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y una historia de fracturas con fractura de hueso largo en miembros inferiores o aplastamiento vertebral&#44; o 2 o m&#225;s fracturas de hueso largo en miembros superiores<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Los primeros estudios en edad pedi&#225;trica evaluando el papel de la salud &#243;sea en las fracturas se realizaron en ni&#241;os blancos en Nueva Zelanda<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">En ni&#241;os africanos sanos entre 5-9 a&#241;os de edad un estudio prospectivo que analiza la relaci&#243;n entre el nivel de vitamina D y las fracturas concluye que un n&#250;mero significativos de ni&#241;os con fracturas tienen a su vez niveles bajos de vitamina D &#40;59&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; El d&#233;ficit de vitamina D parece tener un papel previamente desconocido en las fracturas en la edad pedi&#225;trica&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Asimismo&#44; se ha demostrado en ni&#241;os sanos y adultos que el uso de vitamina D cuando existe d&#233;ficit aumenta de forma significativa la DMO disminuyendo el riesgo de fracturas<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Los ni&#241;os con enfermedad de c&#233;lulas falciformes &#40;ECF&#41; presentan a menudo complicaciones &#243;seas en forma de crisis de dolor vaso-oclusivo &#243;seo&#44; dactilitis&#44; osteomielitis&#44; osteonecrosis avascular&#44; deformaci&#243;n vertebral&#46; En esta poblaci&#243;n se ha descrito una disminuci&#243;n de la DMO secundaria a la anemia cr&#243;nica e hiperplasia de la m&#233;dula &#243;sea con mayor riesgo de osteopenia y osteoporosis<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Estudios recientes demuestran que los ni&#241;os con ECF con frecuencia tienen d&#233;ficit importante de vitamina D&#46; En este sentido&#44; un estudio transversal realizado en nuestro centro en 78 ni&#241;os con ECF encontr&#243; que solo un 20&#44;5&#37; ten&#237;an niveles de 25 &#40;OH&#41; D<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; considerados como &#243;ptimos para una buena salud &#243;sea<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A pesar del mayor riesgo en esta poblaci&#243;n de patolog&#237;a &#243;sea&#44; en la actualidad no existe mucha informaci&#243;n acerca de la DMO en ni&#241;os con ECF y la relaci&#243;n con sus niveles de 25 &#40;OH&#41; D y el riesgo de fracturas&#46; Este trabajo eval&#250;a la prevalencia de alteraciones de la DMO en ni&#241;os de la Comunidad de Madrid con ECF&#44; mediante densitometr&#237;a &#40;DEXA&#41;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> y analiza posibles factores de riesgo asociados a una baja DMO&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0040" class="elsevierStylePara elsevierViewall">Se realiza un estudio transversal en un periodo comprendido entre octubre 2009 y febrero 2011&#44; en una cohorte de 120 ni&#241;os con ECF residentes en la Comunidad de Madrid y seguidos en la Secci&#243;n de Hematolog&#237;a Pedi&#225;trica del Hospital Gregorio Mara&#241;&#243;n &#40;HGUGM&#41;&#44; con el fin de conocer la DMO en dicha poblaci&#243;n mediante DEXA&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se incluyeron un total de 40 pacientes a partir de 3-4 a&#241;os de edad&#44; para evitar la necesidad de sedaci&#243;n al realizar la t&#233;cnica&#46; Se incluy&#243; a todos los pacientes posibles que realizaron una visita al centro en el periodo de tiempo del estudio&#46; Fueron excluidos aquellos ni&#241;os que presentaban alteraciones conocidas que afectan al crecimiento&#44; estado nutricional&#44; alteraciones cr&#243;nicas de funci&#243;n hep&#225;tica y&#47;o renal&#44; tratamiento con f&#225;rmacos que afectan al esqueleto y aquellos que hab&#237;an presentado alguna complicaci&#243;n de su enfermedad en el mes previo &#40;crisis vaso oclusivas&#44; episodios febriles&#44; s&#237;ndrome tor&#225;cico agudo&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Dicho estudio fue aprobado por el Comit&#233; de &#201;tica del centro y todos los participantes firmaron el correspondiente consentimiento informado&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Los datos demogr&#225;ficos y antropom&#233;tricos se recogen coincidiendo con alguna visita rutinaria de seguimiento del paciente por un m&#233;dico del equipo&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">La DMO se valor&#243; mediante DEXA&#46; Las mediciones se realizaron en espina postero-anterior y se obvi&#243; la cadera y