Illness Perceptions are Associated with Quality of Life in Patients with Fibrous Dysplasia

Craniofacial fibrous dysplasia: A review of current literature

INTRODUCTION

Fibrous dysplasia (FD) is a rare genetic disease, in which normal bone is replaced by fibro-osseus tissue. Disease severity varies greatly from single monostotic lesions to widespread polyostotic disease. Craniofacial lesions are common and, due to the complex anatomy, can cause several disabling symptoms and local extra-skeletal complications. Since relatively rare, reported cases of craniofacial FD (CFD), specifically, are few and the appropriate management remains incompletely defined.

METHODOLOGY

We performed a systematic literature review following the PRISMA guidelines for articles considering CFD in the years 2010-2023. The search was conducted in the PubMed and OVID Medline libraries. Altogether 193 articles were retrieved and reviewed.

RESULTS

Overall, the clinical presentation of CFD is highly variable depending on site and extent of lesion, with pain, deformity or impairment of function being most common. Diagnoses are often incidental and primarily based on CT imaging, while more extensive imaging, genetic studies and lesion biopsies are reserved for unclear cases. Asymptomatic patients are suitable for observation, while symptomatic or widespread disease may require more active approach with medical or surgical treatment. Follow-up is encouraged in all patients to observe possible lesion reactivation, late-stage complications and, though rarely, malignant transformation. Management should be individually tailored with a multidisciplinary team and wholesome consideration of individual needs.

CONCLUSIONS

This review provides an updated discussion on craniofacial FD with focus on improved understanding of disease pathophysiology, appropriate line of surgical management, and new potential means of medical treatment.

A multidisciplinary care pathway improves quality of life and reduces pain in patients with fibrous dysplasia/McCune-Albright syndrome: a multicenter prospective observational study

BACKGROUND

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) may cause pain, impaired ambulation and decreased quality of life (QoL). International guidelines advocate management of FD/MAS in a tertiary multidisciplinary care pathway, but no longitudinal data are available to support this recommendation. This multicenter prospective observational study aimed to evaluate effects of 1 year of treatment in the FD/MAS care pathway in 2 tertiary clinics on QoL and pain, assessed by change in Short Form 36 and Brief Pain Inventory between baseline and follow-up. Patients completing baseline questionnaires < 1 year after intake were classified as new referrals, others as under chronic care.

RESULTS

92 patients were included, 61 females (66%). 22 patients (24%) had monostotic disease, 16 (17%) isolated craniofacial FD, 27 (40%) polyostotic FD and 17 (19%) MAS. 26 were new referrals (28%) and 66 chronic patients (72%). Median age at baseline was 47 years (Q1-Q3 36-56). Skeletal burden correlated with baseline Physical Function (r_s = - 0.281, p = 0.007). QoL was in all domains lower compared to the general population. New referrals reported clinically important differences (CID) over time in domains Physical Function (mean 67 ± SD24 to 74 ± 21, effect size (ES) 0.31, p = 0.020), Role Physical (39 ± 41 to 53 ± 43, ES 0.35, p = 0.066), Social Functioning (64 ± 24 to 76 ± 23, ES 0.49, p = 0.054), and Health Change (39 ± 19 to 53 ± 24, ES 0.76, p = 0.016), chronic patients in Physical Function (52 ± 46 to 66 ± 43, ES 0.31, p = 0.023) and Emotional Wellbeing (54 ± 27 to 70 ± 15, ES 0.59, p < 0.001). New referrals reported a CID of 1 point in maximum pain, average pain and pain interference, chronic patients reported stable scores. Change in pain interference and Role Physical were correlated (r_s = - 0.472, p < 0.001). Patients with limited disease extent improved more than patients with severe disease. Patients receiving FD-related therapy had lower baseline scores than patients not receiving therapy and reported improvements in QoL after 1 year. Yet also patients without FD-related therapy improved in Physical Function.

CONCLUSIONS

All FD-subtypes may induce pain and reduced QoL. A multidisciplinary care pathway for FD/MAS may improve pain and QoL, mainly in new referrals without MAS comorbidities with low baseline scores. Therefore, we recommend referral of patients with all subtypes of FD/MAS to specialized academic centers.

