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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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Madhuchani D, Seneviratne SN, Ward LM. Bone health in childhood and adolescence: an overview on dual-energy X-ray absorptiometry scanning, fracture surveillance and bisphosphonate therapy for low-middle-income countries. Front Endocrinol (Lausanne) 2023; 14:1082413. [PMID: 37139332 PMCID: PMC10150014 DOI: 10.3389/fendo.2023.1082413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/16/2023] [Indexed: 05/05/2023] Open
Abstract
Bone accrual in childhood determines bone health in later life. Loss of bone strength in early life can lead to increased morbidity and reduced quality of life in childhood and adolescence. Increased availability of assessment tools and bisphosphonate therapy, together with increased awareness on the significance of fracture history and risk factors, have led to greater opportunities, to improve detection and optimize management of children and adolescents with bone fragility globally, including those in lower resource settings. Bone mineral density z-scores and bone mineral content are surrogate measures of bone strength, which can be measured by dual-energy X-ray absorptiometry (DXA), in growing individuals. DXA can aid in the diagnosis and management of primary and secondary bone fragility disorders in childhood. DXA helps evaluate children with clinically significant fractures, and monitor those with bone fragility disorders, or at high risk for compromised bone strength. Obtaining DXA images can however be challenging, especially in younger children, due to difficulty in positioning and movement artefacts, while paediatric DXA interpretation can be confounded by effects of growth and puberty. Furthermore, access to DXA facilities as well as appropriate paediatric reference norms and expertise for interpretation, may not be easily available especially in lower resource settings. Pediatric bone experts are now placing increasing emphasis on the fracture phenotype and clinical context to diagnose osteoporosis over bone mineral density (BMD) by DXA. Low trauma vertebral fractures are now recognized as a hallmark of bone fragility, and spinal fracture surveillance by either conventional lateral thoracolumbar radiographs or vertebral fracture assessment by DXA is gaining increasing importance in diagnosing childhood osteoporosis, and initiating bone protective therapy. Furthermore, it is now understood that even a single, low-trauma long bone fracture can signal osteoporosis in those with risk factors for bone fragility. Intravenous bisphosphonate therapy is the mainstay of treatment for childhood bone fragility disorders. Other supportive measures to improve bone strength include optimizing nutrition, encouraging weight bearing physical activity within the limits of the underlying condition, and treating any associated endocrinopathies. With this paradigm shift in childhood osteoporosis evaluation and management, lack of DXA facilities to assess BMD at baseline and/or provide serial monitoring is not a major barrier for initiating IV bisphosphonate therapy in children in whom it is clinically indicated and would benefit from its use. DXA is useful, however, to monitor treatment response and optimal timing for treatment discontinuation in children with transient risk factors for osteoporosis. Overall, there is lack of awareness and paucity of guidelines on utilizing and adopting available resources to manage paediatric bone disorders optimally in lower-resource settings. We provide an evidence-based approach to the assessment and management of bone fragility disorders in children and adolescents, with appropriate considerations for lower resource settings including LMIC countries.
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Affiliation(s)
| | - Sumudu Nimali Seneviratne
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- *Correspondence: Sumudu Nimali Seneviratne,
| | - Leanne M. Ward
- Department of Pediatrics, University of Ottawa and Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
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Claude F, Ubertini G, Szinnai G. Endocrine Disorders in Children with Brain Tumors: At Diagnosis, after Surgery, Radiotherapy and Chemotherapy. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1617. [PMID: 36360345 PMCID: PMC9688119 DOI: 10.3390/children9111617] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Brain tumors are the second most frequent type of all pediatric malignancies. Depending on their localization, patients with brain tumors may present neurological or ophthalmological symptoms, but also weight anomalies and endocrine disorders ranging from growth hormone deficiency, anomalies of puberty, diabetes insipidus to panhypopituitarism. Immediately at diagnosis, all patients with brain tumors require a complete assessment of the hypothalamic-pituitary function in order to address eventual endocrine disorders. Moreover, children and adolescents undergoing brain surgery must receive peri- and postoperative hydrocortisone stress therapy. Post-operative disorders of water homeostasis are frequent, ranging from transient diabetes insipidus, as well as syndrome of inappropriate antidiuretic hormone secretion to persistent diabetes insipidus. Late endocrine disorders may result from surgery near or within the hypothalamic-pituitary region. Pituitary deficits are frequent after radiotherapy, especially growth hormone deficiency. Thyroid nodules or secondary thyroid cancers may arise years after radiotherapy. Gonadal dysfunction is frequent after chemotherapy especially with alkylating agents. CONCLUSION Early detection and treatment of specific endocrine disorders at diagnosis, perioperatively, and during long-term follow-up result in improved general and metabolic health and quality of life.
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Affiliation(s)
- Fabien Claude
- Department of Pediatric Endocrinology and Diabetology, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
| | - Graziamaria Ubertini
- Department of Pediatric Endocrinology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy
| | - Gabor Szinnai
- Department of Pediatric Endocrinology and Diabetology, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, 4056 Basel, Switzerland
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Study on the Relationship between the Use of Bisphosphonates for Antiosteoporosis and Vertebral Re-Fracture after Vertebroplasty. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:3223437. [PMID: 36193124 PMCID: PMC9525755 DOI: 10.1155/2022/3223437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022]
Abstract
Objective. To explore the effect of bisphosphonates after vertebroplasty in patients with osteoporotic vertebral compression fractures (OVCF), and to analyze the relationship between the use of bisphosphonates and vertebral refracture. Methods. A total of 150 patients with OVCF were selected from the pain department of our hospital from January 2018 to May 2020. All patients received vertebroplasty after admission, and were divided into the surgery group (62 cases) and combined with the bisphosphonates group (combined group, 88 cases) according to whether patients had used bisphosphonates after surgery. Before surgery, 1 month, 3 months, 6 months, and 1 year after surgery, visual analogue scale (VAS), Oswestry disability index (ODI), vertebral body and femoral neck bone mineral density (BMD), and Cobb Angle were collected, and the differences among groups were compared to analyze the treatment effect. After the follow-up, patients were divided into two groups according to whether vertebral refracture occurred during the follow-up period. Clinical characteristics, general information, and surgical indicators of patients in the two groups were collected, and related factors of postoperative vertebral refracture were analyzed. Results. There were no significant differences in preoperative VAS score, ODI index, BMD value, and Cobb angle between the two groups
. At 12 months after surgery, VAS score, ODI index, and Cobb angle decreased, while BMD value increased in both groups. The VAS score, ODI index, and Cobb angle in the combined group were lower than those in the operation group, while the BMD value was higher than that in the operation group, and the difference was significant
. The results of multivariate regression analysis showed that in BMD, no postoperative antiosteoporosis treatment, bone cement leakage, and poor cement diffusion were independent risk factors for vertebral refracture after vertebroplasty in patients with vertebral compression fractures. Conclusion. In order to avoid recurrent fractures in OVCF patients, attention should be paid to BMD, whether patients take antiosteoporosis drugs, whether bone cement permeation occurs and the diffusion of bone cement, etc. The above factors are the main influencing factors leading to recurrent fractures after PKP and PVP in the clinic.
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