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Loscalzo E, See J, Bharill S, Yousefzadeh N, Gough E, Wu M, Crane JL. Growth hormone and testosterone delay vertebral fractures in boys with muscular dystrophy on chronic glucocorticoids. Osteoporos Int 2024; 35:327-338. [PMID: 37872346 PMCID: PMC10837224 DOI: 10.1007/s00198-023-06951-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023]
Abstract
Glucocorticoid use in Duchenne and Becker muscular dystrophy prolongs ambulation but cause significant skeletal toxicity. Our analysis has immediate clinical implications, suggesting that growth hormone and testosterone have a stronger effect prior to first and subsequent vertebral fracture, respectively, relative to bisphosphonates alone in children with dystrophinopathies on chronic glucocorticoids. PURPOSE Glucocorticoids prolong ambulation in boys with Duchenne muscular dystrophy; however, they have significant endocrine side effects. We assessed the impact of growth hormone (GH), testosterone, and/or zoledronic acid (ZA) on vertebral fracture (VF) incidence in patients with dystrophinopathies on chronic glucocorticoids. METHODS We conducted a longitudinal retrospective review of 27 males with muscular dystrophy. Accelerated failure time (AFT) models were used to estimate the relative time to VF while on GH, testosterone, and/or ZA compared to ZA alone. Results are reported as failure time ratio, where >1 indicates prolonged time versus <1 indicates shorter time to next VF. RESULTS The prevalence of growth impairment was 96% (52% utilized GH), pubertal delay was 86% (72% utilized testosterone), and low trauma fractures were 87% (72% utilized ZA). Multivariable analysis of the AFT models showed that participants on either GH or testosterone treatment relative to ZA alone experienced prolonged time to next VF (1.253, P<0.001), with GH being the significant contributor when analyzed independently from testosterone (1.229, P<0.001). Use of ZA with GH or testosterone relative to ZA alone resulted in prolonged time to next VF (1.171, P<0.001), with testosterone being a significant contributor (1.130, P=0.033). CONCLUSION GH and testosterone each decreased VF risk in patients independent of or in combination with ZA, respectively.
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Affiliation(s)
- Emely Loscalzo
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Julia See
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Sonum Bharill
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Nazanin Yousefzadeh
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Ethan Gough
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Malinda Wu
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Janet L Crane
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
- Department of Orthopedic Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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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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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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4
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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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