zona proximal del f&#233;mur dada la gran variabilidad de estas zonas durante el crecimiento&#44; siguiendo las recomendaciones de la Sociedad Internacional de Densitometr&#237;a Cl&#237;nica &#40;ISCD&#41; en ni&#241;os&#46; El equipo utilizado en este trabajo es el LUNAR DPXIQ 5539&#44; que cumple las condiciones requeridas para el estudio en pediatr&#237;a&#46; Los resultados fueron interpretados por un radi&#243;logo experto en la t&#233;cnica y expresados en Z-score&#44; que define el n&#250;mero de desviaciones est&#225;ndar de la DMO de un ni&#241;o respecto al promedio de DMO comparando con otros ni&#241;os de su edad&#44; talla&#44; sexo y etnia&#46; Se consider&#243; Z-score patol&#243;gico el inferior a -2 DS&#46; Baja DMO u osteopenia valores de Z-score entre -1 y -2 DS y estudio normal un Z-score<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>-1 DS&#46; En ning&#250;n caso un resultado de Z-score patol&#243;gico por s&#237; solo fue interpretado como osteoporosis&#46; El diagn&#243;stico de osteoporosis en ni&#241;os solo se hace si se cumplen las 2 condiciones siguientes&#58; una disminuci&#243;n de DMO y una historia de fracturas con fractura de hueso largo en miembros inferiores o aplastamiento vertebral&#44; o 2 o m&#225;s fracturas de hueso largo en miembros superiores<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El resto de pruebas de laboratorios se realizaron el mismo d&#237;a de la DEXA&#46; Hemoglobina&#44; reticulocitos y estudio de metabolismo calcio-f&#243;sforo se midieron con las t&#233;cnicas est&#225;ndar del laboratorio&#46; La vitamina D se midi&#243; mediante la determinaci&#243;n cuantitativa de la 25 &#40;OH&#41; D utilizando LIASON 25 &#40;OH&#41; vitamina D TOTAL Assay &#40;310600&#41;&#46; El d&#233;ficit de vitamina D se define como niveles de 25 &#40;OH&#41; D<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;50<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#41;&#46; Vitamina D insuficiente como niveles de 25 &#40;OH&#41; D entre 21-29<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;52&#44;5-72&#44;5<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#41; y vitamina D normal niveles de 25 &#40;OH&#41; D<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>o<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;75<span class="elsevierStyleHsp" style=""></span>nmol&#47;L&#41;&#46; Asimismo&#44; hiperparatiroidismo se considera en nuestro estudio como concentraci&#243;n en suero de PTH superior a 50<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#46; La osteocalcina se midi&#243; mediante ensayo inmunorradiom&#233;trico &#40;IRMA&#41; y la fosfatasa alcalina &#243;sea &#40;FAO&#41;&#44; mediante un ensayo inmunoenzim&#225;tico&#44; Acces Ostase&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lisis estad&#237;stico</span><p id="par0070" class="elsevierStylePara elsevierViewall">Todos los datos se registraron en una base SPPS statistics 18 y fueron analizados con la misma&#46; Para resumir la poblaci&#243;n se us&#243; estad&#237;stica descriptiva&#46; Las variables cuantitativas se describieron con medidas de centralizaci&#243;n&#46; La comparaci&#243;n se realiz&#243; mediante T de Student y ANOVA para muestras param&#233;tricas y U Mann-Whitney&#44; Wilcoxon Kruskall-Wallis&#44; para no param&#233;tricas&#46; Las variables cualitativas se expresan en frecuencia y porcentajes y se comparan por medio de Chi-cuadrado&#44; exacto de Fisher o Mc Nemar&#44; en funci&#243;n de la muestra&#46; Los estudios de correlaci&#243;n se realizaron mediante coeficiente de correlaci&#243;n de Pearson y Spearman&#46; Asimismo&#44; se realizan estudios de regresi&#243;n simple y m&#250;ltiple&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0075" class="elsevierStylePara elsevierViewall">Los resultados estad&#237;sticos descriptivos en el grupo de pacientes en que se realiza DEXA para valorar la masa &#243;sea se resumen en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Se analizan datos de una muestra de 40 ni&#241;os en los que se ha realizado DEXA entre octubre de 2009 y septiembre de 2011&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Los principales datos de los ni&#241;os con DEXA patol&#243;gica se resumen en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Cuando se explora la relaci&#243;n entre la edad en el momento del estudio DEXA y los valores de Z-score&#44; la mediana de edad est&#225; por debajo de los 7 a&#241;os y medio en los ni&#241;os con DMO normal o disminuida &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&#41;&#44; mientras