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Park SJ, Sim SY, Jeong DC, Suh BK, Ahn MB. Factors affecting bone mineral density in children and adolescents with systemic lupus erythematosus. Ann Pediatr Endocrinol Metab 2024; 29:191-200. [PMID: 38291762 PMCID: PMC11220398 DOI: 10.6065/apem.2346060.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/01/2023] [Accepted: 07/07/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Patients with juvenile-onset systemic lupus erythematosus (JSLE) are at a high risk of entering adulthood with disease-related morbidities like reduced bone mass and osteoporosis. This study aimed to evaluate the clinical characteristics of JSLE and to analyze the factors associated with low bone mineral density (BMD) in these patients. METHODS Children and adolescents diagnosed with JSLE at a single institution in Korea were included. Demographic, clinical, and laboratory data as well as details about the use of glucocorticoids (GCs) and disease-modifying antirheumatic drugs were collected. The lumbar spine (LS) BMD z-score was measured using dual energy x-ray absorptiometry, and lateral thoracolumbar spine radiographs were collected. RESULTS A total of 29 patients with JSLE were included in this study. Of these patients, 7 had a BMD z-score of -2.0 or lower and were designated as the low BMD group. The differences in the clinical parameters and treatment variables between the low BMD and non-low BMD groups were compared. Higher cumulative GC dose, longer GC exposure, and higher cumulative hydroxychloroquine (HCQ) dose were all associated with low BMD; among them, the main factor was the duration of GC exposure. There was no significant correlation between BMD and clinical profile, disease activity, or bone-metabolism markers. CONCLUSION The duration of GC exposure, cumulative GC dose, and cumulative HCQ dose were risk factors for low BMD in patients with JSLE, with the main factor being the duration of GC exposure. Thus, patients with JSLE should be routinely monitored for low BMD and potential fracture risks, and GC-sparing treatment regimens should be considered.
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Affiliation(s)
- Su Jin Park
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Yeun Sim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Kyu Suh
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Moon Bae Ahn
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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2
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Ma J, Siminoski K, Jaremko JL, Koujok K, Matzinger MA, Shenouda N, Wilson N, Cheng M, Alos N, Atkinson S, Cummings EA, Ho J, Rodd C, Sbrocchi AM, Stein R, Barr R, Cairney E, Dix DB, Fernandez CV, Grant R, Halton J, Israels S, Laverdière C, Lewis VA, Cabral DA, Huber A, Houghton K, Jurencak R, Lang B, Larché M, LeBlanc CMA, Miettunen P, Roth J, Scuccimarri R, Bell L, Blydt-Hansen T, Filler G, Feber J, Phan V, Smit K, Rauch F, Ward LM. Vertebral Body Reshaping after Fractures: An Important Index of Recovery in Glucocorticoid-Treated Children. J Clin Endocrinol Metab 2024; 109:e1225-e1237. [PMID: 37843393 DOI: 10.1210/clinem/dgad611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE In this 6-year study we identified factors associated with spontaneous vertebral body reshaping in glucocorticoid (GC)-treated children with leukemia, rheumatic disorders, and nephrotic syndrome. METHODS Subjects were 79 children (mean age 7.4 years) who had vertebral fracture (VF) evaluation on lateral spine radiographs at least 1 year after VF detection. VF were graded using the modified Genant semiquantitative method and fracture burden for individuals was quantified using the spinal deformity index (SDI; sum of grades from T4 to L4). RESULTS Sixty-five children (82.3%) underwent complete vertebral body reshaping (median time from VF detection to complete reshaping 1.3 years by Cox proportional hazard modeling). Of 237 VF, the majority (83.1%) ultimately reshaped, with 87.2% reshaping in the thoracic region vs 70.7% in the lumbar region (P = .004). Cox models showed that (1) every g/m2 increase in GC exposure in the first year after VF detection was associated with a 19% decline in the probability of reshaping; (2) each unit increase in the SDI at the time of VF detection was associated with a 19% decline in the probability of reshaping [hazard ratio (HR) = 0.81; 95% confidence interval (CI) = 0.71, 0.92; P = .001]; (3) each additional VF present at the time of VF detection reduced reshaping by 25% (HR = 0.75; 95% CI = 0.62, 0.90; P = .002); and (4) each higher grade of VF severity decreased reshaping by 65% (HR = 0.35; 95% CI = 0.21, 0.57; P < .001). CONCLUSION After experiencing a VF, children with higher GC exposure, higher SDI, more severe fractures, or lumbar VF were at increased risk for persistent vertebral deformity.
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Affiliation(s)
- Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB T6G 2B7, Canada
| | - Khaldoun Koujok
- Department of Radiology, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Mary Ann Matzinger
- Department of Radiology, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Nazih Shenouda
- Department of Radiology, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Nagwa Wilson
- Department of Radiology, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Megan Cheng
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8N 3Z5, Canada
| | - Nathalie Alos
- Département de pédiatrie, Université de Montréal, Montréal, QC H3T 1C5, Canada
| | - Stephanie Atkinson
- Department of Pediatrics, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Elizabeth A Cummings
- Department of Pediatrics, Dalhousie University/IWK Health, Halifax, NS B3K 6R8, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB T3B 6A8, Canada
| | - Celia Rodd
- Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Anne Marie Sbrocchi
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Robert Stein
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5W9, Canada
| | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Elizabeth Cairney
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5W9, Canada
| | - David B Dix
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Conrad V Fernandez
- Department of Pediatrics, Dalhousie University/IWK Health, Halifax, NS B3K 6R8, Canada
| | - Ronald Grant
- Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Jacqueline Halton
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Sara Israels
- Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Caroline Laverdière
- Département de pédiatrie, Université de Montréal, Montréal, QC H3T 1C5, Canada
| | - Victor A Lewis
- Department of Pediatrics, University of Calgary, Calgary, AB T3B 6A8, Canada
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Adam Huber
- Department of Pediatrics, Dalhousie University/IWK Health, Halifax, NS B3K 6R8, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Roman Jurencak
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University/IWK Health, Halifax, NS B3K 6R8, Canada
| | - Maggie Larché
- Department of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Claire M A LeBlanc
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, AB T3B 6A8, Canada
| | - Johannes Roth
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
- Department of Pediatrics, Kantonsspital Luzern, 6004 Luzern, Switzerland
| | - Rosie Scuccimarri
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Lorraine Bell
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Tom Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5W9, Canada
| | - Janusz Feber
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Véronique Phan
- Département de pédiatrie, Université de Montréal, Montréal, QC H3T 1C5, Canada
| | - Kevin Smit
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Frank Rauch
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Leanne M Ward
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
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Phung K, McAdam L, Ma J, McMillan HJ, Jackowski S, Scharke M, Matzinger MA, Shenouda N, Koujok K, Jaremko JL, Wilson N, Walker S, Hartigan C, Khan N, Page M, Robinson ME, Saleh DS, Smit K, Rauch F, Siminoski K, Ward LM. Risk Factors Associated with Incident Vertebral Fractures in Steroid-treated Males with Duchenne Muscular Dystrophy. J Clin Endocrinol Metab 2024; 109:536-548. [PMID: 37610420 DOI: 10.1210/clinem/dgad435] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE Prevention of fractures is an unmet need in glucocorticoid (GC)-treated Duchenne muscular dystrophy. This study explored factors associated with incident vertebral fractures (VFs) to inform future fracture prevention efforts. METHODS VFs were evaluated prospectively at study baseline and 12 months on lateral spine radiographs in participants aged 4 to 25 years with Duchenne muscular dystrophy. Clinical factors were analyzed for their association with the change in Spinal Deformity Index (sum of the Genant-defined VF grades from T4 to L4) between baseline and 12 months. RESULTS Thirty-eight males were evaluated (mean ± SD age at baseline 11.0 ± 3.6 years; mean ± SD GC duration at baseline 4.1 ± 3.1 years; 74% ambulatory). Nine of 38 participants (24%) had 17 incident VFs, of which 3/17 VFs (18%) were moderate/severe. Participants with 12-month incident VF had lower mean ± SD baseline lumbar spine areal bone mineral density Z-scores (-2.9 ± 1.0 vs -1.9 ± 1.1; P = .049) and lower total body less head areal bone mineral density Z-scores (-3.1 ± 1.2 vs -1.6 ± 1.7; P = .036). Multivariable linear regression showed that at least 1 VF at baseline (P < .001), a higher number of antecedent non-VF (P < .001), and greater bone age delay at baseline (P = .027) were significant predictors of an increase in the Spinal Deformity Index from baseline to 12 months. CONCLUSION The observation that ≥ 1 prevalent VF and/or non-VF were the strongest predictors of incident VFs at 12 months supports the need for prevention of first fractures in this high-risk setting. Bone age delay, a marker of GC exposure, may assist in the prioritization of patients in efforts to prevent first fractures.
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Affiliation(s)
- Kim Phung
- Department of Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Laura McAdam
- Department of Pediatric, Division of Development, Holland Bloorview Kids Rehabilitation Hospital, Bloorview Research Institute, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON L8S 1L9, Canada
| | - Hugh J McMillan
- Department of Pediatrics, Division of Neurology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1H 8L1, Canada
| | - Stefan Jackowski
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Maya Scharke
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Mary-Ann Matzinger
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Nazih Shenouda
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Khaldoun Koujok
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Jacob L Jaremko
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Nagwa Wilson
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Scott Walker
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Colleen Hartigan
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Nasrin Khan
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Marika Page
- Department of Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - Marie-Eve Robinson
- Department of Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
| | - David S Saleh
- Department of Pediatrics, Kingston Health Sciences Centre, Queen's University, Kingston, ON K7M 3N6, Canada
| | - Kevin Smit
- Department of Surgery, Division of Pediatric Orthopedics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K7M 3N6, Canada
| | - Frank Rauch
- Department of Pediatrics, Shriners Hospital for Children, McGill University, Montreal, QC H3A 0B9, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Leanne M Ward
- Department of Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON K1H 8L1, Canada
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4
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Martin H, Henderson A, Allen R, Childs AM, Dunne J, Horrocks I, Joseph S, Kraft JK, Ward K, Mushtaq T, Mason A, Kyriakou A, Wong SC. Reporting of paediatric osteoporotic vertebral fractures in Duchenne muscular dystrophy and potential impact on clinical management: the need for standardised and structured reporting. Pediatr Radiol 2024; 54:117-126. [PMID: 38072887 PMCID: PMC10776500 DOI: 10.1007/s00247-023-05805-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND In boys with Duchenne muscular dystrophy (DMD), initiation of bisphosphonate is recommended upon identification of moderate or severe vertebral fractures, even if asymptomatic. Clear radiological reporting is important for consistency of clinical interpretation and management. OBJECTIVES To audit radiology reports of spine imaging for vertebral fracture assessment in DMD, and assess potential impact on diagnosis and management. MATERIALS AND METHODS Lateral thoracolumbar spine imaging (71 lateral spine radiographs and 13 lateral dual energy absorptiometry spine image) in 84 boys with DMD performed across two centres. Anonymised radiology reports by paediatric radiologists were circulated to two neuromuscular clinicians and two endocrinologists. Clinicians determined if there was vertebral fracture, no vertebral fracture, or unclear interpretation. Endocrinologists also determined if bisphosphonate was indicated. A single observer (a clinician with expertise in vertebral fracture assessment) performed vertebral fracture assessment in 37 images and re-reported using a structured format. Structured reports were re-circulated to the four clinicians to re-evaluate the degree of concordance in clinical diagnosis of vertebral fracture and treatment decisions with bisphosphonate. RESULTS The term "fracture" was used in 25/84 (30%) radiology reports and only in 8/43 (19%) with description of vertebral body abnormalities. Fracture grading was included in 7/43 (16%) radiology reports. Diagnostic concordance by the clinicians was noted in 36/84 (43%). Unclear interpretation was noted in 22% to 51% based on radiology reports. No unclear interpretation was noted with structured reports. Complete diagnostic (37/37, 100%) and treatment (37/37, 100%) concordance was noted with the structured reports, whereas complete diagnostic and treatment concordance was noted in only 16/37 (43%) and 17/37 (46%) of the radiology reports, respectively. CONCLUSION Only a third of radiology reports of spine imaging in DMD explicitly used the terminology "fracture". Grading was only noted in a small percentage. Variability in diagnostic interpretation by clinicians may lead to differing management plans. As identification of vertebral fracture is a trigger for treatment, developing reporting guidelines for paediatric vertebral fracture assessment will improve care. A structured template should be introduced for radiological reporting of paediatric vertebral fracture assessment.