Fibrous dysplasia patients with and without craniofacial involvement report reduced quality of life inclusive of stigma, depression, and anxiety

OBJECTIVES

Fibrous dysplasia is a rare bone disorder that causes deformity, fractures, and pain that typically manifests in childhood and persists as a chronic illness. This study evaluates adult patients with fibrous dysplasia and McCune Albright syndrome to determine whether their quality of life differs from the general population and varies in relation to disease severity and lesion location.

METHODS

This study uses data from the online self-report Fibrous Dysplasia Foundation Patient Registry and operationalizes quality of life using PRO measures: SF-36, Hospital Anxiety and Depression scale, Neuro-Quality of Life Stigma scale, and the Brief Pain Inventory.

RESULTS

One hundred and ninety seven adults, 90% white, 84% women, constitute the sample. Mean scores for all SF-36 domains and the Neuro Q stigma scale were significantly below population benchmarks. A large minority registered moderate to severe levels of anxiety and depression. Group differences were not significant across most of the SF-36 domains but were associated with experienced stigma.

DISCUSSION

This study demonstrates a social psychological impact of fibrous dysplasia on adults, in those with and without craniofacial involvement and with mild and severe forms of the disease. Clinical treatment should encompass assessment of quality of life issues and ensure access to psychosocial treatment resources for all fibrous dysplasia/McCune-Albright syndrome patients.

Extent of Extraskeletal Manifestations of Fibrous Dysplasia/McCune-Albright Syndrome in Patients with Mazabraud's Syndrome

Mazabraud's syndrome (MZB) is a rare condition in which fibrous dysplasia of bone/the McCune-Albright syndrome (FD/MAS) co-exists with intramuscular myxomas. Both FD and the myxomas harbor the GNAS-mutation. Recent studies have shown that extraskeletal, GNAS-related features are associated with a more severe phenotype of FD/MAS. However, patients with MZB are often only seen by orthopedic surgeons. We therefore evaluated MZB patients seen in tertiary referral centers from the Netherlands (LUMC), USA (National Institutes of Health) and France (INSERM UMR 1033 (Lyos), Hôpital Edouard Herriot). All FD/MAS patients known in these centers with an additional diagnosis of a myxoma were included. Demographic information and data on disease extent and extraskeletal manifestations of FD/MAS such as precocious puberty (PP) or café-au-lait patches (CAL) were retrieved from patient's medical records. Thirty MZB patients were included: 20 women (67%) and 10 men (33%). Patients received a diagnosis of MZB (median 42 years, range 16-19) significantly later than the diagnosis of FD/MAS (median 30 years, range 0-60), p < 0.01. Twenty-six patients were diagnosed with polyostotic disease (87%). In 97% the myxoma was located near the skeletal FD lesion. The combination of MZB and MAS was made in 13 patients in whom PP (n = 7), CAL (n = 7), GH-excess (n = 3) and hyperthyroidism (n = 3) were present. Other extraskeletal features were (multinodular) goiter (n = 2) and thyroid cysts (n = 1). Furthermore, in this cohort of patients with MZB several (pre-)malignant tumors were observed; ductal carcinoma in situ of the breast in 3 patients (10%), breast cancer in 1 patient (3.3%), intra pancreatic mucinous neoplasms in 3 patients (10%) and liver adenomas in 2 patients (6.6%). A total of 47% of patients with MZB had an additional extraskeletal feature such as an endocrinopathy. In MZB, 87% of patients suffer from polyostotic FD, 43% of patients have extraskeletal GNAS-features such as an hyperfunctioning endocrinopathy and 30% (pre-)malignant tumors. We therefore advocate that MZB patients should undergo a complete screening and long-term follow-up for extent of bone disease, but also extraskeletal GNAS features of FD/MAS.

Fibrous dysplasia animal models: A systematic review

BACKGROUND

Fibrous dysplasia (FD) is a rare genetic bone disorder resulting in an overproduction of cAMP leading to a structurally unsound tissue, caused by a genetic mutation in the guanine nucleotide-binding protein gene (GNAS). In order to better understand this disease, several animal models have been developed with different strategies and features.

OBJECTIVE

Conduct a systematic review to analyze and compare animal models with the causative mutation and features of FD.

