Technologist's Corner
Comparison of International Reference Values for Bone Speed of Sound in Pediatric Populations: Meta-analysis

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Abstract

The aim of this study was to compare international reference values (RV) for tibial and radial speed of sound (SoS) assessed by quantitative ultrasound (QUS) in pediatric populations. These values were compared by age and country of origin in a systematic review with meta-analysis from studies published on QUS (Sunlight Omnisense). A search was carried out in electronic databases. Nine studies with 6963 patients were included in the meta-analysis. For the newborn populations, 3 studies (from Italy, Portugal, and Israel) were used. These studies included subjects with 27–42 wk gestational age. The mean difference (Portugal-Israel) was found to be 23.62 m/s [95% confidence interval [CI] 6.29, 40.95]. Additionally, no difference was found between Italy-Portugal (p = 0.69), or Italy-Israel (p = 0.28). In pediatric populations, we compared 8 studies from Canada, Mexico, Israel, Greece, Portugal, and Turkey. No significant differences found for SoS RV between Israel-Turkey, Israel-Greece, or Israel-Canada (p > 0.05). Significant differences were found in Mexico-Israel −105.29 m/s (95% CI −140.05, −70.54) (p < 0.001); Mexico-Portugal −115.14 m/s (95% CI −164.86, −65.42) (p < 0.001); Mexico-Greece: −239.14 m/s (95% CI −267.67, −210.62) (p < 0.001); Mexico-Turkey: −115.14 m/s (95% CI −164.86, −65.42) (p < 0.001); Mexico-Canada: −113.51 m/s (95% CI −140.25, −86.77) (p < 0.001).This study demonstrates that there are differences in SoS-RV obtained by tibial and radial QUS in pediatric populations between Mexico and other countries (Israel, Portugal, Greece, Turkey, and Canada).

Introduction

Osteoporosis (OP) is a major public health problem over the world 1, 2. Currently, pediatric population represents a new target in the battle against low bone mass and OP. An adequate peak bone mass during childhood and adolescence could help to prevent fragility fractures and OP later in life, and therefore, establishing programs to monitor bone accretion during this period of life is mandatory. Quantitative ultrasound (QUS) is a safe, inexpensive, and non-radiation method for bone density assessment. QUS correlates with dual-energy X-ray absorptiometry 3, 4. QUS has raised great expectations due to its safety features (radiation-free), low cost, portability, ease of use, and simple logs, making this technology an attractive method to be used in pediatric populations where dual-energy X-ray absorptiometry could be impractical 5, 6.

Several studies have demonstrated that QUS is able to independently assess the risk for fragility fracture, bone accretion, and follow-up monitoring in pediatric populations 7, 8.

Clinical utilization of QUS relies on population-based reference values (RV) to distinguish between normal and abnormal populations. It could be used to recommend changes in life style, especially during the age of bone accretion 9, 10.

Nevertheless, some authors argue that there are differences in bone characteristics between countries due to the interaction of genetics, metabolic, and environmental factors and that this phenomenon can be explained based on evidence of differences in bone growth across different populations 11, 12, 13, 14.

The RV of the Sunlight QUS equipment is based on a paper in Israeli population (15); nevertheless, other authors have published their own local RV, reporting some differences 16, 17. Recently, we reported RV for Mexican population (18), which indeed has different ethnic and genetic background compared with those recently published for European population. Therefore, the goal of the present meta-analysis was to compare the RV reported in the literature with those for the Mexican population looking for differences across studies and trying to demonstrate the importance of using local RV based on similar population backgrounds to obtain reliable measurements.

Section snippets

Methods

A systematic review was performed focusing on healthy pediatric populations (from newborn to 18 yr). We included articles with measurements of bone SoS (tibial SoS and/or radius SoS) using the Sunlight Omnisense QUS equipment.

Description and Quality of Studies

The initial search strategy yielded 128 potential titles to be included in this review. After careful/strict review of the summaries of each article, 67 were excluded by pre-specified criteria because they covered topics not related to our review questions or examined a population of individuals older than 18 yr. After thorough review of the remaining 61 studies, 51 additional studies were discarded (Fig. 1; flow chart) leaving 10 articles for further analysis. Two articles one from Italy

Discussion

The main results of this analysis indicate that RV published for QUS in different populations vary between countries. Israel, Turkey, Greece, Portugal, and Canada have very similar RV, with no statistically significant differences between them. Clearly, these differences did not even reach 100 m/s of the SOS; therefore, they cannot be considered clinically significant. A very different scenario is found with the Mexican RV: statistically significant differences were found in all measured

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