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Affiliation(s)
- H Martin
- Department of Paediatric Endocrinology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - A Henderson
- Department of Paediatric Neurology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - R Allen
- Department of Paediatric Radiology, Royal Hospital for Children, Glasgow, UK
| | - A M Childs
- Department of Paediatric Neurology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - J Dunne
- Department of Paediatric Neurology, Royal Hospital for Children, Glasgow, UK
| | - I Horrocks
- Department of Paediatric Neurology, Royal Hospital for Children, Glasgow, UK
| | - S Joseph
- Department of Paediatric Neurology, Royal Hospital for Children, Glasgow, UK
| | - J K Kraft
- Department of Paediatric Radiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - K Ward
- Department of Paediatric Neurology, Royal Hospital for Children, Glasgow, UK
| | - T Mushtaq
- Department of Paediatric Endocrinology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - A Mason
- Department of Paediatric Endocrinology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - A Kyriakou
- Department of Paediatric Endocrinology, Makarios Children's Hospital, Nicosia, Cyprus
| | - S C Wong
- Department of Paediatric Endocrinology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK.
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
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5
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Phung K, Crabtree N, Connolly AM, Furlong P, Hoffman EP, Jackowski SA, Jayash SN, Johnson A, Koujok K, Munns CF, Niks E, Rauch F, Schrader R, Turner C, Vroom E, Weber DR, Wong BL, Guglieri M, Ward LM, Wong SC. Moving Beyond the 2018 Minimum International Care Considerations for Osteoporosis Management in Duchenne Muscular Dystrophy (DMD): Meeting Report from the 3rd International Muscle-Bone Interactions Meeting 7th and 14th November 2022. J Neuromuscul Dis 2024; 11:233-252. [PMID: 37980681 PMCID: PMC10789336 DOI: 10.3233/jnd-230176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Affiliation(s)
- Kim Phung
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Nicola Crabtree
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Anne M. Connolly
- Nationwide Children’s Hospital, Ohio State University, Columbus, OH, USA
| | - Pat Furlong
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Eric P. Hoffman
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences Binghamton University, State University of New York, Binghamton, NY, USA
| | - Stefan A. Jackowski
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Soher Nagi Jayash
- Roslin institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Khaldoun Koujok
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Craig F. Munns
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Department of Endocrinology and Diabetes, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Erik Niks
- Leiden University Medical Center, Leiden, The Netherlands
| | - Frank Rauch
- Shriners Hospital for Children, Montreal, QC, Canada
| | | | | | | | | | | | | | - Leanne M. Ward
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Sze Choong Wong
- Correspondence to: Dr. Sze Choong Wong, Department of Paediatric Endocrinology, Royal Hospital for Children, 1345 Govan Road, Glasgow G51 4TF United Kingdom. Tel.: +44 141 451 5841; E-mail:
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6
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol 2023; 75:2088-2102. [PMID: 37845798 DOI: 10.1002/art.42646] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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7
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Humphrey MB, Russell L, Danila MI, Fink HA, Guyatt G, Cannon M, Caplan L, Gore S, Grossman J, Hansen KE, Lane NE, Ma NS, Magrey M, McAlindon T, Robinson AB, Saha S, Womack C, Abdulhadi B, Charles JF, Cheah JTL, Chou S, Goyal I, Haseltine K, Jackson L, Mirza R, Moledina I, Punni E, Rinden T, Turgunbaev M, Wysham K, Turner AS, Uhl S. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res (Hoboken) 2023; 75:2405-2419. [PMID: 37884467 DOI: 10.1002/acr.25240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVE The objective is to update recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients with rheumatic or nonrheumatic conditions receiving >3 months treatment with glucocorticoids (GCs) ≥2.5 mg daily. METHODS An updated systematic literature review was performed for clinical questions on nonpharmacologic, pharmacologic treatments, discontinuation of medications, and sequential therapy. Grading of Recommendations Assessment, Development and Evaluation approach was used to rate the certainty of evidence. A Voting Panel achieved ≥70% consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS For adults beginning or continuing >3 months of GC treatment, we strongly recommend as soon as possible after initiation of GCs, initial assessment of fracture risks with clinical fracture assessment, bone mineral density with vertebral fracture assessment or spinal x-ray, and Fracture Risk Assessment Tool if ≥40 years old. For adults at medium, high, or very high fracture risk, we strongly recommend pharmacologic treatment. Choice of oral or intravenous bisphosphonates, denosumab, or parathyroid hormone analogs should be made by shared decision-making. Anabolic agents are conditionally recommended as initial therapy for those with high and very high fracture risk. Recommendations are made for special populations, including children, people with organ transplants, people who may become pregnant, and people receiving very high-dose GC treatment. New recommendations for both discontinuation of osteoporosis therapy and sequential therapies are included. CONCLUSION This guideline provides direction for clinicians and patients making treatment decisions for management of GIOP. These recommendations should not be used to limit or deny access to therapies.
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Affiliation(s)
- Mary Beth Humphrey
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Maria I Danila
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Howard A Fink
- Geriatric Research Education and Clinical Center, VA Health Care System, Minneapolis, Minnesota
| | | | - Michael Cannon
- Arthritis Consultants of Tidewater, Virginia Beach, Virginia
| | | | | | | | | | | | - Nina S Ma
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
| | - Marina Magrey
- Case Western Reserve University, MetroHealth, Cleveland, Ohio
| | | | | | | | | | - Basma Abdulhadi
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Jonathan T L Cheah
- UMass Memorial Health and UMass Chan Medical School, Worcester, Massachusetts
| | - Sharon Chou
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Itivrita Goyal
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | - Lesley Jackson
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | - Iram Moledina
- University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, Alabama
| | - Emma Punni
- University of Oklahoma Health Sciences Center and U.S. Department of Veterans Affairs, Oklahoma City, Oklahoma
| | | | | | - Katherine Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Stacey Uhl
- ECRI Institute, Plymouth Meeting, Pennsylvania
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A Scoping Review of the Recent Clinical Practice Regarding the Evaluation of Bone Mineral Density in Children and Adolescents with Neuromuscular Diseases. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020312. [PMID: 36837513 PMCID: PMC9967238 DOI: 10.3390/medicina59020312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/22/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Introduction: Neuromuscular Diseases (NMD) are associated with decreased bone strength due to altered muscle-bone interaction. However, the evaluation of bone quality remains a certain challenge in these patients. The purpose of this scoping review is to investigate the recent literature regarding the assessment of Bone Mineral Density (BMD) in this population. Methods: An electronic search of the PubMed and Scopus database was performed considering studies published in the English literature after 2007 that evaluated BMD in pediatric and adolescent patients with NMD. We excluded studies that evaluated patients > 20 years, studies not involving humans, and studies investigating bone mineral density in various pediatric conditions, but without specific data on NMD. Results: Overall, 19 studies were included that evaluated BMD in 1983 patients with NMD. Duchenne Muscular Dystrophy was the most widely studied disease (n = 11 studies). Dual energy X-ray absorptiometry (DEXA) was the most common diagnostic modality for BMD evaluation, while the most frequent site for BMD measurement was the lumbar spine (89.4%, n = 17 studies), followed by total body BMD (68.4%, n = 13 studies). Low BMD in children with NMD was demonstrated in all studies, especially after loss of ambulation. Moreover, a positive correlation between lower BMD and older age was shown. Conclusions: BMD evaluation in NMD remains a clinical challenge, as indicated by the high heterogeneity regarding the optimal site and technique for the evaluation of bone quality in these patients. Although DXA is currently the diagnostic modality of choice, a consensus regarding the optimal site for BMD measurement, and the adjustment method for its obtained measurements for parameters such as age and height is needed.
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9
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Phung K, McAdam L, Ma J, McMillan HJ, Jackowski S, Scharke M, Matzinger MA, Shenouda N, Koujok K, Jaremko JL, Smit K, Walker S, Hartigan C, Khan N, Konji VN, MacLeay L, Page M, Sykes E, Robinson ME, Alos N, Cummings EA, Ho J, Sbrocchi AM, Stein R, Saleh D, Craven BC, Dang UJ, Siminoski K, Rauch F, Ward LM. Risk factors associated with prevalent vertebral fractures in Duchenne muscular dystrophy. Osteoporos Int 2023; 34:147-160. [PMID: 36342539 DOI: 10.1007/s00198-022-06578-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
UNLABELLED Patients with Duchenne muscular dystrophy (DMD) have a high fracture burden due to progressive myopathy and steroid-induced osteoporosis. This study in males with DMD showed that markers of systemic glucocorticoid exposure including shorter stature, greater bone age delay, and lower lumbar spine bone mineral density were associated with spine fragility. INTRODUCTION Fragility fractures are frequent in DMD. The purpose of this study was to identify clinical factors associated with prevalent vertebral fractures (VF) in boys, teens/young adults with Duchenne muscular dystrophy (DMD). METHODS This was a cross-sectional study of males aged 4-25 years with DMD. VF were evaluated using the modified Genant semi-quantitative method on T4-L4 lateral spine radiographs. Areal bone mineral density (aBMD) was measured at the lumbar spine (LS) and used to estimate volumetric BMD (vBMD). Clinical factors were analyzed for their association with the Spinal Deformity Index (SDI, the sum of the Genant grades). RESULTS Sixty participants were enrolled (mean age 11.5 years, range 5.4-19.5). Nineteen participants (32%) had a total of 67 VF; 23/67 VF (34%) were moderate or severe. Participants with VF were shorter (mean height Z-score ± standard deviation: - 3.1 ± 1.4 vs. - 1.8 ± 1.4, p = 0.001), had longer glucocorticoid exposure (mean duration 6.0 ± 3.3 vs. 3.9 ± 3.3 years, p = 0.027), greater bone age (BA) delay (mean BA to chronological age difference - 3.2 ± 3.4 vs. - 1.3 ± 1.2 years, p = 0.035), and lower LSaBMD Z-scores (mean - 3.0 ± 1.0 vs. - 2.2 ± 1.2, p = 0.023). There was no difference in LSvBMD Z-scores. Multivariable Poisson regression showed that every 0.1 mg/kg/day increment in average glucocorticoid daily dose was associated with a 1.4-fold SDI increase (95% confidence interval: 1.1-1.7, p = 0.013). Greater BA delay (p < 0.001), higher weight Z-score (p = 0.004), decreased height Z-score (p = 0.025), and lower LSvBMD Z-score (p = 0.025) were also associated with SDI increase. CONCLUSION Readily measurable clinical variables were associated with prevalent VF in males with glucocorticoid-treated DMD. These variables may be useful to identify candidates for primary osteoporosis prevention after glucocorticoid initiation.
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Affiliation(s)
- Kim Phung
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Laura McAdam
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hugh J McMillan
- Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Stefan Jackowski
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Maya Scharke
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kevin Smit
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Scott Walker
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Colleen Hartigan
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nasrin Khan
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Victor N Konji
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Lynn MacLeay
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Marika Page
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Elizabeth Sykes
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Marie-Eve Robinson
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Nathalie Alos
- CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | | | - Josephine Ho
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | | | - Robert Stein
- London Health Sciences Centre, Western University, London, ON, Canada
| | - David Saleh
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - B Catharine Craven
- Department of Medicine, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Utkarsh J Dang
- Department of Health Sciences, Carleton University, Ottawa, ON, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Frank Rauch
- Shriners Hospital for Children, McGill University, Montreal, QC, Canada
| | - Leanne M Ward
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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10
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Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics 2022; 150:e2022060055. [PMID: 36404756 DOI: 10.1542/peds.2022-060055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.
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Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| | - Lynn Davidson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Steingass
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
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11
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Charuvanij S, Malakorn H, Densupsoontorn N, Nakavachara P. Bone Mineral Density and Serum 25OHD in Children and Adolescents With Juvenile Idiopathic Arthritis. Clin Pediatr (Phila) 2022; 62:456-465. [PMID: 36366793 DOI: 10.1177/00099228221136982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Low bone mass is one of the complications of juvenile idiopathic arthritis (JIA). However, a study focusing on the low bone mass in children and adolescents with JIA in Southeast Asian countries is limited. This study aimed to evaluate the bone mineral density (BMD) of Thai patients with JIA and identify factors correlated with BMD. A cross-sectional study was conducted at a tertiary-care center. The BMD of the lumbar spines (BMDLS) and the total body (BMDTB) were measured by dual-energy X-ray absorptiometry. Thirty-eight patients were enrolled between July 2015 and January 2016. No patient had low BMDLS, and only 2 (5.3%) had low BMDTB. Serum 25-hydroxyvitamin D (25OHD) levels were significantly positively correlated with the BMDTB Z-score (coefficient: 0.047; 95% confidence interval = 0.011-0.082; P = .012). Our study demonstrated a very low prevalence of low bone mass. Optimization of the serum 25OHD level should be encouraged.
