title: Automated determination of bone age and bone mineral density in patients with juvenile idiopathic arthritis: a feasibility study.
abstract: BACKGROUND
  Chronic inflammation combined with glucocorticoid treatment and immobilization puts juvenile idiopathic arthritis (JIA) patients at risk of impaired growth and reduced bone mineral density (BMD). Conventional methods for evaluating bone age and BMD are time-consuming or come with additional costs and radiation exposure. In addition, an automated measurement of bone age and BMD is likely to be more consistent than visual evaluation. In this study, we aimed to evaluate the feasibility of an automated method for determination of bone age and (cortical) bone mineral density (cBMD) in severely affected JIA patients. A secondary objective was to describe bone age and cBMD in this specific JIA population eligible for biologic treatment.
  
  
  METHODS
  In total, 69 patients with standard hand radiographs at the start of etanercept treatment and of calendar age within the reliability ranges (2.5 to 17 years for boys and 2 to 15 years for girls) were extracted from the Dutch Arthritis and Biologicals in Children register. Radiographs were analyzed using the BoneXpert method, thus automatically determining bone age and cBMD expressed as bone health index (BHI). Agreement between measurements of the left- and right-hand radiographs and a repeated measurement of the left hand were assessed with the intraclass correlation coefficient (ICC). Regression analysis was used to identify variables associated with Z-scores of bone age and BHI.
  
  
  RESULTS
  The BoneXpert method was reliable in the evaluation of radiographs of 67 patients (radiographs of 2 patients were rejected because of poor image quality). Agreement between left- and right-hand radiographs (ICC = 0.838 to 0.996) and repeated measurements (ICC = 0.999 to 1.000) was good. Mean Z-scores of bone age (-0.36, P = 0.051) and BHI (-0.85, P < 0.001) were lower compared to the healthy population. Glucocorticoid use was associated with delayed bone age (0.79 standard deviation (SD), P = 0.028), and male gender was associated with a lower Z-score of BHI (0.65 SD, P = 0.021).
  
  
  CONCLUSIONS
  BoneXpert is an easy-to-use method for assessing bone age and cBMD in patients with JIA, provided that radiographs are of reasonable quality and patients' bone age lies within the age ranges of the program. The population investigated had delayed bone maturation and lower cBMD than healthy children.
authors.forename: Janneke
authors.initials: J
authors.lastname: Anink
authors.forename: Charlotte M
authors.initials: CM
authors.lastname: Nusman
authors.forename: Lisette W A
authors.initials: LW
authors.lastname: van Suijlekom-Smit
authors.forename: Rick R
authors.initials: RR
authors.lastname: van Rijn
authors.forename: Mario
authors.initials: M
authors.lastname: Maas
authors.forename: Marion A J
authors.initials: MA
authors.lastname: van Rossum
mesh_terms: D000293:Adolescent; D000365:Age Determination by Skeleton / Q000379:methods*; D001171:Arthritis, Juvenile / Q000000981:diagnostic imaging* / Q000188:drug therapy; D001331:Automation; D015519:Bone Density / Q000187:drug effects*; D002648:Child; D002675:Child, Preschool; D000068800:Etanercept; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000009:adverse effects; D008297:Male; D011857:Radiographic Image Interpretation, Computer-Assisted / Q000379:methods*; D018124:Receptors, Tumor Necrosis Factor
chemical_list: D007074:Immunoglobulin G; D007166:Immunosuppressive Agents; D018124:Receptors, Tumor Necrosis Factor; D000068800:Etanercept