METHODS

A PRISMA search was conducted in Scopus, PubMed, and Web of Science. Studies reporting an in vivo model of FD that expressed the causative mutation were included for analysis. Models without the causative mutation, but developed an FD phenotype and models of FD cell implantation were included for subanalysis.

RESULTS

Seven unique models were identified. The models were assessed and compared for their face validity, construct validity, mosaicism, and induction methods. This was based on the features of clinical FD that were reported within the categories of: macroscopic features, imaging, histology and histomorphometry, histochemical and cellular markers, and blood/urine markers.

LIMITATIONS

None of the models reported all features of FD and some features were only reported in one model. This made comparing models a challenge, but indicates areas where further research is necessary.

CONCLUSION

The benefits and disadvantages of every model were assessed from a practical and scientific standpoint. While all published reports lacked complete data, the models have nonetheless informed our understanding of FD and provided meaningful information to guide researchers in bench and clinical research.

Stigma and psychological distress among pediatric participants in the FD/MAS Alliance Patient Registry

Background

Stigma, both enacted and internalized, is part of the illness experience of many chronic conditions / diseases and has been found to increase psychological distress, lower self-esteem, and impact social engagement lowering quality of life (QOL). Stigma among pediatric patients is of particular concern due to its potential impact on identity formation. Using patient data from the online FD/MAS Alliance Patient Registry (FDMASAPR), this study seeks to 1) determine levels of enacted and self-stigma in a pediatric population of fibrous dysplasia (FD) / McCune Albright syndrome (MAS) patients and 2) to explore the relationship between stigma and anxiety and depression.

Methods

This is a cross sectional analysis of deidentified self-report data from 18 pediatric patients. Key analytic variables include the Neuro-QOL stigma short form, the Hospital Anxiety and Depression Scale (HADS), diagnostic category and craniofacial involvement, and select demographics. Sample means and score distributions are examined. Bivariate relationships between stigma, anxiety and depression and patient’s personal and medical characteristics are established through analysis of variance and correlation.

Results

Composite stigma levels for FD/MAS pediatric patients were comparable to those of children with multiple sclerosis, epilepsy, and muscular dystrophy. Self-stigma was more frequently reported than enacted/felt stigma, but few patients indicated complete freedom from either type of stigma. Diagnosis was significantly related to self-stigma. Significant bivariate relationships were found between depression and enacted/felt and self-stigma and between anxiety and self-stigma.

Conclusions

This study establishes the illness experience of pediatric patients with FD / MAS is impacted by stigma and suggests they should be regularly screened for stigma and psychological distress. It supports the integration of clinical psychologists/ therapists in regular patient care, referral of families to advocacy organizations, and indicates that rare disease patient registries can be a useful tool in efforts to improve the QOL of patients.

Assessing quality of life in pediatric fibrous dysplasia and McCune Albright syndrome: PEDS-QL and HADS data from the Fibrous Dysplasia Foundation Patient Registry

PURPOSE

The International FD/MAS Consortium recently encouraged using the Pediatric Quality of Life Inventory (PEDS-QL) and the Hospital Anxiety and Depression scales (HADS) in clinical care. This study examines scores on these measures among pediatric fibrous dysplasia and McCune Albright (FD/MAS) patients to initiate consideration of their use in clinical treatment.

METHODS

This is a retrospective analysis of pediatric data from 39 minors, ages 2-17, entered in the Fibrous Dysplasia Foundation Patient Registry from July 2016 to December 2018. Sample means and score distributions are compared to general population and chronic disease benchmarks. Associations with medical and demographic variables are also explored.

RESULTS

Mean PEDS-QL scores for children 2-7 were inconclusive in determining at risk status for impaired quality of life (QOL). Individual score distributions suggested up to half experienced extensive physical or social impairment. Means and individual score distributions for the physical and psychosocial components of the PEDS-QL for children 8-17 suggested many were at risk of impaired QOL. Over half of 13-17 year-olds met the clinical benchmark for anxiety. Older males scored better than females on the PEDS-QL and HADS. Pain frequency was associated with physical function for older children.

CONCLUSIONS

Older children with FD/MAS may be more compromised in terms of psychosocial QOL than previously reported. Clinicians should be attentive to the influence of gender on QOL in older children. Online patient registries associated with rare diseases have the potential to serve as efficient and cost-effective mechanisms to jumpstart examination of new measures in consideration for clinical use.