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Affiliation(s)
- Sirirat Charuvanij
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Hathaikan Malakorn
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narumon Densupsoontorn
- Division of Nutrition, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pairunyar Nakavachara
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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12
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Sarkissian A, Oberle E, Al Ahmed O, Piccinich D, Barbar-Smiley F, Zak H, Sivaraman V. Improving Vitamin D Screening in a Pediatric Rheumatology Clinic Using Structured Quality Improvement Process. Pediatr Qual Saf 2022; 7:e594. [PMID: 38584959 PMCID: PMC10997281 DOI: 10.1097/pq9.0000000000000594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Monitoring levels of 25-hydroxyvitamin D (25-OHD) is an integral part of bone health assessment in the general pediatric population, especially in at-risk populations such as children with juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (c-SLE), and juvenile dermatomyositis (JDM). However, only 38% of the patients with JIA, c-SLE, and JDM receiving care at Nationwide Children's Hospital Rheumatology clinic in 2016 had a 25-OHD level ordered in the preceding year. The objective of this project was to increase the percentage of 25-OHD levels ordered in patients with JIA, c-SLE, and JDM from 38% to 80% in 11 months and sustain it for 6 months. Methods A multidisciplinary team initiated a continuous improvement project utilizing the Lean Six Sigma methodology. The team diagrammed the clinical process and identified steps that needed improvement. In addition, the team completed a root cause analysis of the process and brainstormed subsequent countermeasures. Results The team did not meet the 80% target but did order a 25-OHD level on 61% of patients by the end of the study period compared to 38% at the start of the study (P value 0.001). The level was sustained after the study period, with 68% of these children having a 25-OHD level ordered. Conclusion The team successfully improved the screening processes for vitamin D deficiency in a busy subspecialty clinic setting using Lean Six Sigma methodology.
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Affiliation(s)
- Aliese Sarkissian
- From the Division of Rheumatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Edward Oberle
- Nationwide Children’s Hospital and The Ohio State University Medical Center, Columbus, Ohio
| | - Ohoud Al Ahmed
- Nationwide Children’s Hospital and The Ohio State University Medical Center, Columbus, Ohio
| | - Dawn Piccinich
- Nationwide Children’s Hospital and The Ohio State University Medical Center, Columbus, Ohio
| | - Fatima Barbar-Smiley
- Nationwide Children’s Hospital and The Ohio State University Medical Center, Columbus, Ohio
| | | | - Vidya Sivaraman
- Nationwide Children’s Hospital and The Ohio State University Medical Center, Columbus, Ohio
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13
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Sigurdsson GV, Schmidt S, Mellström D, Ohlsson C, Saalman R, Lorentzon M. Young Adult Male Patients With Childhood-onset IBD Have Increased Risks of Compromised Cortical and Trabecular Bone Microstructures. Inflamm Bowel Dis 2022:6673056. [PMID: 35993421 DOI: 10.1093/ibd/izac181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Young adults with childhood-onset inflammatory bowel disease (IBD) have increased risks of low areal bone mineral density and low skeletal muscle mass. Volumetric BMD (vBMD), bone geometry and microstructures, in addition to possible associations with skeletal muscle index (SMI) and physical exercise have been scarcely studied in this patient group. PATIENTS AND METHODS In total, 49 young adult male patients with childhood-onset IBD and 245 age- and height-matched young adult male controls were scanned with high-resolution peripheral quantitative computed tomography. Bone geometry, vBMD, and bone microstructures were calculated as median values and compared between the patients and controls. Multivariable linear regression analyses were performed to determine the independent associations among IBD diagnosis, SMI (kg/m2), and physical exercise. RESULTS The group of young adult patients had, in comparison with the controls, significantly smaller median cortical area (126.1 mm2 vs151.1 mm2, P < .001), lower median total vBMD (296.7 mg/cm3 vs 336.7 mg/cm3, P < .001), and lower median cortical vBMD (854.4 mg/cm3 vs 878.5 mg/cm3, P < .001). Furthermore, the patients compared with the controls had lower median trabecular volume fraction (16.8% vs 18.2%, P < .001) and thinner median trabeculae (0.084 mm vs 0.089 mm, P < .001). The differences between the patients with IBD and controls persisted in multivariable analyses that included adjustments for SMI and physical exercise. CONCLUSIONS Young adult men with childhood-onset IBD are at increased risk of having reduced bone quality in both the cortical and trabecular bone structures compared with normative matched controls.
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Affiliation(s)
- Gudmundur Vignir Sigurdsson
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at the University of Gothenburg, and Queen Silvia's Children's Hospital, Gothenburg, Sweden.,Heilbrigdisstofnun Sudurlands, Selfoss, Iceland
| | | | - Dan Mellström
- Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Claes Ohlsson
- Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Drug Treatment, Gothenburg, Sweden
| | - Robert Saalman
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at the University of Gothenburg, and Queen Silvia's Children's Hospital, Gothenburg, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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14
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Rodd C, Kirouac N, Orkin J, Grimes R. Evaluating and optimizing bone health in children with chronic health conditions. Paediatr Child Health 2022; 27:232-242. [PMID: 35859678 DOI: 10.1093/pch/pxac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.
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Affiliation(s)
- Celia Rodd
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Nicole Kirouac
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Julia Orkin
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Ruth Grimes
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
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15
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Rodd C, Kirouac N, Orkin J, Grimes R. L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques. Paediatr Child Health 2022; 27:232-242. [PMID: 35859683 DOI: 10.1093/pch/pxac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.
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Affiliation(s)
- Celia Rodd
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Nicole Kirouac
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Julia Orkin
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Ruth Grimes
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
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Abstract
Osteoporosis is a skeletal disorder with enhanced bone fragility, usually affecting the elderly. It is very rare in children and young adults and the definition is not only based on a low BMD (a Z-score < - 2.0 in growing children and a Z-score ≤ - 2.0 or a T-score ≤ - 2.5 in young adults) but also on the occurrence of fragility fractures and/or the existence of underlying chronic diseases or secondary factors such as use of glucocorticoids. In the absence of a known chronic disease, fragility fractures and low BMD should prompt extensive screening for secondary causes, which can be found in up to 90% of cases. When fragility fractures occur in childhood or young adulthood without an evident secondary cause, investigations should explore the possibility of an underlying monogenetic bone disease, where bone fragility is caused by a single variant in a gene that has a major role in the skeleton. Several monogenic forms relate to type I collagen, but other forms also exist. Loss-of-function variants in LRP5 and WNT1 may lead to early-onset osteoporosis. The X-chromosomal osteoporosis caused by PLS3 gene mutations affects especially males. Another recently discovered form relates to disturbed sphingolipid metabolism due to SGMS2 mutations, underscoring the complexity of molecular pathology in monogenic early-onset osteoporosis. Management of young patients consists of treatment of secondary factors, optimizing lifestyle factors including calcium and vitamin D and physical exercise. Treatment with bone-active medication should be discussed on a personalized basis, considering the severity of osteoporosis and underlying disease versus the absence of evidence on anti-fracture efficacy and potential harmful effects in pregnancy.
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Affiliation(s)
- Outi Mäkitie
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
- Folkhälsan Research Center, Biomedicum Helsinki, P.O. Box 63, FI-00014, Helsinki, Finland.
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, 3015, Rotterdam, The Netherlands
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17
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Eyre TA, Jensen P, Booth S, El-Galaly TC. Bone health and glucocorticoid-containing lymphoma therapy - a review of risk factors and preventative measures. Br J Haematol 2022; 198:431-442. [PMID: 35235226 DOI: 10.1111/bjh.18104] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 01/20/2023]
Abstract
With survival outcomes ever improving for patients with a wide range of lymphoma histologies, the focus on reducing long-term complications of therapy has increased. Recently published, complimentary population and retrospective series have highlighted the importance of considering bone health in patients treated for lymphoma. Fracture-related events or the requirement for secondary bone prophylaxis, likely linked to glucocorticoid-induced osteoporosis (GIO) are substantial and clinically meaningful in a significant minority of patients following routinely employed steroid-containing immunochemotherapy. In this review, we describe the pathophysiology of GIO, the risk of GIO in observational front-line lymphoma studies and efficacy of prophylactic measures from several prospective clinical trials are summarized. Finally, areas of importance for future research are discussed and recommendations for GIO risk assessment and management in lymphoma are provided based on the current available literature.
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Affiliation(s)
- Toby A Eyre
- Department of Haematology, Haematology and Cancer Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paw Jensen
- Department of Haematology, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Stephen Booth
- Department of Haematology, Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
| | - Tarec Christoffer El-Galaly
- Department of Haematology, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Drug Treatment of Low Bone Mass and Other Bone Conditions in Pediatric Patients. Paediatr Drugs 2022; 24:103-119. [PMID: 35013997 DOI: 10.1007/s40272-021-00487-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
Osteoporosis may affect young individuals, albeit infrequently. In childhood, bone mass increases, reaching its peak between the second and third decades; then, after a period of stability, it gradually declines. Several conditions, including genetic disorders, chronic diseases, and some medications, can have an impact on bone homeostasis. Diagnosis in young patients is based on the criteria defined by the International Society for Clinical Densitometry (ISCD), published in 2013. High risk factors should be identified and monitored. Often simple interventions aimed to eliminate the underlying cause, to minimize the negative bone effects linked to drugs, or to increase calcium and vitamin D intake can protect bone mass. However, in selected cases, pharmacological treatment should be considered. Bisphosphonates remain the main therapeutic agent for children with significant skeletal fragility and are also useful in a large number of other bone conditions. Denosumab, an anti-RANKL antibody, could become a potential alternative treatment. Clinical trials to evaluate the long-term effects and safety of denosumab in children are ongoing.
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19
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Ha EK, Kim JH, Kwak JH, Lee S, Cha HR, Chung EH, Han MY. Association of clinical and social factors with risk of fracture in children with atopic dermatitis. Pediatr Allergy Immunol 2022; 33:e13712. [PMID: 34862671 DOI: 10.1111/pai.13712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children with atopic dermatitis (AD) have multiple risk factors for accidental fractures, injuries that can lead to significant morbidity and mortality. However, little is known about the factors that mediate the relationship between AD and fracture in children. OBJECTIVE Our purpose was to examine the association of AD with fracture and to identify potential mediating factors. METHODS This retrospective cohort study examined children with and without AD from a longitudinal matched cohort database of 353,040 children registered in the national health insurance service and participated in the national health-screening program of Korea. We defined AD using medical claims and medication prescription records. We investigated accidental fracture events between the index date and the end of follow-up in a propensity score-matched cohort. Pre-specified subgroup analyses considered fractures in four different regions of the body. The mediating effects of 10 possible clinical factors (including the use of antihistamines and systemic corticosteroids) and social factors (including nutritional status and parental safety awareness) were determined. RESULTS There were 145,704 participating children, 20% with AD and 49% girls. Fractures occurred in 6,652 of the children with AD (23%, mean age: 64.6 ± 29.2 months) and in 24,698 of the control group (21%, mean age 65.0 ± 28.9 months). Children with AD had an 8% greater risk of fracture events overall (adjusted relative risk [aRR]: 1.08, 95% CI: 1.05-1.10). In subgroup analysis, AD was related to increased rates of skull and facial bone fracture (aRR: 1.09, 95% CI: 1.04-1.14), for trunk including vertebrae (aRR: 1.58, 95% CI: 1.22- 2.05), and for distal limbs (aRR: 1.11, 95% CI: 1.07-1.15). However, the relationship with proximal limb fracture was insignificant. Duration of systemic corticosteroid prescription was the largest mediating factor, followed by duration of antihistamine prescription, and infant feeding practices. In particular, the duration of systemic corticosteroid prescription was significantly associated with fracture events (incidence: 20.1% at the 25th percentile and 23.6% at the 75th percentile; difference: 3.4% [95% CI: 2.8-4.0%]). CONCLUSIONS Children with AD were related to increased fracture events. The key factors with mediating effects were systemic use of corticosteroid and antihistamine. Infant feeding practices had weaker mediating effects.