que aquellos con DMO patol&#243;gica tienen su mediana de edad superior a los 12 a&#241;os y medio &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Los estudios de correlaci&#243;n&#44; buscando asociaci&#243;n entre Z-score y otras variables cuantitativas&#44; solo encuentran una correlaci&#243;n lineal de Pearson significativa estad&#237;sticamente entre valor de Z-score y valor de Hb &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;368&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41;&#44; es decir&#44; aquellos ni&#241;os con valores m&#225;s altos de Hb tienen un valor de Z-score m&#225;s alto&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">No se encuentra correlaci&#243;n con el resto de variables cuantitativas analizadas&#58; calcio total&#44; calcio i&#243;nico&#44; magnesio&#44; f&#243;sforo&#44; fosfatasa alcalina&#44; fosfatasa alcalina &#243;sea&#44; PTH&#44; osteocalcina&#44; niveles de 25 &#40;OH&#41; D&#44; hierro&#44; ferritina&#44; edad en el momento del estudio&#44; meses de lactancia&#44; meses de profilaxis con vitamina D&#44; d&#237;as de ingreso&#47;a&#241;o&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Los diferentes estudios de regresi&#243;n simple y m&#250;ltiple no encuentran asociaci&#243;n lineal ni un modelo explicativo &#40;causa-efecto&#41; entre las diferentes variables cuantitativas y los valores de Z-score&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Cuando se compara el resultado de la DEXA&#44; expresado como valor num&#233;rico Z-score&#44; entre diferentes grupos de ni&#241;os&#44; clasificados por sexo mediante la prueba no param&#233;trica de U Mann Whitney&#44; la diferencia no es significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;21&#41;&#46; Esta misma prueba tampoco obtiene diferencias en el Z-score entre el grupo que recibe profilaxis el primer a&#241;o de vida y el que no &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;65&#41;&#44; ni en aquellos que reciben hidroxiurea frente a los que no &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;467&#41;&#46; Tampoco hay diferencias significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;45&#41; entre las diferentes etnias o los tipos de ECF &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;28&#41;&#44; utilizando la prueba no param&#233;trica de Kruskal Wallis&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">El an&#225;lisis de variables categ&#243;ricas mediante test de Chi-cuadrado y&#47;o exacto de Fisher no encuentra resultados significativos cuando se compara Z-score patol&#243;gico con niveles de 25 &#40;OH&#41; D inferiores a 20 y a 30&#44; respectivamente&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cuando se realiza test de Chi-cuadrado para comparar los resultados del Z-score en el grupo que recibe hidroxiurea frente al que no&#44; el 36&#37; de ni&#241;os que no reciben hidroxiurea tienen un Z-score alterado&#46; Este resultado aumenta al 53&#44;3&#37; en el grupo que recibe tratamiento&#44; sin ser significativo &#40;p<span class="elsevierStyleHsp" style=""></span>0&#44;336&#41;&#46; Tampoco hay diferencia estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;531&#41; entre los ni&#241;os con hiperparatiroidismo &#40;39&#44;1 vs 50&#37;&#41;&#44; ni cuando el an&#225;lisis se realiza en los diferentes sexos &#40;28&#44;6 en mujeres vs 50&#37; en varones&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>0&#44;191&#41;&#46; De los ni&#241;os con r&#233;gimen transfusional&#44; el 80&#37; tienen DEXA normal y el 20&#37; alterada &#40;p<span class="elsevierStyleHsp" style=""></span>0&#44;373&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discusi&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">En este trabajo se realiza un estudio observacional transversal para conocer la salud &#243;sea mediante DEXA a partir de los 3 a&#241;os con rango de edad entre 3-16 a&#241;os &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#41;&#46; El Z-score es patol&#243;gico en algunos pacientes menores de 5 a&#241;os&#44; no pudiendo definir de forma significativa un punto de corte para la edad a partir del cual la DEXA se altera de forma significativa&#44; aunque el grupo con Z-score patol&#243;gico &#40;&#60;<span class="elsevierStyleHsp" style=""></span>-2&#41; que representa un 17&#44;5&#37; de la muestra&#44; tiene una edad mayoritariamente por encima de los 10 a&#241;os&#46; Este resultado se ajustar&#237;a a la recomendaci&#243;n de la ISDC de iniciar controles de DEXA a partir de los 10 a&#241;os considerado para otras