Patients With Isolated Craniofacial Dysplasia Report Better Quality of Life Compared With Those With Craniofacial Dysplasia and Extracranial Involvement

PURPOSE

Craniofacial fibrous dysplasia (CFD) is a subtype of fibrous dysplasia/McCune-Albright syndrome (FD/MAS) characterized by FD lesions in one or more of the skull bones. The orbit is often involved, with facial pain, facial deformity, and increased risk of compressive optic neuropathy as associated clinical manifestations possibly leading to altered illness perceptions and impairments in quality of life(QoL). The aim of this study was to evaluate illness perceptions and QoL in patients with CFD among our FD/MAS cohort.

METHODS

One hundred ninety-one patients were included. Illness perceptions and QoL were assessed by using validated questionnaires, that is, the Illness Perceptions Questionnaire-Revised and the Short-Form 36. Patients were first grouped as CFD versus non-CFD, a second selection was based on the presence of "Isolated CFD" versus "CFD+PFD/MAS." Non-CFD patients were grouped as monostotic fibrous dysplasia "MFD" versus polyostotic "PFD/MAS."

RESULTS

Patients with isolated CFD attributed less symptoms to their disease compared with patients with CFD+PFD/MAS (p < 0.05). Furthermore, patients with isolated CFD reported better QoL on all domains (except role emotional and mental health) compared with patients with CFD+PFD/MAS (p < 0.05). Patients with isolated CFD also reported better QoL compared with non-CFD groups (on 3 out of 8 subscales) (p < 0.05).

CONCLUSIONS

Patients with isolated CFD attribute less symptoms to their disease and report better QoL compared with patients with CFD with extracranial involvement or FD without cranial involvement. These findings indicate that craniofacial involvement alone is not sufficient to cause negative illness perceptions and impairments in QoL. Therefore, it can be postulated that isolated CFD should be considered a unique patient subtype within the spectrum of FD/MAS patients.

New Factor Structure of the Tampa Scale for Kinesiophobia in Older Japanese Adults After Lumbar Surgery

Purpose

The Tampa Scale for Kinesiophobia (TSK) has been used worldwide as a measure of kinesiophobia, but its factor structure in older Japanese adults after lumbar surgery is unknown. The purpose of this study was to fill this research gap by identifying the factors that comprise TSK in older Japanese adults after lumbar surgery.

Patients and Methods

Participants were older Japanese adults who had undergone surgery for lumbar spinal stenosis. Clinicodemographic data, TSK, intensity of low back pain and leg pain, dysesthesia (using an 11-point numerical rating scale), and HRQOL (using the EQ-5D-5L) were collected. After supplementing the missing values by the multiple assignment method, the hypothetical model of TSK was developed by categorical exploratory factor analysis (weighted least squares method, promax rotation). Confirmatory factor analysis (WLSMV method, promax rotation) was used to compare the hypothetical model and the traditional one-factor and two-factor models. Furthermore, we confirmed the relationship between factors extracted from the hypothetical model and HRQOL, pain, and dysesthesia.

Results

Questionnaires were mailed to 302 individuals, and responses were obtained from 211 (72.4±4.2 years [range: 65–88]; 115 men and 96 women; 804±343.1 [380–1531] days after surgery; 137 who had undergone decompression and fixation surgery, 74 who had undergone decompression surgery) (response rate: 69.9%). The hypothesized model consisted of “somatic focus,” “activity avoidance,” and “efficacy of physical activities,” all of which were highly consistent. The fit of the hypothetical model was slightly inferior to that of the traditional two-factor model, but the hypothetical model met the criteria for fit. Somatic focus in the hypothetical model was significantly associated with HRQOL, pain, and dysesthesia.

Conclusion

In older Japanese adults after lumbar surgery, the goodness of fit of the TSK model was maintained by adding efficacy of physical activities as a third factor to the traditional two factors.