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Affiliation(s)
- Eun Kyo Ha
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Ju Hee Kim
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Ji Hee Kwak
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soonchul Lee
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hye Ryeong Cha
- Department of Data Science, Sejong University College of Software Convergence, Seoul, Korea
| | - Eun Hee Chung
- Department of Pediatrics, Chungnam National University College of Medicine, Daejeon, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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20
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Ward LM, Choudhury A, Alos N, Cabral DA, Rodd C, Sbrocchi AM, Taback S, Padidela R, Shaw NJ, Hosszu E, Kostik M, Alexeeva E, Thandrayen K, Shenouda N, Jaremko JL, Sunkara G, Sayyed S, Aftring RP, Munns CF. Zoledronic Acid vs Placebo in Pediatric Glucocorticoid-induced Osteoporosis: A Randomized, Double-blind, Phase 3 Trial. J Clin Endocrinol Metab 2021; 106:e5222-e5235. [PMID: 34228102 DOI: 10.1210/clinem/dgab458] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Glucocorticoids (GCs) prescribed for chronic pediatric illnesses are associated with osteoporotic fractures. OBJECTIVE This study aims to determine the efficacy and safety of intravenous (IV) zoledronic acid (ZA) compared with placebo to treat pediatric GC-induced osteoporosis (GIO). METHODS Children aged 5 to 17 years with GIO were enrolled in this multinational, randomized, double-blind, placebo-controlled phase 3 trial (ClinicalTrials.gov NCT00799266). Eligible children were randomly assigned 1:1 to 6 monthly IV ZA 0.05 mg/kg or IV placebo. The primary end point was the change in lumbar spine bone mineral density z score (LSBMDZ) from baseline to month 12. Incident fractures and safety were assessed. RESULTS Thirty-four children were enrolled (mean age 12.6 ± 3.4 years [18 on ZA, 16 on placebo]), all with low-trauma vertebral fractures (VFs). LSBMDZ increased from -2.13 ± 0.79 to -1.49 ± 1.05 on ZA, compared with -2.38 ± 0.90 to -2.27 ± 1.03 on placebo (least squares means difference 0.41 [95% CI, 0.02-0.81; P = .04]); when corrected for height z score, the least squares means difference in LBMDZ was 0.75 [95% CI, 0.27-1.22; P = .004]. Two children on placebo had new low-trauma VF vs none on ZA. Adverse events (AEs) were reported in 15 of 18 children (83%) on ZA, and in 12 of 16 (75%) on placebo, most frequently within 10 days after the first infusion. There were no deaths or treatment discontinuations due to treatment-emergent AEs. CONCLUSION LSBMDZ increased significantly on ZA compared with placebo over 1 year in children with GIO. Most AEs occurred after the first infusion.
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Affiliation(s)
- Leanne M Ward
- Children's Hospital of Eastern Ontario and The University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - David A Cabral
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Celia Rodd
- Montréal Children's Hospital, Montréal, Quebec H4A 3J1, Canada
| | | | - Shayne Taback
- Winnipeg Children's Hospital, Winnipeg, Manitoba, Canada
| | - Raja Padidela
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Nick J Shaw
- Birmingham Children's Hospital, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Eva Hosszu
- 2nd Department of Pediatrics, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Mikhail Kostik
- Saint- Petersburg State Pediatric Medical University of the MoH, St Petersburg, Russia
| | - Ekaterina Alexeeva
- Federal State Autonomous Institution "National Medical Research Center of Children's Health" of the Ministry of Health of the Russian Federation, Moscow, Russia
- Federal State Autonomous Educational Institution of Higher Education, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Kebashni Thandrayen
- Department of Pediatrics, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Nazih Shenouda
- Children's Hospital of Eastern Ontario and The University of Ottawa, Ottawa, Ontario, Canada
| | - Jacob L Jaremko
- Stollery Children's Hospital and The University of Alberta, Edmonton, Alberta, Canada
| | | | | | - R Paul Aftring
- Novartis Pharmaceuticals Corp; East Hanover, New Jersey, USA
| | - Craig F Munns
- Children's Hospital at Westmead, Sydney, Westmead, New South Wales 2145, Australia and Discipline of Paediatrics & Child Health, University of Sydney, Sydney, NSW, Australia
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21
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Ward LM, Ma J, Robinson ME, Scharke M, Ho J, Houghton K, Huber A, Scuccimarri R, Barsalou J, Roth J, Shenouda N, Matzinger MA, Lentle B, Jaremko JL, Koujok K, Watanabe Duffy K, Stein R, Sbrocchi AM, Rodd C, Miettunen PM, LeBlanc CMA, Larche M, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Sykes E, Konji VN, Rauch F, Siminoski K, Lang B. Osteoporotic Fractures and Vertebral Body Reshaping in Children With Glucocorticoid-treated Rheumatic Disorders. J Clin Endocrinol Metab 2021; 106:e5195-e5207. [PMID: 34232311 DOI: 10.1210/clinem/dgab494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Osteoporotic fractures are an important cause of morbidity in children with glucocorticoid-treated rheumatic disorders. OBJECTIVE This work aims to evaluate the incidence and predictors of osteoporotic fractures and potential for recovery over six years following glucocorticoid (GC) initiation in children with rheumatic disorders. METHODS Children with GC-treated rheumatic disorders were evaluated through a prospective inception cohort study led by the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium. Clinical outcomes included lumbar spine bone mineral density (LS BMD), vertebral fractures (VF), non-VF, and vertebral body reshaping. RESULTS A total of 136 children with GC-treated rheumatic disorders were enrolled (mean age 9.9 years, SD 4.4). The 6-year cumulative fracture incidence was 16.3% for VF, and 10.1% for non-VF. GC exposure was highest in the first 6 months, and 24 of 38 VF (63%) occurred in the first 2 years. Following VF, 16 of 19 children (84%) had complete vertebral body reshaping. Increases in disease activity and body mass index z scores in the first year and declines in LS BMD z scores in the first 6 months predicted incident VF over the 6 years, while higher average daily GC doses predicted both incident VF and non-VF. LS BMD z scores were lowest at 6 months (mean -0.9, SD 1.2) and remained low by 6 years even when adjusted for height z scores (-0.6, SD 0.9). CONCLUSION VF occurred early and were more common than non-VF in children with GC-treated rheumatic disorders. Eighty-four percent of children with VF underwent complete vertebral body reshaping, whereas vertebral deformity persisted in the remainder of children. On average, LS BMD z scores remained low at 6 years, consistent with incomplete recovery.
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Affiliation(s)
- Leanne M Ward
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | - Jinhui Ma
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | - Maya Scharke
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Josephine Ho
- University of Calgary, Calgary T3B 6A8, Alberta, Canada
| | - Kristin Houghton
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | - Adam Huber
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
| | | | - Julie Barsalou
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Johannes Roth
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | | | | | - Brian Lentle
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | | | | | - Robert Stein
- University of Western Ontario, London N6A 5A5, Ontario, Canada
| | | | - Celia Rodd
- University of Manitoba, Winnipeg R3E 0Z3, Manitoba, Canada
| | | | | | - Maggie Larche
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | | | - Robert Couch
- University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - David A Cabral
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | - Nathalie Alos
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Elizabeth Sykes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Victor N Konji
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Frank Rauch
- McGill University, Montréal H4A 3J1, Quebec, Canada
| | | | - Bianca Lang
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
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22
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Ma J, Siminoski K, Wang P, Jaremko JL, Koujok K, Matzinger MA, Shenouda N, Lentle B, Alos N, Cummings EA, Ho J, Houghton K, Miettunen PM, Scuccimarri R, Rauch F, Ward LM. The Accuracy of Incident Vertebral Fracture Detection in Children Using Targeted Case-Finding Approaches. J Bone Miner Res 2021; 36:1255-1268. [PMID: 33784410 DOI: 10.1002/jbmr.4294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022]
Abstract
Vertebral fractures are clinically important sequelae of a wide array of pediatric diseases. In this study, we examined the accuracy of case-finding strategies for detecting incident vertebral fractures (IVF) over 2 years in glucocorticoid-treated children (n = 343) with leukemia, rheumatic disorders, or nephrotic syndrome. Two clinical situations were addressed: the prevalent vertebral fracture (PVF) scenario (when baseline PVF status was known), which assessed the utility of PVF and low lumbar spine bone mineral density (LS BMD; Z-score <-1.4), and the non-PVF scenario (when PVF status was unknown), which evaluated low LS BMD and back pain. LS BMD was measured by dual-energy X-ray absorptiometry, vertebral fractures were quantified on spine radiographs using the modified Genant semiquantitative method, and back pain was assessed by patient report. Forty-four patients (12.8%) had IVF. In the PVF scenario, both low LS BMD and PVF were significant predictors of IVF. Using PVF to determine which patients should have radiographs, 11% would undergo radiography (95% confidence interval [CI] 8-15) with 46% of IVF (95% CI 30-61) detected. Sensitivity would be higher with a strategy of PVF or low LS BMD at baseline (73%; 95% CI 57-85) but would require radiographs in 37% of children (95% CI 32-42). In the non-PVF scenario, the strategy of low LS BMD and back pain produced the highest specificity of any non-PVF model at 87% (95% CI 83-91), the greatest overall accuracy at 82% (95% CI 78-86), and the lowest radiography rate at 17% (95% CI 14-22). Low LS BMD or back pain in the non-PVF scenario produced the highest sensitivity at 82% (95% CI 67-92), but required radiographs in 65% (95% CI 60-70). These results provide guidance for targeting spine radiography in children at risk for IVF. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging and Department of Internal Medicine, University of Alberta, Edmonton, Canada
| | - Peiyao Wang
- Faculty of Science, McMaster University, Hamilton, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, Canada
| | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, Canada
| | - Nathalie Alos
- Department of Pediatrics, Université de Montréal, Montréal, Canada
| | | | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | | | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
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- Canadian Pediatric Bone Health Working Group, Ottawa, Canada
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23
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Sigurdsson GV, Schmidt S, Mellström D, Ohlsson C, Karlsson M, Lorentzon M, Saalman R. Physical exercise is associated with beneficial bone mineral density and body composition in young adults with childhood-onset inflammatory bowel disease. Scand J Gastroenterol 2021; 56:699-707. [PMID: 33945377 DOI: 10.1080/00365521.2021.1913759] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have an increased risk of compromised bone mineral density (BMD) and body composition. There are limited data on the physical exercise (PE) habits of patients with childhood-onset IBD and on the associations between PE and BMD and body composition. PATIENTS AND METHODS In total, 72 young adults with childhood-onset IBD and 1341 normative young adult controls answered questionnaires regarding PE [hours/week (h/w)] in the last 12 months. BMD and body composition were measured with dual x-ray absorptiometry (DXA) and presented as age- and gender-adjusted Z-scores for BMD, skeletal muscle index (SMI, the weight of lean mass in arms and legs/m2), and percentage body fat (Fat %). RESULTS A total of 41 (57%) patients with IBD engaged in PE during the previous 12 months, as compared to 913 (68%) of the controls (p = .053). Sedentary patients had significantly lower median BMD, SMI, and Fat % Z-scores than the controls with corresponding PE habits (all p < .05). In contrast, highly active (>4 h/week) patients had total body BMD, SMI, and Fat % in the same range as the controls with corresponding PE levels (p = .151, p = .992, and p = .189, respectively), albeit with lower BMDs in the spine (p = .007) and femoral neck (p = .015). Using multiple regression analyses, a diagnosis of childhood-onset IBD was independently associated with inferior BMD and body composition, regardless of the amount of PE. CONCLUSION Physical exercise is associated with beneficial bone mineral density and body composition in patients with IBD despite the negative effects of the disease.
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Affiliation(s)
- Gudmundur Vignir Sigurdsson
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg and Queen Silvia's Children's Hospital, Gothenburg, Sweden
| | | | - Dan Mellström
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Drug Treatment, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences and Orthopedics, Lund University and Skåne University Hospital, Malmo, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Mary MacKillop Institute for Health Research, Melbourne, Australia
| | - Robert Saalman
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg and Queen Silvia's Children's Hospital, Gothenburg, Sweden
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24
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Hsu HE, Hsu YP, Yu CH. Multiple vertebral compression fractures in a human immunodeficiency virus-positive patient with glucocorticoid-induced Cushing syndrome treated with percutaneous vertebroplasty: a case report. Osteoporos Int 2021; 32:1233-1237. [PMID: 33575910 DOI: 10.1007/s00198-021-05880-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
The authors present a rare case of multiple vertebral compression fractures in a young female with iatrogenic glucocorticoid-induced Cushing syndrome and concomitant human immunodeficiency virus (HIV) infection. Both long-term steroid use and HIV infection may lead to osteopenia or even osteoporosis. Multiple vertebral fractures in young patients are very uncommon and should alert the examiner to investigate any underlying cause. Treatment choices include pharmacological agents such as bisphosphonates or parathyroid hormone and even surgical interventions such as percutaneous vertebroplasty.
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Affiliation(s)
- H-E Hsu
- Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Y-P Hsu
- Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - C-H Yu
- Department of Orthopedic Surgery, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan.