hemoglobinopat&#237;as como la talasemia major<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Los estudios realizados en ni&#241;os con ECF con DEXA para evaluar la masa &#243;sea son estudios transversales&#44; realizados en grupos peque&#241;os de pacientes&#44; sin datos suficientes para evaluar la t&#233;cnica en esta poblaci&#243;n y en general a partir de los 9 a&#241;os de edad<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a>&#46; Concluyen que el d&#233;ficit en la mineralizaci&#243;n &#243;sea probablemente comienza en edades m&#225;s tempranas&#44; y el impacto de corregir el d&#233;ficit de calcio y vitamina D merecen m&#225;s investigaciones&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">El estudio m&#225;s interesante es el realizado por Buison<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Se trata de un estudio casos-control que incluye 90 ni&#241;os con ECF &#40;Hb SS&#41;&#44; de edades entre 4-19 a&#241;os&#44; compar&#225;ndolos con 198 ni&#241;os sanos de similares caracter&#237;sticas&#46; Encuentran en el grupo de enfermos una disminuci&#243;n de la densidad &#243;sea significativa evaluada mediante DEXA &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">De todas las variables analizadas&#44; nuestro estudio s&#243;lo encuentra correlaci&#243;n lineal entre el Z-score y los niveles de hemoglobina&#46; Esto se explica por una disminuci&#243;n de la eritropoyesis en aquellos ni&#241;os que mantienen hemoglobinas m&#225;s altas y menor hem&#243;lisis&#44; lo que evita la hiperplasia de m&#233;dula &#243;sea con el consecuente descenso de cortical&#46; Este resultado es coincidente con el trabajo de Buison et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> y tambi&#233;n este mismo hallazgo ha sido descrito en adultos brasile&#241;os con ECF<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Igualmente&#44; Sarrai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> en un estudio retrospectivo en 103 adultos con ECF&#44; encuentran una alta prevalencia de densidad &#243;sea anormal &#40;79&#44;6&#37;&#41; medida mediante DEXA&#46; No encuentran relaci&#243;n con la edad&#44; s&#237; con los niveles de hemoglobina&#44; siendo la Hb baja un predictor de densidad &#243;sea alterada&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Tambi&#233;n se ha postulado en alg&#250;n estudio que el nivel de 25 &#40;OH&#41; D es un factor que influye en la DMO en pacientes con ECF&#46; A este respecto&#44; un estudio realizado en adultos de Arabia Saud&#237; comparando enfermos con ECF y poblaci&#243;n sana de similares caracter&#237;sticas&#44; describe DMO significativamente inferior en el grupo de enfermos respecto al control &#40;&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001 tanto en columna como en f&#233;mur&#41;&#46; La prevalencia de osteoporosis en pacientes con ECF y d&#233;ficit de vitamina D es de 73&#44;8&#37; &#40;45&#47;61&#41; en varones y 92&#44;4&#37; &#40;85&#47;92&#41; en mujeres&#59; sin embargo&#44; en el grupo control la osteoporosis tiene prevalencia del 30&#37; en varones y 63&#44;6&#37; en mujeres&#46; Este estudio no eval&#250;a otras causas de baja DMO&#44; como hipogonadismo y alteraciones hormonales&#44; y tampoco la sobrecarga de hierro<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Nuestro trabajo no encuentra correlaci&#243;n entre los niveles de 25 &#40;OH&#41; D y la DMO medida como Z-score&#44; dato que coincide con los trabajos realizados en ni&#241;os con ECF<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Son necesarios estudios prospectivos con determinaciones repetidas de 25 &#40;OH&#41; D para intentar aclarar este hallazgo&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Asimismo&#44; el riesgo de osteoporosis y osteopenia en pacientes pedi&#225;tricos con ECF no est&#225; bien establecido&#44; y hoy en d&#237;a se desconoce el valor de la DEXA alterada&#46; En adultos s&#237; hay estudios en los que se demuestra mayor riesgo de osteopenia y osteoporosis en esta poblaci&#243;n&#46; Un estudio de 36 adultos realizado en Arabia Saud&#237; encuentra que un 82&#37; de varones y un 76&#37; de mujeres tienen osteoporosis u osteopenia<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; Posteriormente&#44; ampl&#237;an este estudio a 87 pacientes&#44; encontrando que un 65&#37; de hombres y un 65&#44;2&#37; de mujeres tienen osteopenia y&#47;u osteoporosis<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Se han realizado algunos estudios en adultos sanos sobre la asociaci&#243;n entre niveles de 25 &#40;OH&#41; D