The effect of illness perception on life quality in psoriasis patients

Psoriasis is a chronic disease that has negative effects on quality of life. Understanding the illness perception of psoriasis is important for effective management of the disease and improving quality of life. The aim of this study was to determine the relationship between illness perception and quality of life in psoriasis patients. This cross-sectional study was performed with 306 patients who applied to a psoriasis outpatient clinic of a university hospital in Istanbul, Turkey. Data were collected using a sociodemographic characteristics and disease information form, the Dermatology Life Quality Index (DLQI), the Revised Illness Perception Questionnaire (IPQ-R) and the Psoriasis Area Severity Index (PASI) score. Data were analyzed using descriptive statistics, Kruskal-Wallis test and Mann-Whitney U test, Spearman correlation analysis, and multiple regression analysis. A positive relationship was found between scores on the DLQI and scores on the IPQ-R subscales of Illness identity, Consequences, Emotional representations, Time (cyclic), Personal attributions, External attributions, and Chance. A negative correlation was determined between DLQI scores and scores on the IPQ-R subscales of Treatment control and Illness coherence. Furthermore, there was a positive correlation between the PASI score and the DLQI scores and scores on the IPQ-R subscales of Consequences and Emotional representation. Multiple regression analysis showed that illness identity, PASI scores, treatment control, illness coherence, consequences, and personal attributions were significantly associated with quality of life (R2 = 0.365, p < 0.01). The quality of life of the psoriasis patients who associated their symptoms with the disease, who had a high PASI score, thought that they were adversely affected by the disease, and who saw personal attributions as the cause of the disease was negatively affected. The quality of life of patients who thought that their disease could be kept under control and who understood their disease was positively affected.

Fibrous Dysplasia/McCune-Albright Syndrome: A Rare, Mosaic Disease of Gα s Activation

Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) is a rare disorder of striking complexity. It arises from somatic, gain-of-function mutations in GNAS, leading to mosaic Gα s activation and inappropriate production of intracellular cyclic adenosine monophosphate (cAMP). The clinical phenotype is largely determined by the location and extent of affected tissues, and the pathophysiological effects of Gα s activation within these tissues. In bone, Gα s activation results in impaired differentiation of skeletal stem cells, leading to discrete skeletal lesions prone to fracture, deformity, and pain. Extraskeletal manifestations include a variable combination of hyperpigmented macules and hyperfunctioning endocrinopathies. Distinctive age-related changes in disease development has key effects on histologic, radiographic, and clinical features. FD/MAS thus presents along a uniquely broad clinical spectrum, and the resulting challenges in diagnosis and management can be difficult for clinicians. This review presents FD/MAS in the context of a mosaic disorder of Gα s activation, providing an intellectual framework within which to understand, evaluate, and treat this interesting disease. It includes a comprehensive summary of current understanding of FD/MAS pathogenesis, and a detailed discussion of clinical presentation and management. Critical areas of unmet need are highlighted, including discussion of key challenges and potential solutions to advance research and clinical care in FD/MAS.

Passive Coping Strategies Are Associated With More Impairment In Quality Of Life In Patients With Fibrous Dysplasia

Impairments in quality of life (QoL) have been reported in patients with fibrous dysplasia (FD). Here, we examine coping strategies in FD and assess whether these coping strategies are associated with QoL and disease severity. Ninety-two patients (66% females) filled out the Utrecht Coping List (UCL), Short Form-36, and the Brief Pain Inventory (BPI). Coping strategies of patients with FD were compared with reference data from a random sample of Dutch women and patients with chronic pain. Compared to healthy adults, patients expressed more emotions (p < 0.01). Compared to patients with chronic pain, patients with FD used more active coping strategies (p < 0.001), and sought more distraction (p = 0.01) and more social support (p < 0.001). Using more passive coping strategies was associated with more impairment in social function, physical role, mental health, vitality (all p < 0.001), and general health (p < 0.01). Using more avoidant coping strategies was associated with worse mental health and less vitality (both p < 0.01). More expression of emotions was associated with worse mental health (p < 0.01). Type and clinical severity of FD were not associated with coping behavior. Patients with FD have different coping strategies compared to random Dutch reference populations with or without pain. In FD, using more passive coping strategies was associated with more impairment in several aspects of QoL. There was no relationship between coping behavior and clinical characteristics, pointing to biomedical variables not determining the way patients cope with their illness. Recognition of less effective coping strategies can be helpful in the understanding and adaptation of these coping strategies, improving personalized clinical care, with the ultimate goal to improve QoL in patients with FD.