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25
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Abstract
PURPOSE OF THE REVIEW Underlying conditions which adversely affect skeletal strength are one of the most common reasons for consultations in pediatric bone health clinics. The diseases most frequently linked to fragility fractures include leukemia and other cancers, inflammatory disorders, neuromuscular disease, and those treated with osteotoxic drugs (particularly glucocorticoids). The decision to treat a child with secondary osteoporosis is challenged by the fact that fractures are frequent in childhood, even in the absence of risk factors. Furthermore, some children have the potential for medication-unassisted recovery from osteoporosis, obviating the need for bisphosphonate therapy. RECENT FINDINGS Over the last decade, there have been important advances in our understanding of the skeletal phenotypes, fracture frequencies, and risk factors for bone fragility in children with underlying disorders. With improved knowledge about the importance of fracture characteristics in at-risk children, there has been a shift away from a bone mineral density (BMD)-centric definition of osteoporosis in childhood, to a fracture-focused approach. As a result, attention is now drawn to the early identification of fragility fractures, which includes asymptomatic vertebral collapse. Furthermore, even a single, long bone fracture can represent a major osteoporotic event in an at-risk child. Fundamental biological principles of bone strength development, and the ways in which these go awry in chronic illnesses, form the basis for monitoring and diagnosis of osteoporosis in children with underlying conditions. Overall, the goal of monitoring is to identify early, rather than late, signs of osteoporosis in children with limited potential to undergo medication-unassisted recovery. These are the children who should undergo bisphosphonate therapy, as discussed in part 1 (monitoring and diagnosis) and part 2 (recovery and the decision to treat) of this review.
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Affiliation(s)
- Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Pediatric Bone Health Research Group, The CHEO Pediatric Genetic and Metabolic Bone Disease Clinic, The Children's Hospital of Eastern Ontario (CHEO), Room 250H, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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26
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d’Angelo DM, Di Donato G, Breda L, Chiarelli F. Growth and puberty in children with juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2021; 19:28. [PMID: 33712046 PMCID: PMC7953722 DOI: 10.1186/s12969-021-00521-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 03/04/2021] [Indexed: 12/13/2022] Open
Abstract
Juvenile Idiopathic Arthritis is one of the most prevalent chronic diseases in children, with an annual incidence of 2-20 cases per 100,000 and a prevalence of 16-150 per 100,000. It is associated with several complications that can cause short-term or long-term disability and reduce the quality of life. Among these, growth and pubertal disorders play an important role. Chronic inflammatory conditions are often associated with growth failure ranging from slight decrease in height velocity to severe forms of short stature. The prevalence of short stature in JIA varies from 10.4% in children with polyarticular disease to 41% of patients with the systemic form, while oligoarthritis is mostly associated with localized excessive bone growth of the affected limb, leading to limb dissymmetry. The pathogenesis of growth disorders is multifactorial and includes the role of chronic inflammation, long-term use of corticosteroids, undernutrition, altered body composition, delay of pubertal onset or slow pubertal progression. These factors can exert a systemic effect on the GH/IGF-1 axis and on the GnRH-gonadotropin-gonadic axis, or a local influence on the growth plate homeostasis and function. Although new therapeutic options are available to control inflammation, there are still 10-20% of patients with severe forms of the disease who show continuous growth impairment, ending in a short final stature. Moreover, delayed puberty is associated with a reduction in the peak bone mass with the possibility of concomitant or future bone fragility. Monitoring of puberty and bone health is essential for a complete health assessment of adolescents with JIA. In these patients, an assessment of the pubertal stage every 6 months from the age of 9 years is recommended. Also, linear growth should be always evaluated considering the patient's bone age. The impact of rhGH therapy in children with JIA is still unclear, but it has been shown that if rhGH is added at high dose in a low-inflammatory condition, post steroids and on biologic therapy, it is able to favor a prepubertal growth acceleration, comparable with the catch-up growth response in GH-deficient patients. Here we provide a comprehensive review of the pathogenesis of puberty and growth disorders in children with JIA, which can help the pediatrician to properly and timely assess the presence of growth and pubertal disorders in JIA patients.
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Affiliation(s)
| | - Giulia Di Donato
- grid.412451.70000 0001 2181 4941Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Luciana Breda
- grid.412451.70000 0001 2181 4941Department of Pediatrics, University of Chieti, Chieti, Italy
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27
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Thandrayen K, Kala UK, Lala N, Okudo G, Parbhoo KB, Moosa FY, Verwey C, Hauptfleisch M, Hajinicolaou C, Ambaram PR, Mistry BJ, Petersen KL, Pettifor JM. Bone mass and vertebral fractures in South African children on prolonged oral glucocorticoids for chronic non-malignant illnesses. Bone Rep 2021; 14:100751. [PMID: 33644265 PMCID: PMC7887385 DOI: 10.1016/j.bonr.2021.100751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction We hypothesized that the prevalence of vertebral fractures would be low and that bone mineral density (BMD) would be less severely affected in a black South African (SA) population treated with glucocorticoids (GCs) than that reported in mainly white populations. Methods All children aged 5–17.9 years with chronic non-malignant illnesses who were on GCs (intravenous or oral) for greater than 3 months duration were evaluated. DXA scans were performed using a Hologic Discovery machine (Software version Apex 4.0.2) and the Hologic paediatric reference database. Whole body less head (WBLH) and lumbar spine (LS) bone mineral content (BMC) and density (BMD) Z-scores unadjusted and adjusted for height were calculated using the Zemel equation calculator. Results Seventy-two patients (49% with renal, 24% with rheumatic, 14% with neurological, 11% with hepatic and 3% with respiratory conditions; mean age 11.6 ± 3.3 years, 57% boys, 92% SA black) were enrolled. The mean duration of GC treatment was 34.1 (±25.1) months. Mean WBLH and LS height adjusted BMD Z-scores were −1.2 ± 1.5 and −0.9 ± 1.0 respectively. Eleven percent of patients had a LS height adjusted BMD Z-score ≤ −2. The prevalence of vertebral fractures on lateral vertebral fracture assessment (VFA) was 15% (11 of 72 patients). Conclusion The prevalence of vertebral fractures (15%) in predominantly black children on GCs with chronic non-malignant illnesses is similar to that reported from North America suggesting that routine yearly DXA scans including VFA are warranted in this highly at-risk population. Prevalence of vertebral fractures in black South African children on GCs is 15%. Majority of patients had 25(OH)D levels >30 nmol/L. A quarter of the patients with vitamin D deficiency had a LS BMD Z score ≤ −2. None of the vitamin D deficient patients had vertebral fractures. Routine yearly DXA scans are thus warranted on all children treated with GCs.
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Affiliation(s)
- Kebashni Thandrayen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Udai Keshav Kala
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nilesh Lala
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Grace Okudo
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kiran Bhagoo Parbhoo
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fatima Yakoub Moosa
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charl Verwey
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc Hauptfleisch
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Christina Hajinicolaou
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Priya Ramanlal Ambaram
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bhadrish Jayantkumar Mistry
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Lavinia Petersen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John Morley Pettifor
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Diacinti D, Pisani D, Cipriani C, Celli M, Zambrano A, Diacinti D, Kripa E, Iannacone A, Colangelo L, Nieddu L, Pepe J, Minisola S. Vertebral fracture assessment (VFA) for monitoring vertebral reshaping in children and adolescents with osteogenesis imperfecta treated with intravenous neridronate. Bone 2021; 143:115608. [PMID: 32829035 DOI: 10.1016/j.bone.2020.115608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/21/2020] [Accepted: 08/15/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE The study was aimed at monitoring vertebral bodies changes with the use of Vertebral Fracture Assessment (VFA) in children and adolescents affected by osteogenesis imperfecta (OI) during treatment with intravenous neridronate. METHODS 60 children and adolescents (35 males and 25 females; age 1-16 years) with OI type I, III and IV were included in the study. Intravenous neridronate was administered at the dose of 2 mg/kg every 3 months in all patients. Lumbar spine (LS) bone mineral density (BMD) and VFA by dual X-ray absorptiometry (DXA) were assessed every 6 months up to 24 months during treatment. VFA with vertebral morphometry (MXA) was used to calculate the three indices of vertebral deformity: wedging, concavity and crushing. Serum calcium, phosphate, parathyroid hormone (PTH), 25-hydroxy-vitamin D [25(OH)D], total alkaline phosphatase (ALP), bone alkaline phosphatase (BALP) and urinary C-terminal telopeptide of type 1 collagen (CTx) were measured at any time point. RESULTS Mean LS BMD values significantly increased at 24 months compared to baseline (p < 0.0001); the corresponding Z-score values were -1.28 ± 1.23 at 24 months vs -2.46 ± 1.25 at baseline; corresponding mean Bone Mineral Apparent Density (BMAD) values were 0.335 ± 0.206 vs 0.464 ± 0.216. Mean serum levels of ALP, BALP and CTx significantly decreased from baseline to 24 months. By MXA, we observed a significant 19.1% reduction of the mean wedging index of vertebral reshaping at 12 months, and 38.4% at 24 months (p < 0.0001) and of the mean concavity index (16.3% at 12 months and 35.9% at 24 months; p < 0.0001). Vertebral reshaping was achieved for 66/88 (75%) wedge fractures and 59/70 (84%) concave fractures, but there were 4 incident mild fractures. Finally, VF rate was reduced at 24 months compared to baseline: 37/710 (5.2%) vs 158/710 (22.2%). CONCLUSION Our study demonstrates the utility of VFA as a safe and alternative methodology in the follow-up of children and adolescents with OI.
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Affiliation(s)
- D Diacinti
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, viale Regina Elena 324, 00161 Rome, Italy
| | - D Pisani
- Department of Clinical and Molecular Medicine, Saint'Andrea Hospital, Sapienza University of Rome, via Grottarossa, 1035, Rome, Italy
| | - C Cipriani
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161,Rome, Italy.
| | - M Celli
- Department Materno-Infantile, Center of Rare Disease and Skeletal Dysplasia, Policlinico Umberto I Hospital, Viale del Policlinico, 155, 00161 Rome, Italy
| | - A Zambrano
- Department Materno-Infantile, Center of Rare Disease and Skeletal Dysplasia, Policlinico Umberto I Hospital, Viale del Policlinico, 155, 00161 Rome, Italy
| | - D Diacinti
- Department of Oral and Maxillo-Facial Sciences, Policlinico Umberto I Hospital, Sapienza University of Rome, via Caserta 6, 00161, Rome, Italy; Department of Diagnostic and Molecular Imaging, Radiology and Radiotherapy, University Foundation Hospital Tor Vergata, Rome, Italy
| | - E Kripa
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, viale Regina Elena 324, 00161 Rome, Italy
| | - A Iannacone
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, viale Regina Elena 324, 00161 Rome, Italy
| | - L Colangelo
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161,Rome, Italy
| | - L Nieddu
- Faculty of Economics, UNINT University, Via Cristoforo Colombo 200, 00147, Rome, Italy
| | - J Pepe
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161,Rome, Italy
| | - S Minisola
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161,Rome, Italy
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29
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Weare-Regales N, Hudey SN, Lockey RF. Practical Guidance for Prevention and Management of Glucocorticoid-Induced Osteoporosis for the Allergist/Immunologist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1841-1850. [PMID: 33444813 DOI: 10.1016/j.jaip.2020.12.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a silent disorder with dire consequences, and glucocorticoid use remains the most common iatrogenic cause illustrated by the fact that 30% to 50% of subjects on such long-term therapy experience fractures (Oimomi M, Nakamichi T, Ohara T, Sakai M, Igaki N, Hata F, et al. Fructose-related glycation. Diabetes Res Clin Pract 1989;7:137-9; Reid IR. Glucocorticoid osteoporosis--mechanisms and management. Eur J Endocrinol 1997;137:209-17). By directly affecting bone quality while actively used, glucocorticoids increase the risk of fracture that is independent of a subject's bone density status at the time (Weinstein RS. True strength. J Bone Miner Res 2000;15:621-5). A large number of subjects seen in an allergy and immunology clinic have asthma, chronic rhinosinusitis, or other chronic inflammatory diseases, necessitating the use of these medications and placing them at higher risk for this disease. Data on the effects of both oral and inhaled glucocorticoids on fracture risk are presented. This review concretizes the importance of osteoporosis, its pathophysiology, and provides practical guidelines to prevent and treat it. Management recommendations are tailored to 2 different age groups. The first group consists of children, adolescents, and adults 40 years or younger with a focus on attaining peak bone mass. The second group consists of adults 40 years or older where the use of imaging modalities and Fracture Risk Assessment Tool scores helps triage subjects into fracture risk categories. Those at moderate to high risk require bone-sparing medications. Universal preventive measures for both groups are reviewed. Complicated and severe cases may need additional expertise by an endocrinologist or rheumatologist.
