Arora, Stephanie Atkinson, Ronald Barr, Craig Coblentz, Peter B. Dent, Maggie Larche; Montreal Children's Hospital, Montreal: Sharon Abish, Lorraine Bell, Claire LeBlanc, Anne Marie Sbrocchi, Rosie Scuccimarri; Ottawa Hospital Research Institute, Ottawa: David Moher, Monica Taljaard; Shriners Hospital for Children, Montreal: Frank Rauch; Ste. Justine Hospital, Montreal: Nathalie Alos, Josee Dubois, Caroline Laverdiere, Veronique Phan, Claire Saint‐Cyr, Julie Barsalou; Stollery Children's Hospital, Edmonton: Robert Couch, Janet Ellsworth, Jacob Jaremko, Kerry Siminoski, Beverly Wilson; Toronto Hospital for Sick Children, Toronto: Ronald Grant, Martin Charron, Diane Hebert; Universite de Sherbrooke, Sherbrooke: Isabelle Gaboury; Winnipeg Children's Hospital, Winnipeg, Manitoba: Shayne Taback, Sara Israels, Kiem Oen, Maury Pinsk, Martin Reed, Celia Rodd. Authors{\textquoteright} roles: Study design: JM, KS, and LMW. Study conduct: JM, KS, and LMW, and the STOPP Consortium. Data collection: LMW and the STOPP Consortium. Data analysis: JM, PW, and KS. Data interpretation: JM, KS, and LMW. Drafting manuscript: JM and KS. Revising manuscript content: LMW, EC, JF, JH, KH, PM, RS, and FR. Approving final version of the manuscript: All authors and the STOPP Consortium. LMW takes responsibility for the integrity of the raw data, and JM takes responsibility for the integrity of the data analysis. Publisher Copyright: {\textcopyright} 2019 American Society for Bone and Mineral Research",

year = "2020",

month = mar,

day = "1",

doi = "10.1002/jbmr.3922",

language = "English",

volume = "35",

pages = "460--468",

journal = "Journal of Bone and Mineral Research",

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TY - JOUR

T1 - The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

AU - and the Canadian Steroid-Induced Osteoporosis in the Pediatric Population (STOPP) Consortium

AU - Ma, Jinhui

AU - Siminoski, Kerry

AU - Wang, Peiyao

AU - Alos, Nathalie

AU - Cummings, Elizabeth A.

AU - Feber, Janusz

AU - Halton, Jacqueline

AU - Ho, Josephine

AU - Houghton, Kristin

AU - Lang, Bianca

AU - Miettunen, Paivi M.

AU - Scuccimarri, Rosie

AU - Jaremko, Jacob L.

AU - Koujok, Khaldoun

AU - Lentle, Brian

AU - Matzinger, Mary Ann

AU - Shenouda, Nazih

AU - Rauch, Frank

AU - Ward, Leanne M.

N1 - Funding Information: This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers. Funding Information: This study was primarily funded by an operating grant from the Canadian Institutes for Health Research (FRN 64285). Additional funding for this work was provided to LMW by a Canadian Institutes for Health Research New Investigator Award, a Canadian Child Health Clinician Scientist Career Enhancement Award, a University of Ottawa Research Chair Award, a CHEO Research Institute Capacity Building Award and the CHEO Departments of Pediatrics and Surgery. This work was also supported by the University of Alberta Women and Children's Health Research Institute. The Canadian STOPP Consortium thanks the children and their families who participated in the study and without whom the STOPP research program would not have been possible. We also thank the research associates at all the study centers. The Canadian STOPP Consortium (a Pan‐Canadian, Pediatric Bone Health Working Group): Principal Investigator: Leanne M. Ward (Children's Hospital of Eastern Ontario, Ottawa); Alberta Children's Hospital, Calgary: Josephine Ho, Reinhard Kloiber, Victor Lewis, Julian Midgley, Paivi Miettunen, David Stephure; British Columbia Women's Hospital and Health Sciences, Vancouver: Brian C. Lentle; British Columbia Children's Hospital, Vancouver: Tom Blydt‐Hansen, David Cabral, David B. Dix, Kristin Houghton, Helen R. Nadel; Brock University, St. Catharines: John Hay; Children's Hospital of Eastern Ontario, Ottawa: Janusz Feber, Jacqueline Halton, Roman Jurencak, Jinhui Ma, MaryAnn Matzinger, Johannes Roth, Nazih Shenouda, Karen Watanabe‐Duffy; Children's Hospital, London Health Sciences Centre, University of Western Ontario, London: Elizabeth Cairney, Cheril Clarson, Guido Filler, Joanne Grimmer, Scott McKillop, Keith Sparrow, Robert Stein; IWK Health Center, Halifax: Elizabeth Cummings, Conrad Fernandez, Adam M. Huber, Bianca Lang, Kathy O'Brien: McMaster Children's Hospital, Hamilton: Steve Arora, Stephanie Atkinson, Ronald Barr, Craig Coblentz, Peter B. Dent, Maggie Larche; Montreal Children's Hospital, Montreal: Sharon Abish, Lorraine Bell, Claire LeBlanc, Anne Marie Sbrocchi, Rosie Scuccimarri; Ottawa Hospital Research Institute, Ottawa: David Moher, Monica Taljaard; Shriners Hospital for Children, Montreal: Frank Rauch; Ste. Justine Hospital, Montreal: Nathalie Alos, Josee Dubois, Caroline Laverdiere, Veronique Phan, Claire Saint‐Cyr, Julie Barsalou; Stollery Children's Hospital, Edmonton: Robert Couch, Janet Ellsworth, Jacob Jaremko, Kerry Siminoski, Beverly Wilson; Toronto Hospital for Sick Children, Toronto: Ronald Grant, Martin Charron, Diane Hebert; Universite de Sherbrooke, Sherbrooke: Isabelle Gaboury; Winnipeg Children's Hospital, Winnipeg, Manitoba: Shayne Taback, Sara Israels, Kiem Oen, Maury Pinsk, Martin Reed, Celia Rodd. Authors’ roles: Study design: JM, KS, and LMW. Study conduct: JM, KS, and LMW, and the STOPP Consortium. Data collection: LMW and the STOPP Consortium. Data analysis: JM, PW, and KS. Data interpretation: JM, KS, and LMW. Drafting manuscript: JM and KS. Revising manuscript content: LMW, EC, JF, JH, KH, PM, RS, and FR. Approving final version of the manuscript: All authors and the STOPP Consortium. LMW takes responsibility for the integrity of the raw data, and JM takes responsibility for the integrity of the data analysis. Publisher Copyright: © 2019 American Society for Bone and Mineral Research

PY - 2020/3/1

Y1 - 2020/3/1

N2 - 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.

AB - 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.

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The Accuracy of Prevalent Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches

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