y salud &#243;sea&#44; con resultados dispares<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#46; Muchos estudios observacionales en adultos se han planteado la cuesti&#243;n sobre cu&#225;les son los niveles cr&#237;ticos de 25 &#40;OH&#41; D a partir de los cuales el riesgo de fracturas aumenta&#46; Algunos estudios sit&#250;an esa cifra en niveles inferiores a 16<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#44; otros&#44; en inferiores a 20<span class="elsevierStyleHsp" style=""></span>ng&#47;ml<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#8211;30</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Existen muy pocas publicaciones sobre fracturas en ECF&#59; la mayor&#237;a son casos cl&#237;nicos aislados y una cohorte de ni&#241;os con osteomielitis y ECF<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#8211;33</span></a>&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Los individuos de etnia negra no afectos de ECF&#44; a pesar de tener d&#233;ficit de 25 &#40;OH&#41; D mayor que la etnia blanca de similares caracter&#237;sticas&#44; tienen parad&#243;jicamente menos riesgo de fracturas&#44; debido a una mayor masa &#243;sea &#40;10-15&#37; mayor que otras etnias&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Se desconoce si esta ventaja se mantiene en el grupo con ECF&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Aunque siguen sin resolverse muchas dudas&#44; y las publicaciones actuales no aclaran el valor de la DEXA patol&#243;gica en ni&#241;os&#44; publicaciones del a&#241;o 2011 y 2012 sobre adultos y ni&#241;os con ECF describen que el d&#233;ficit de vitamina D se asocia a mayor riesgo de fracturas&#44; menor DMO y dolor m&#250;sculo-esquel&#233;tico cr&#243;nico<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;40</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Los resultados de nuestro trabajo est&#225;n limitados por el tama&#241;o de la muestra&#44; tratarse de un solo centro y no disponer de un grupo control&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="par0190" class="elsevierStylePara elsevierViewall">Aunque nuestro estudio no define la edad a partir de la cual se altera la DMO en ni&#241;os con ECF&#46; Sugiere una menor DMO a partir de los 10 a&#241;os con DEXA patol&#243;gica a partir de 12 a&#241;os&#46; En la actualidad no existen recomendaciones basadas en la evidencia sobre cuando evaluar la DMO y niveles de 25 &#40;OH&#41; D en esta poblaci&#243;n&#46; Sin embargo&#44; parece apropiado desarrollar una estrategia para mejorar el pico de masa &#243;sea y prevenir fracturas y osteoporosis&#46; La intervenci&#243;n en la edad pedi&#225;trica es fundamental y en este sentido un control seriado de los niveles de vitamina D y la correcci&#243;n de los mismos merece atenci&#243;n&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicto de intereses</span><p id="par0195" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "identificador" => "sec0035"
          "titulo" => "Conflicto de intereses"
        ]
        10 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-11-17"
    "fechaAceptado" => "2014-04-03"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec490398"
          "palabras" => array:5 [
            0 => "Densidad mineral &#243;sea"
            1 => "Densitometr&#237;a"
            2 => "Enfermedad de c&#233;lulas falciformes"
            3 => "Osteopenia"
            4 => "Osteoporosis"
          ]
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      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec490399"
          "palabras" => array:5 [
            0 => "Bone mineral density"
            1 => "Densitometry"
            2 => "Sickle cell disease"
            3 => "Low bone mineral density"
            4 => "Osteoporosis"
          ]
        ]
      ]
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar la densidad mineral &#243;sea &#40;DMO&#41; en ni&#241;os con enfermedad de c&#233;lulas falciformes &#40;ECF&#41; de la Comunidad de Madrid&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se valora la DMO en un total de 40 ni&#241;os con ECF y rango de edad entre 3-16 a&#241;os&#44; mediante densitometr&#237;a &#40;DEXA&#41; siguiendo las recomendaciones de la Sociedad Internacional de Densitometr&#237;a Cl&#237;nica &#40;ISCD&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La edad media en el momento del estudio fue de 7&#44;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#44;95 a&#241;os&#59; el valor medio de la DEXA expresado en Z-score es de -0&#44;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;46 