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Affiliation(s)
- Natalia Weare-Regales
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, University of South Florida, Morsani College of Medicine and James A. Haley Veterans' Hospital, Tampa, Fla
| | - Stephanie N Hudey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla.
| | - Richard F Lockey
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, Fla
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30
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Abstract
Glucocorticoids (GC) are an important risk factor for bone fragility in children with serious illnesses, largely due to their direct adverse effects on skeletal metabolism. To better appreciate the natural history of fractures in this setting, over a decade ago the Canadian STeroid-associated Osteoporosis in the Pediatric Population ("STOPP") Consortium launched a 6 year, multi-center observational cohort study in GC-treated children. This study unveiled numerous key clinical-biological principles about GC-induced osteoporosis (GIO), many of which are unique to the growing skeleton. This was important, because most GIO recommendations to date have been guided by adult studies, and therefore do not acknowledge the pediatric-specific principles that inform monitoring, diagnosis and treatment strategies in the young. Some of the most informative observations from the STOPP study were that vertebral fractures are the hallmark of pediatric GIO, they occur early in the GC treatment course, and they are frequently asymptomatic (thereby undetected in the absence of routine monitoring). At the same time, some children have the unique, growth-mediated ability to restore normal vertebral body dimensions following vertebral fractures. This is an important index of recovery, since spontaneous vertebral body reshaping may preclude the need for osteoporosis therapy. Furthermore, we now better understand that children with poor growth, older children with less residual growth potential, and children with ongoing bone health threats have less potential for vertebral body reshaping following spine fractures, which can result in permanent vertebral deformity if treatment is not initiated in a timely fashion. Therefore, pediatric GIO management is now predicated upon early identification of vertebral fractures in those at risk, and timely intervention when there is limited potential for spontaneous recovery. A single, low-trauma long bone fracture can also signal an osteoporotic event, and a need for treatment. Intravenous bisphosphonates are currently the recommended therapy for pediatric GC-induced bone fragility, typically prescribed to children with limited potential for medication-unassisted recovery. It is recognized, however, that even early identification of bone fragility, combined with timely introduction of intravenous bisphosphonate therapy, may not completely rescue the osteoporosis in those with the most aggressive forms, opening the door to novel strategies.
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Affiliation(s)
- Leanne M. Ward
- The Ottawa Pediatric Bone Health Research Group, The Children's Hospital of Eastern Ontario Genetic and Metabolic Bone Disease Clinic, University of Ottawa, Ottawa, ON, Canada
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31
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Abstract
The last 2 decades have seen tremendous growth in understanding the clinical characteristics of various childhood bone disorders, their mechanisms and natural histories, and their responses to treatment. In this review, the authors describe advances in bone assessment techniques for children. In addition, they provide their skeletal site-specific applications, underscore the principles that are relevant to the biology of the growing child, show how these methods assist in the diagnosis and management of pediatric bone diseases, and highlight how these techniques have shed light on bone development and underlying disease mechanisms.
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Affiliation(s)
- Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada.
| | - Victor N Konji
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
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32
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Sakka SD, Cheung MS. Management of primary and secondary osteoporosis in children. Ther Adv Musculoskelet Dis 2020; 12:1759720X20969262. [PMID: 33224280 PMCID: PMC7649886 DOI: 10.1177/1759720x20969262] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
Abstract
Osteoporosis in children differs from adults in terms of definition, diagnosis, monitoring and treatment options. Primary osteoporosis comprises primarily of osteogenesis imperfecta (OI), but there are significant other causes of bone fragility in children that require treatment. Secondary osteoporosis can be a result of muscle disuse, iatrogenic causes, such as steroids, chronic inflammation, delayed or arrested puberty and thalassaemia major. Investigations involve bone biochemistry, dual-energy X-ray absorptiometry scan for bone densitometry and vertebral fracture assessment, radiographic assessment of the spine and, in some cases, quantitative computed tomography (QCT) or peripheral QCT. It is important that bone mineral density (BMD) results are adjusted based on age, gender and height, in order to reflect size corrections in children. Genetics are being used increasingly for the diagnosis and classification of various cases of primary osteoporosis. Bone turnover markers are used less frequently in children, but can be helpful in monitoring treatment and transiliac bone biopsy can assist in the diagnosis of atypical cases of osteoporosis. The management of children with osteoporosis requires a multidisciplinary team of health professionals with expertise in paediatric bone disease. The prevention and treatment of fragility fractures and improvement of the quality of life of patients are important aims of a specialised service. The drugs used most commonly in children are bisphosphonates, that, with timely treatment, can give good results in improving BMD and reshaping vertebral fractures. The data regarding their effect on reducing long bone fractures are equivocal. Denosumab is being used increasingly for various conditions with mixed results. There are more drugs trialled in adults, but these are not yet licenced for children. Increasing awareness of risk factors for paediatric osteoporosis, screening and referral to a specialist team for appropriate management can lead to early detection and treatment of asymptomatic fractures and prevention of further bone damage.
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Affiliation(s)
- Sophia D Sakka
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, 3rd Floor, Becket House, Westminster Bridge Road, SE1 7EH, London, UK
| | - Moira S Cheung
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, London, UK
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33
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Bar M, Ott SM, Lewiecki EM, Sarafoglou K, Wu JY, Thompson MJ, Vaux JJ, Dean DR, Saag KG, Hashmi SK, Inamoto Y, Dholaria BR, Kharfan-Dabaja MA, Nagler A, Rodriguez C, Hamilton BK, Shah N, Flowers MED, Savani BN, Carpenter PA. Bone Health Management After Hematopoietic Cell Transplantation: An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant 2020; 26:1784-1802. [PMID: 32653624 DOI: 10.1016/j.bbmt.2020.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/14/2022]
Abstract
Bone health disturbances commonly occur after hematopoietic cell transplantation (HCT) with loss of bone mineral density (BMD) and avascular necrosis (AVN) foremost among them. BMD loss is related to pretransplantation chemotherapy and radiation exposure and immunosuppressive therapy for graft-versus-host-disease (GVHD) and results from deficiencies in growth or gonadal hormones, disturbances in calcium and vitamin D homeostasis, as well as osteoblast and osteoclast dysfunction. Although the pathophysiology of AVN remains unclear, high-dose glucocorticoid exposure is the most frequent association. Various societal treatment guidelines for osteoporosis exist, but the focus is mainly on menopausal-associated osteoporosis. HCT survivors comprise a distinct population with unique comorbidities, making general approaches to bone health management inappropriate in some cases. To address a core set of 16 frequently asked questions (FAQs) relevant to bone health in HCT, the American Society of Transplant and Cellular Therapy Committee on Practice Guidelines convened a panel of experts in HCT, adult and pediatric endocrinology, orthopedics, and oral medicine. Owing to a lack of relevant prospective controlled clinical trials that specifically address bone health in HCT, the answers to the FAQs rely on evidence derived from retrospective HCT studies, results extrapolated from prospective studies in non-HCT settings, relevant societal guidelines, and expert panel opinion. Given the heterogenous comorbidities and needs of individual HCT recipients, answers to FAQs in this article should be considered general recommendations, with good medical practice and judgment ultimately dictating care of individual patients. Readers are referred to the Supplementary Material for answers to additional FAQs that did not make the core set.
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Affiliation(s)
- Merav Bar
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
| | - Susan M Ott
- Department of Medicine, University of Washington, Seattle, Washington
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico; Bone Health TeleECHO, UNM Health Sciences Center, Albuquerque, New Mexico
| | - Kyriakie Sarafoglou
- Department of Pediatrics, Divisions of Endocrinology and Genetics & Metabolism, University of Minnesota Medical School, Minneapolis, Minnesota; Department of Experimental & Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota
| | - Joy Y Wu
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew J Thompson
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jonathan J Vaux
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - David R Dean
- Department of Oral Medicine, University of Washington School of Dentistry, Seattle, Washington
| | - Kenneth G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Shahrukh K Hashmi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Bhagirathbhai R Dholaria
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Arnon Nagler
- Bone Marrow Transplantation Department, Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Cesar Rodriguez
- Department of Internal Medicine Hematology and Oncology, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Nina Shah
- Division of Hematology-Oncology, University of California, San Francisco, California
| | - Mary E D Flowers
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Bipin N Savani
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul A Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
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Edouard T, Guillaume-Czitrom S, Bacchetta J, Sermet-Gaudelus I, Dugelay E, Martinez-Vinson C, Salles JP, Linglart A. Guidelines for the management of children at risk of secondary bone fragility: Expert opinion of a French working group. Arch Pediatr 2020; 27:393-398. [PMID: 32921532 DOI: 10.1016/j.arcped.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 07/30/2020] [Indexed: 11/30/2022]
Abstract
The current French national guidelines were elaborated by a working group consisting of experts in the field of pediatric endocrinology, rheumatology, hepatogastroenterology, nephrology, and pneumology. A systematic search was undertaken of the literature published between 2008 and 2018 and indexed in PubMed. The recommendations developed were then validated by an external evaluation group comprising representatives from the various highly specialized fields in pediatrics, representatives of the societies and groups supporting the development of the guidelines, and representatives of different healthcare professions. The objective of these guidelines was to detail the current optimal management of children at risk of secondary bone fragility.
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Affiliation(s)
- T Edouard
- Unité d'endocrinologie, maladies osseuses et génétique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, ERN BOND, hôpital des Enfants, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France.
| | - S Guillaume-Czitrom
- AP-HP, médecine des adolescents, GHU Bicêtre Paris-Saclay, 94270 Le Kremlin-Bicêtre cedex, France
| | - J Bacchetta
- Service de néphrologie, rhumatologie et dermatologie pédiatrique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, CHU de Lyon, 69677 Bron cedex, France
| | | | - E Dugelay
- Service de gastroentérologie et hépatologie pédiatrique, CHU Robert-Debré, 75019 Paris, France
| | - C Martinez-Vinson
- Service de gastroentérologie et hépatologie pédiatrique, CHU Robert-Debré, 75019 Paris, France
| | - J P Salles
- Unité d'endocrinologie, maladies osseuses et génétique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, ERN BOND, hôpital des Enfants, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France
| | - A Linglart
- AP-HP, endocrinologie et diabète de l'enfant, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, GHU Bicêtre Paris-Saclay, 94270 Le Kremlin-Bicêtre cedex, France
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35
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Vincze A, Bodoki L, Szabó K, Nagy-Vincze M, Szalmás O, Varga J, Dankó K, Gaál J, Griger Z. The risk of fracture and prevalence of osteoporosis is elevated in patients with idiopathic inflammatory myopathies: cross-sectional study from a single Hungarian center. BMC Musculoskelet Disord 2020; 21:426. [PMID: 32616032 PMCID: PMC7333418 DOI: 10.1186/s12891-020-03448-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/23/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The prevalence of osteoporosis and risk of fractures is elevated in rheumatoid arthritis (RA), but we have limited information about the bone mineral density (BMD) and fracture risk in patients with inflammatory myopathies. We intended to ascertain and compare fracture risk, bone mineral density and the prevalence of vertebral fractures in patients with inflammatory myositis and rheumatoid arthritis and to assess the effect of prevalent fractures on the quality of life and functional capacity. METHODS Fifty-two patients with myositis and 43 patients with rheumatoid arthritis were included in the study. Fracture Risk was determined using FRAX® Calculation Tool developed by the University of Sheffield. Dual energy X-ray absorptiometry and bidirectional thoracolumbar radiographs were performed to assess BMD and vertebral fractures. Quality of life was measured with Short Form-36 (SF-36) and physical function assessment was performed using Health Assessment Questionnaire (HAQ). RESULTS We found a significantly elevated fracture risk in RA as compared to myositis patients if the risk assessment was performed without the inclusion of the BMD results. If BMD results and glucocorticoid dose adjustment were taken into account, the differences in fracture risk were no longer significant. The prevalence of osteoporosis was found to be significantly higher in the myositis group (7% vs. 13.5%, p: 0.045), but the fracture prevalence was similar in the two groups (75% vs. 68%). The fracture rates were independently associated with age in the myositis group, and with lower BMD results in the RA patients. The number of prevalent fractures was significantly correlated to poorer physical function in both groups, and poorer health status in the myositis group, but not in the RA group. CONCLUSIONS Our findings suggest that inflammatory myopathies carry significantly elevated risks for osteoporosis and fractures. These higher risks are comparable to ones detected with RA in studies and strongly affect the physical function and quality of life of patients. Therefore further efforts are required to make the fracture risk assessment reliable and to facilitate the use of early preventive treatments.
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Affiliation(s)
- Anett Vincze
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary.,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary
| | - Levente Bodoki
- Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary.,Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Szabó
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary.,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary
| | - Melinda Nagy-Vincze
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary.,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary
| | - Orsolya Szalmás
- Department of Medical Imaging, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - József Varga
- Department of Medical Imaging, Division of Nuclear Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Dankó
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary.,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary
| | - János Gaál
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary.,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary.,Department of Medicine, Kenézy Gyula University Hospital, University of Debrecen, Debrecen, Hungary
| | - Zoltán Griger
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Móricz Zsigmond út 22, Debrecen, H-4032, Hungary. .,Gyula Petrányi Doctoral School of Clinical Immunology and Allergology, University of Debrecen, Debrecen, Hungary.
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Sato D, Takahata M, Ota M, Fukuda C, Hasegawa T, Yamamoto T, Amizuka N, Tsuda E, Okada A, Hiruma Y, Fujita R, Iwasaki N. Siglec-15-targeting therapy protects against glucocorticoid-induced osteoporosis of growing skeleton in juvenile rats. Bone 2020; 135:115331. [PMID: 32217159 DOI: 10.1016/j.bone.2020.115331] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
Effective treatment of juvenile osteoporosis, which is frequently caused by glucocorticoid (GC) therapy, has not been established due to limited data regarding the efficacy and adverse effects of antiresorptive therapies on the growing skeleton. We previously demonstrated that sialic acid-binding immunoglobulin-like lectin 15 (Siglec-15) targeting therapy, which interferes with osteoclast terminal differentiation in the secondary, but not primary, spongiosa, increased bone mass without adverse effects on skeletal growth, whereas bisphosphonate, a first-line treatment for osteoporosis, increased bone mass but impaired long bone growth in healthy growing rats. In the present study, we investigated the efficacy of anti-Siglec-15 neutralizing antibody (Ab) therapy against GC-induced osteoporosis in a growing rat model. GC decreased bone mass and deteriorated mechanical properties of bone, due to a disproportionate increase in bone resorption. Both anti-Siglec-15 Ab and alendronate (ALN) showed protective effects against GC-induced bone loss by suppressing bone resorption, which was more pronounced with anti-Siglec-15 Ab treatment, possibly due to a reduced negative impact on bone formation. ALN induced histological abnormalities in the growth plate and morphological abnormalities in the long bone metaphysis but did not cause significant growth retardation. Conversely, anti-Siglec-15 Ab did not show any negative impact on the growth plate and preserved normal osteoclast and chondroclast function at the primary spongiosa. Taken together, these results suggest that anti-Siglec-15 targeting therapy could be a safe and efficacious prophylactic therapy for GC-induced osteoporosis in juvenile patients.
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Affiliation(s)
- Dai Sato
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan.
| | - Masahiro Ota
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
| | - Chie Fukuda
- Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Tomoka Hasegawa
- Hokkaido University, Department of Developmental Biology of Hard Tissue, Graduate School of Dental Medicine, Sapporo, Japan
| | - Tomomaya Yamamoto
- Hokkaido University, Department of Developmental Biology of Hard Tissue, Graduate School of Dental Medicine, Sapporo, Japan
| | - Norio Amizuka
- Hokkaido University, Department of Developmental Biology of Hard Tissue, Graduate School of Dental Medicine, Sapporo, Japan
| | - Eisuke Tsuda
- Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Akiko Okada
- Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yoshiharu Hiruma
- Pharmacovigilance Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Ryo Fujita
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan
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[Injuries in children and adolescents with inflammatory rheumatic diseases : Special risks and techniques for fracture treatment of the growing skeleton]. Unfallchirurg 2020; 123:607-615. [PMID: 32444884 DOI: 10.1007/s00113-020-00818-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Inflammatory rheumatic diseases in childhood and adolescence are a special challenge in the treatment of acute trauma. The pharmaceutical treatment strategies for children and adolescents have been modified. OBJECTIVE Which special aspects must be considered in young patients suffering from rheumatism when a trauma necessitates an operative procedure? MATERIAL AND METHOD A literature search was carried out to elaborate recommendations for the practice. RESULTS The joint-related alterations in young patients suffering from rheumatism differ with respect to the differently altered inflammatory rheumatic destruction. The extent of these inflammatory destructive alterations dictates the operative approach. Consequences arise in paying attention to the concurrent medication with respect to avoidance of events triggering an exacerbation and tissue infections. The bone strength necessitates an individualized selection of implants and sometimes influences the duration of follow-up treatment. In the early stages of the inflammatory process the approach in cases of trauma is no different to that for healthy patients but in later stages (Larsen stage III) it does differ. CONCLUSION An interdisciplinary concept can help to avoid disadvantages in the treatment of the underlying disease. Due to the special dysplastic anatomy and tissue alterations, trauma in these patients is a particular challenge.
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Abstract
PURPOSE OF REVIEW Steroid-induced osteoporosis or glucocorticoid-induced osteoporosis (GIOP) is a common form of secondary osteoporosis and is a cause of increased morbidity and mortality. The pathogenesis of GIOP includes decreased bone formation and increased bone resorption. Clinicians can rely on several effective medications for the treatment and prevention of GIOP, including antiresorptive drugs (i.e. bisphosphonates) and bone anabolic drugs (i.e. teriparatide). RECENT FINDINGS Recent studies have further highlighted that GIOP is a major public health concern and have provided new insights on the pathogenesis of GIOP, in particular, the dose-dependent effects of glucocorticoids on bone. New evidence on the real-world effectiveness of established GIOP therapies have been recently published as well as the results of the 24-months denosumab randomized controlled trial in GIOP. SUMMARY GIOP and fragility fractures are important adverse events related to the long-term use of glucocorticoids. Recent studies have provided additional data on the epidemiology and pathogenesis of GIOP and on the efficacy and effectiveness of GIOP therapies.
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Ward LM, Weber DR, Munns CF, Högler W, Zemel BS. A Contemporary View of the Definition and Diagnosis of Osteoporosis in Children and Adolescents. J Clin Endocrinol Metab 2020; 105:5684884. [PMID: 31865390 PMCID: PMC7121121 DOI: 10.1210/clinem/dgz294] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/19/2019] [Indexed: 01/09/2023]
Abstract
The last 2 decades have seen growing recognition of the need to appropriately identify and treat children with osteoporotic fractures. This focus stems from important advances in our understanding of the genetic basis of bone fragility, the natural history and predictors of fractures in chronic conditions, the use of bone-active medications in children, and the inclusion of bone health screening into clinical guidelines for high-risk populations. Given the historic focus on bone densitometry in this setting, the International Society for Clinical Densitometry published revised criteria in 2013 to define osteoporosis in the young, oriented towards prevention of overdiagnosis given the high frequency of extremity fractures during the growing years. This definition has been successful in avoiding an inappropriate diagnosis of osteoporosis in healthy children who sustain long bone fractures during play. However, its emphasis on the number of long bone fractures plus a concomitant bone mineral density (BMD) threshold ≤ -2.0, without consideration for long bone fracture characteristics (eg, skeletal site, radiographic features) or the clinical context (eg, known fracture risk in serious illnesses or physical-radiographic stigmata of osteoporosis), inappropriately misses clinically relevant bone fragility in some children. In this perspective, we propose a new approach to the definition and diagnosis of osteoporosis in children, one that balances the role of BMD in the pediatric fracture assessment with other important clinical features, including fracture characteristics, the clinical context and, where appropriate, the need to define the underlying genetic etiology as far as possible.
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Affiliation(s)
- Leanne M Ward
- Departments of Pediatrics and Surgery, University of Ottawa, and the Children’s Hospital of Eastern Ontario, Division of Endocrinology and Metabolism, Ottawa, Ontario, Canada
- Correspondence and Reprint Requests: Leanne Ward MD FRCPC, Research Chair in Pediatric Bone Health, Professor of Pediatrics, University of Ottawa, Medical Director, The CHEO Bone Health Clinic, Scientific Director, The Ottawa Pediatric Bone Health Research Group, Room 250H, Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1. E-mail:
| | - David R Weber
- Golisano Children’s Hospital, University of Rochester, New York
| | - Craig F Munns
- Department of Endocrinology, The Children’s Hospital at Westmead, Westmead, Australia, and Discipline of Paediatrics & Child Health, University of Sydney, Australia
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria, and the Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Wong SPY, Mok CC. Management of glucocorticoid-related osteoporotic vertebral fracture. Osteoporos Sarcopenia 2020; 6:1-7. [PMID: 32226826 PMCID: PMC7093682 DOI: 10.1016/j.afos.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/15/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022] Open
Abstract
The vertebral column is the most common site of osteoporotic fractures in long-term users of glucocorticoids. Vertebral fracture leads to significant morbidities such as unrelenting pain, spinal deformities and reduced mobility, leading to diminished quality of life. Epidemiological data on the prevalence of glucocorticoid-induced vertebral fractures are limited. As vertebral fracture is a strong risk factor for further fragility fractures and mortality, it should be treated appropriately. This article reviews recent data on the prevalence of vertebral fractures in glucocorticoid users, fracture risk stratification, and evidence-based treatment options. The risk of osteoporotic fractures estimated by FRAX should be adjusted for glucocorticoid users. The first-line treatment of glucocorticoid-induced osteoporosis remains the bisphosphonates. Teriparatide and denosumab are alternative options. Percutaneous vertebroplasty and kyphoplasty may be considered for symptomatic control of acute vertebral fracture-related pain when conservative measures fail.
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Affiliation(s)
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
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Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
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Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
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Sigurdsson GV, Schmidt S, Mellström D, Ohlsson C, Karlsson M, Lorentzon M, Saalman R. Altered body composition profiles in young adults with childhood-onset inflammatory bowel disease. Scand J Gastroenterol 2020; 55:169-177. [PMID: 32008409 DOI: 10.1080/00365521.2020.1716061] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Patients with inflammatory bowel disease (IBD) often develop alterations in body composition in terms of their proportions of lean mass and fat mass, as well as reduced bone mineral density (BMD). However, there are limited data on the skeletal muscle index (SMI) and percentage fat (fat %) for young adults with childhood-onset IBD. Our aim was to investigate the body compositions of these patients, with the focus on SMI and fat %.Methods: Body composition was estimated by dual x-ray absorptiometry for 94 young adults with childhood-onset IBD aged 18-27 years, 65 of whom had ulcerative colitis. The Z-scores for SMI, fat %, and BMD were calculated using the normative data from 1,289 individuals with corresponding age. Based on the SMI and fat % Z-scores, each patient was classified as having a body composition profile that was: (i) normal; (ii) obese (fat % Z-score >1); (iii) myopenic (SMI Z-score < -1); or (iv) myopenic-obese.Results: A higher proportion of young adults with childhood-onset IBD had a body composition profile classified as myopenic (24%) or myopenic-obese (9%), as compared to the controls (myopenic [16%, p = .016]; myopenic-obese [2%, p = .002]). Patients with the myopenic or myopenic-obese profile had significantly lower total body BMD Z-scores (-1.3 ± 0.7 and -1.4 ± 0.9, respectively) than patients with the normal profile (-0.2 ± 1.1; p < .001 and p = .004, respectively). Diagnosis of IBD in childhood represented an additional risk for low BMD, regardless of SMI Z-score.Conclusion: Young adults with childhood-onset IBD have a high risk for having altered body composition traits.SummaryYoung adults with childhood-onset IBD carry a high risk for altered body composition traits. The myopenic and myopenic-obese body composition profiles were more frequently observed in patients with IBD than controls, and these profiles were strongly associated with low BMD.
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Affiliation(s)
- Gudmundur Vignir Sigurdsson
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg and Queen Silviás Children Hospital, Gothenburg, Sweden
| | | | - Dan Mellström
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magnus Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences and Orthopedics, Lund University and Skåne University Hospital, Malmö, Sweden
| | - Mattias Lorentzon
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg and Region Västra Götaland, Geriatric Medicine Clinic, Sahlgrenska University Hospital Mölndal, Sweden
| | - Robert Saalman
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg and The Queen Silvia Children's Hospital, Gothenburg, Sweden
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Affiliation(s)
- Emily Kraus
- Department of Orthopaedic Surgery (E.K.) and Division of Endocrinology, Department of Pediatrics (L.K.B. and M.G.), Stanford University School of Medicine, Stanford, California
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Weber DR, Boyce A, Gordon C, Högler W, Kecskemethy HH, Misra M, Swolin-Eide D, Tebben P, Ward LM, Wasserman H, Shuhart C, Zemel BS. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. J Clin Densitom 2019; 22:567-589. [PMID: 31421951 PMCID: PMC7010480 DOI: 10.1016/j.jocd.2019.07.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 11/20/2022]
Abstract
Dual-energy X-ray absorptiometry (DXA) is widely used in the evaluation of bone fragility in children. Previous recommendations emphasized total body less head and lumbar spine DXA scans for clinical bone health assessment. However, these scan sites may not be possible or optimal for all groups of children with conditions that threaten bone health. The utility of DXA scans of the proximal femur, forearm, and radius were evaluated for adequacy of reference data, precision, ability of predict fracture, and applicability to all, or select groups of children. In addition, the strengths and limitations of vertebral fracture assessment by DXA were evaluated. The new Pediatric Positions provide guidelines on the use of these additional measures in the assessment of skeletal health in children.