con un rango de valores m&#237;nimo de -5&#44;30 y m&#225;ximo de 2&#44;30&#46; Un 57&#44;5&#37; de los ni&#241;os tiene DMO normal &#40;Z<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>-1&#41;&#44; un 25&#37; tienen DMO baja &#40;Z entre -1 y -2&#41; y un 17&#44;5&#37; presentan Z-score patol&#243;gico con valores de osteoporosis &#40;Z-score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>-2&#41;&#46; Los estudios de correlaci&#243;n solo encuentran una correlaci&#243;n lineal de Pearson significativa estad&#237;sticamente entre valor de Z-score y valor de Hb &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;368&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;019&#41;&#44; no encontrando correlaci&#243;n con los niveles de 25 &#40;OH&#41; D&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se necesitan estudios prospectivos&#44; con mayor n&#250;mero de enfermos para conocer las implicaciones futuras de la densitometr&#237;a alterada y los factores de riesgo asociados&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusi&#243;n"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate bone mineral density &#40;BMD&#41; in children with sickle cell disease &#40;SCD&#41; in the Community of Madrid&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The BMD was estimated in 40 children with SCD&#44; and with an age range between 3 and 16 years&#44; using densitometry &#40;DXA&#41;&#44; as recommended by the International Society for Clinical Densitometry &#40;ISCD&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The mean age at the time of the study was 7&#46;97<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;95 years&#44; the mean value of the DXA expressed in Z -score was -0&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;46 with a range of minimum values - 5&#46;30 and 2&#46;30 maximum&#46; More than half &#40;57&#46;5&#37;&#41; of all the children had normal BMD &#40;Z<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>-1&#41;&#44; 25&#37; had low BMD &#40;Z between -1 and -2&#41;&#44; and 17&#46;5&#37; showed an abnormal Z -score values of osteoporosis &#40;Z -score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>-2&#41;&#46; The Pearson linear correlation was statistically significant between Z -score value and the haemoglobin level &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;368&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;019&#41;&#44; finding no correlation with the levels of 25 &#40;OH&#41; vitamin D&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Prospective studies are needed with a larger number of patients to understand the future implications of bone densitometry changes and associated risk factors&#46;</p></span>"
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            "identificador" => "abst0025"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material and Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusion"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;64-1&#44;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mg mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#44;70-3&#44;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#44;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;068&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>P mg&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4-6&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#44;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;326&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PTH ng&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6-185&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#44;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>47&#44;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;267&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FA total U&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64-461&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">199&#44;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>79&#44;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;305&#44;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FAO mcg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19-115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#44;93<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">712&#44;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Osteocalcina mcg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1-10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#44;74<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#44;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>25 &#40;OH&#41; D ng&#47;ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4-44&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#44;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#44;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PCR mg&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;10-2&#44;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Resumen de datos epidemiol&#243;gicos&#44; anal&#237;ticos y Z-score del grupo de ni&#241;os con enfermedad de c&#233;lulas falciformes &#40;ECF&#41; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#41; en que se realiza densitometr&#237;a &#40;DEXA&#41; para valorar la densidad mineral &#243;sea &#40;DMO&#41;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Hb&#58; hemoglobina&#59; PTH&#58; hormona paratiroidea&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sexo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mujer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Var&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mujer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Edad &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tipo Hb&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#946;<span class="elsevierStyleSup">0</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Etnia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Africana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Afroamericana&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tanner&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hb &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#44;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">PTH &#40;ng&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">25 &#40;OH&#41; D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#44;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#40;ng&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Z-score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-2&#44;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-3&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-2&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-3&#44;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-5&#44;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fracturas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">R&#233;gimen transfusional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Profil&#225;xis con vitamina D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Datos de los ni&#241;os con densitometr&#237;a patol&#243;gica</p>"
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                            2 => "J&#46;P&#46; Bilezikian"
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                      "titulo" => "Prevalence of vitamin D insufficiency in African American children with forearm fractures&#58; A preliminary study"
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                            0 => "A&#46; Ganguly"
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                      "doi" => "10.1155/2011/794283"
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                      "titulo" => "Official positions of the International Society for Clinical Densitometry &#40;ISCD&#41; on DXA evaluation in children and adolescents"
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "N&#46;J&#46; Bishop"
                            3 => "C&#46;M&#46; Gordon"
                            4 => "D&#46;B&#46; Hans"
                            5 => "C&#46;B&#46; Langman"
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                        "tituloSerie" => "Pediatr Nephrol"
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                      "titulo" => "Osteoporosis in young adults&#58; pathophysiology&#44; diagnosis and management&#46; Committee of Scientific Advisors Working Group on Osteoporosis Patophysiology"
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                            2 => "J&#46;A&#46; Eisman"
                            3 => "J&#46;A&#46; Foldes"
                            4 => "S&#46; Adami"
                            5 => "D&#46;A&#46; Wahl"
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                        ]
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                    ]
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                      "titulo" => "Bone mineral density in children with beta-thalassemia major in Diyarbakir"
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