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Affiliation(s)
- David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Alison Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Catherine Gordon
- Divisions of Adolescent/Young Adult Medicine and Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wolfgang Högler
- Institute of Metabolism and Systems Research, Birmingham Women's and Children's NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, UK
| | - Heidi H Kecskemethy
- Departments of Biomedical Research & Medical Imaging, Nemours/Alfred I. duPont Hospital for Children Wilmington, DE, USA
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Diana Swolin-Eide
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Region Västra Götaland, Sahlgrenska University Hospital, The Queen Silvia Children's Hospital, Department of Pediatrics, Gothenburg, Sweden
| | - Peter Tebben
- Division of Pediatric Endocrinology, Department of Pediatrics and Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism; Children's Hospital of Eastern Ontario, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Halley Wasserman
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Babette S Zemel
- Division of GI, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Delucchi Á, Toro L, Alzamora R, Barrientos V, González M, Andaur R, León P, Villanueva F, Galindo M, Las Heras F, Montecino M, Moena D, Lazcano A, Pinto V, Salas P, Reyes ML, Mericq V, Michea L. Glucocorticoids Decrease Longitudinal Bone Growth in Pediatric Kidney Transplant Recipients by Stimulating the FGF23/FGFR3 Signaling Pathway. J Bone Miner Res 2019; 34:1851-1861. [PMID: 31099911 DOI: 10.1002/jbmr.3761] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/05/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
Renal transplantation (RTx) is an effective therapy to improve clinical outcomes in pediatric patients with terminal chronic kidney disease. However, chronic immunosuppression with glucocorticoids (GCs) reduces bone growth and BMD. The mechanisms causing GC-induced growth impairment have not been fully clarified. Fibroblast growth factor 23 (FGF23) is a peptide hormone that regulates phosphate homeostasis and bone growth. In pathological conditions, FGF23 excess or abnormal FGF receptors (FGFR) activity leads to bone growth impairment. Experimental data indicate that FGF23 expression is induced by chronic GC exposure. Therefore, we hypothesize that GCs impair bone growth by increasing FGF23 expression, which has direct effects on bone growth plate. In a post hoc analysis of a multicentric randomized clinical trial of prepubertal RTx children treated with early GC withdrawal or chronic GC treatment, we observed that GC withdrawal was associated with improvement in longitudinal growth and BMD, and lower plasma FGF23 levels as compared with a chronic GC group. In prepubertal rats, GC-induced bone growth retardation correlated with increased plasma FGF23 and bone FGF23 expression. Additionally, GC treatment decreased FGFR1 expression whereas it increased FGFR3 expression in mouse tibia explants. The GC-induced bone growth impairment in tibiae explants was prevented by blockade of FGF23 receptors using either a pan-FGFR antagonist (PD173074), a C-terminal FGF23 peptide (FGF23180-205) which blocks the binding of FGF23 to the FGFR-Klotho complex or a specific FGFR3 antagonist (P3). Finally, local administration of PD173074 into the tibia growth plate ameliorated cartilage growth impairment in GC-treated rats. These results show that GC treatment partially reduces longitudinal bone growth via upregulation of FGF23 and FGFR3 expression, thus suggesting that the FGF23/Klotho/FGFR3 axis at the growth plate could be a potential therapeutic target for the management of GC-induced growth impairment in children.
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Affiliation(s)
- Ángela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clínico Universidad de Chile, Santiago, Chile.,Clinica Las Condes, Santiago, Chile
| | - Rodrigo Alzamora
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Nucleus of Ion Channel-Associated Diseases (MiNICAD), Santiago, Chile
| | - Victor Barrientos
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Magdalena González
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rodrigo Andaur
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Pablo León
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Francisco Villanueva
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Mario Galindo
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
| | - Facundo Las Heras
- Clinica Las Condes, Santiago, Chile.,Department of Anatomic Pathology, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martín Montecino
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Daniel Moena
- Institute of Biomedical Sciences, Faculty of Medicine and Faculty of Life Sciences, Universidad Andrés Bello, Santiago, Chile.,FONDAP Center for Genome Regulation, Universidad Andres Bello, Santiago, Chile
| | - Andrea Lazcano
- Division of Nephrology, Clínica Alemana de Santiago, Santiago, Chile.,Division of Nephrology, Hospital de Niños Roberto del Río, Santiago, Chile
| | - Viola Pinto
- Clinica Las Condes, Santiago, Chile.,Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - Paulina Salas
- Pediatric Nephrology Unit, Hospital Doctor Exequiel González Cortés, Santiago, Chile
| | - María Loreto Reyes
- Pediatric Endocrinology Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Verónica Mericq
- Clinica Las Condes, Santiago, Chile.,Institute of Maternal and Child Research, Universidad de Chile, Santiago, Chile
| | - Luis Michea
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile.,Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Millennium Institute on Immunology and Immunotherapy (MIII), Santiago, Chile
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Yanbeiy ZA, Hansen KE. Denosumab in the treatment of glucocorticoid-induced osteoporosis: a systematic review and meta-analysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2019; 13:2843-2852. [PMID: 31616133 PMCID: PMC6698580 DOI: 10.2147/dddt.s148654] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/24/2019] [Indexed: 02/04/2023]
Abstract
Objective Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. In May 2018, denosumab was approved for the treatment of GIOP in men and women at high risk of fracture. We undertook a systematic review and meta-analysis to summarize the efficacy and safety of denosumab in the prevention and treatment of GIOP. Methods We searched PubMed, CINAHL, American College of Rheumatology and American Society for Bone and Mineral Research meeting abstracts for relevant studies. We included studies in which subjects were taking systemic glucocorticoid therapy and were assigned to take denosumab or control therapy, and assessed the effect of treatment on areal bone mineral density (BMD), fractures and/or safety. Results Three eligible studies were included in the primary meta-analysis. Denosumab significantly increased lumbar spine BMD (2.32%, 95% CI 1.73%, 2.91%, P<0.0001) and hip BMD (1.52%, 95% CI 1.1%,1.94%, P<0.0001) compared to bisphosphonates. Adverse events, serious adverse events and fractures were similar between denosumab and bisphosphonate arms. Conclusion Results suggest that denosumab is superior to bisphosphonates in its effects on lumbar spine and total hip BMD in patients with GIOP. There was no difference in the incidence of infections, adverse events or serious adverse events. Studies were underpowered to detect differences in the risk of fracture. Denosumab is a reasonable option for treatment of GIOP. However, further studies are needed to guide transitions off denosumab.
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Affiliation(s)
- Zeina A Yanbeiy
- Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | - Karen E Hansen
- Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
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Hofmann C, Girschick H, Lapa C, Semler O, Jakob F. [Fractures and bone mineral density in childhood]. Z Rheumatol 2019; 78:636-644. [PMID: 31338681 DOI: 10.1007/s00393-019-0671-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In juvenile idiopathic arthritis and related chronic inflammatory diseases, proinflammatory cytokines inhibit bone formation and stimulate bone resorption. Anti-inflammatory drugs, such as glucocorticoids and nonsteroidal antirheumatic drugs (NSARD) have as a side effect the potential to inhibit growth and maintenance of bone. These issues are of particular importance for the growing skeleton in childhood and adolescence. OBJECTIVE This article presents a narrative overview about the dimension of the problem, a critical evaluation of diagnostic procedures and a discussion of available countermeasures. METHODS A systematic literature search was carried out and the available evidence was evaluated based on the authors' knowledge and clinical experience as experts in the field. RESULTS AND CONCLUSION In recent years solid data have been accumulated with respect to the interpretation of bone mineral density (BMD) measurements in children and adolescents. Based on these data from the literature and given that the radiation exposure is also very low, it is now possible to clinically apply BMD measurements in this population using dual energy X‑ray absorption (DXA) technology for risk evaluation and diagnosis, taking the respective phase of development and body length into consideration. Dynamic measurements over time appear to be especially valuable in the context of individual clinical data. Hence, BMD measurements can be helpful in monitoring bone health, especially in juvenile idiopathic arthritis and other related inflammatory diseases. Apart from the specific indications for extended diagnostics and bone targeted pharmacological treatment, this method can also contribute to the management of preventive measures, such as sufficient calcium and vitamin D intake and targeted exercise interventions. Even in times of extremely effective antirheumatic drugs, children with chronic inflammatory diseases still bear a risk for bone health.
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Affiliation(s)
- Christine Hofmann
- Kinderklinik und Poliklinik, Pädiatrische Rheumatologie und Osteologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Herrmann Girschick
- Klinik für Kinder- und Jugendmedizin, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
| | - Constantin Lapa
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Oliver Semler
- Medizinische Fakultät und Uniklinik Köln, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universität zu Köln, Köln, Deutschland
| | - Franz Jakob
- Orthopädische Klinik im König-Ludwig-Haus, Bernhard-Heine-Centrum für Bewegungsforschung, Brettreichstr. 11, 97074, Würzburg, Deutschland.
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Kao KT, Denker M, Zacharin M, Wong SC. Pubertal abnormalities in adolescents with chronic disease. Best Pract Res Clin Endocrinol Metab 2019; 33:101275. [PMID: 31047817 DOI: 10.1016/j.beem.2019.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pubertal disorders in the context of chronic disease especially in those with chronic inflammatory disorders or those requiring prolonged periods of treatment with glucocorticoid are common reasons for referral to the paediatric endocrine clinic. Disorders of puberty are also common in adolescents with disability requiring management by paediatric endocrinologists. In these adolescents, impaired skeletal development is also observed and this can be associated with fragility fractures. Chronic inflammation, glucocorticoid and sub-optimal nutrition all impact on the hypothalamic-pituitary gonadal axis, and can also impact on skeletal development locally by their effects on the growth plate and bone. Addressing pubertal disorders is important to ensure adolescents with chronic disease are matched with their peers, promote adequate bone mass accrual and linear growth. Careful discussion with primary clinicians, the young person and the family is needed when instituting endocrine therapies to address puberty and manage bone health.
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Affiliation(s)
- K T Kao
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Australia; Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - M Denker
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - M Zacharin
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Australia
| | - S C Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom.
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Pathological fracture due to prolonged steroid use in a child with transverse myelitis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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50
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Lentle B, Koromani F, Brown JP, Oei L, Ward L, Goltzman D, Rivadeneira F, Leslie WD, Probyn L, Prior J, Hammond I, Cheung AM, Oei EH. The Radiology of Osteoporotic Vertebral Fractures Revisited. J Bone Miner Res 2019; 34:409-418. [PMID: 30645770 DOI: 10.1002/jbmr.3669] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/17/2018] [Accepted: 01/05/2019] [Indexed: 01/31/2023]
Abstract
Until recently there has been little evidence available to validate any method by which to make an accurate diagnosis of an osteoporotic vertebral fractures (OVFs) from plain radiographs. In part this reflects a lack of a completely satisfactory "gold standard," but primarily it relates to the absence of well-designed prospective studies in this context. Historically, OVFs were recognized by evidence of macroscopic structural failure in vertebrae using the criteria applied elsewhere in the skeleton. This comprised altered alignment, fragmentation, cortical disruptions, and breaks, among other changes. However, these morphological criteria were replaced by vertebral morphometry, referring to the use of quantitative or quasi-quantitative measurement tools for fracture diagnosis. Vertebral morphometry emerged as an understanding of and treatment for osteoporosis evolved, mainly in response to the need for expeditious assessments of large numbers of spine images for epidemiological and pharmaceutical purposes. Although most of the descriptions of such morphometric tools have stressed that they were not to be applied to clinical diagnosis with respect to individual patients, this constraint has been widely disregarded. Here we review the major attempts to develop a diagnostic strategy for OVF and describe their characteristics in adults and children. Recent evidence suggests that morphometric (quantitative; ie, based on measurement of dimensions and shape description) criteria are inferior to morphologic (qualitative; ie, based on structural integrity) vertebral damage assessment in identifying people with low bone density and at an increased risk of future fracture. Thus there is now an evidentiary basis for suggesting that morphological assessment is the preferred strategy for use in diagnosing OVF from radiographs. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Fjorda Koromani
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Jacques P Brown
- Department of Medicine, Division of Rheumatology, CHU de Québec Research Centre, Laval University, Québec City, QC, Canada
| | - Ling Oei
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Leanne Ward
- Division of Bone Health, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - David Goltzman
- Department of Medicine, McGill University and McGill University Health Centre, Montréal, QC, Canada
| | - Fernando Rivadeneira
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Linda Probyn
- Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jerilynn Prior
- Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Ian Hammond
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, Centre of Excellence in Skeletal Health Assessment, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Edwin H Oei
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
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