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Punchak MA, Sarris C, Xu E, Flanders TM, Lang SS, Swanson JW, Taylor JA, Heuer GG. Craniosynostosis in primary metabolic bone disorders: a single-institution experience. Childs Nerv Syst 2023; 39:3583-3588. [PMID: 37420034 DOI: 10.1007/s00381-023-06059-z] [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: 03/15/2023] [Accepted: 06/24/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE The incidence of metabolic bone diseases in pediatric neurosurgical patients is rare. We examined our institutional experience of metabolic bone diseases along with a review of the literature in an effort to understand management for this rare entity. METHODS Retrospective review of the electronic medical record database was performed to identify patients with primary metabolic bone disorders who underwent craniosynostosis surgery between 2011 and 2022 at a quaternary referral pediatric hospital. Literature review was conducted for primary metabolic bone disorders associated with craniosynostosis. RESULTS Ten patients were identified, 6 of whom were male. The most common bone disorders were hypophosphatemic rickets (n = 2) and pseudohypoparathyroidism (n = 2). The median age at diagnosis of metabolic bone disorder was 2.02 years (IQR: 0.11-4.26), 2.52 years (IQR: 1.24-3.14) at craniosynostosis diagnosis, and 2.65 years (IQR: 0.91-3.58) at the time of surgery. Sagittal suture was most commonly fused (n = 4), followed by multi-suture craniosynostosis (n = 3). Other imaging findings included Chiari (n = 1), hydrocephalus (n = 1), and concurrent Chiari and hydrocephalus (n = 1). All patients underwent surgery for craniosynostosis, with the most common operation being bifronto-orbital advancement (n = 4). A total of 5 patients underwent reoperation, 3 of which were planned second-stage surgeries and 2 of whom had craniosynostosis recurrence. CONCLUSIONS We advocate screening for suture abnormalities in children with primary metabolic bone disorders. While cranial vault remodeling is not associated with a high rate of postoperative complications in this patient cohort, craniosynostosis recurrences may occur, and parental counseling is recommended.
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Affiliation(s)
- Maria A Punchak
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA.
| | - Christina Sarris
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily Xu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy M Flanders
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jordan W Swanson
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse A Taylor
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory G Heuer
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA, 19146, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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2
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Charoenngam N, Thongpiya J, Yingchoncharoen P, Ponvilawan B, Marangoz MS, Chenbhanich J, Ungprasert P. Atypical Femoral Fracture in Hypophosphatasia: A Systematic Review. Int J Endocrinol 2023; 2023:5544148. [PMID: 37731773 PMCID: PMC10508997 DOI: 10.1155/2023/5544148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/03/2023] [Accepted: 08/31/2023] [Indexed: 09/22/2023] Open
Abstract
Objective To summarize the characteristics of all reported patients with hypophosphatasia (HPP) who sustained atypical femoral fracture (AFF) and identify all available evidence to quantify the rate of coexistence between HPP and AFF. Methods Potentially eligible articles were identified from the MEDLINE and EMBASE databases from its inception to September 2022, using a search strategy consisting of terms related to "Hypophosphatasia" and "Atypical femoral fracture." Eligible articles must report one of the following information: (1) individual data of patients diagnosed with HPP and AFF, (2) prevalence of HPP among patients with AFF, or (3) prevalence of AFF among patients of HPP. Characteristics of patients reported in each study were extracted. Results A total of 148 articles were identified. After the systematic review, 24 articles met the eligibility criteria. A total of 28 patients with AFF and HPP were identified. The mean ± SD age of the reported patients was 53.8 ± 12.5 years, and 22 patients (78.6%) were female. Nine patients (32.1%) received antiresorptive medication (bisphosphonate and/or denosumab), and two patients (7.1%) received teriparatide prior to the development of AFF. Seven (25.0%) and eighteen (64.3%) patients sustained unilateral and bilateral AFF, respectively (laterality not reported in three cases). Thirteen patients (46.4%) had a history of fractures at other sites. Four (14.3%) and seven (25.0%) patients received asfotase alfa and teriparatide after sustaining AFF. Two studies reported the prevalence of AFF among patients with HPP of approximately 10%. One study reported one HPP patient in a cohort of 72 patients with AFF. Conclusions Based on the limited evidence, AFF occurred in up to 10% of patients with HPP. Based on the 28 case reports, about two-thirds did not receive antiresorptive treatment, suggesting that the HPP itself could potentially be a risk factor for AFF.
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Affiliation(s)
- Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jerapas Thongpiya
- Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Ben Ponvilawan
- Department of Medicine, University of Kansas Missouri Medical Center, Jefferson, MO, USA
| | - Mehmet S. Marangoz
- Department of Endocrinology and Metabolism, Mount Auburn Hospital, Cambridge, MA, USA
| | - Jirat Chenbhanich
- Department of Genetics and Genomic Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Legare JM, Basel D. What the pediatric endocrinologist needs to know about skeletal dysplasia, a primer. Front Pediatr 2023; 11:1229666. [PMID: 37675393 PMCID: PMC10477785 DOI: 10.3389/fped.2023.1229666] [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: 05/26/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023] Open
Abstract
Children with skeletal dysplasia are frequently referred to pediatric endocrinologists due to short stature. These children may present with disproportionate growth or medical histories that point to a skeletal dysplasia. This primer will discuss when to be concerned about skeletal dysplasia, the initial steps in evaluation for a skeletal dysplasia, and new therapies that are either recently approved or in development.
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Affiliation(s)
- Janet M. Legare
- Department of Pediatrics, University of Wisconsin School of Medicineand Public Health, Madison, WI, United States
| | - Donald Basel
- Department of Pediatrics, Medical Collegeof Wisconsin, Milwaukee, WI, United States
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Gnoli M, Brizola E, Tremosini M, Di Cecco A, Sangiorgi L. Vitamin D and Bone fragility in Individuals with Osteogenesis Imperfecta: A Scoping Review. Int J Mol Sci 2023; 24:ijms24119416. [PMID: 37298368 DOI: 10.3390/ijms24119416] [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: 04/26/2023] [Revised: 05/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Vitamin D affects several body functions, and thus general health, due to its pleiotropic activity. It plays a key role in bone metabolism, and its deficiency impacts bone development, leading to bone fragility. In osteogenesis imperfecta (OI), a group of hereditary connective tissue disorders characterized by bone fragility, additional factors, such as vitamin D deficiency, can affect the expression of the phenotype and aggravate the disorder. The aim of this scoping review was to assess the incidence of vitamin D deficit in OI patients and the association between vitamin D status and supplementation in individuals affected by OI. We searched the PubMed Central and Embase databases and included studies published between January/2000 and October/2022 evaluating vitamin D measurement and status (normal, insufficiency, deficiency) and supplementation for OI. A total of 263 articles were identified, of which 45 were screened by title and abstract, and 10 were included after a full-text review. The review showed that low levels of vitamin D was a frequent finding in OI patients. Vitamin D supplementation was mainly indicated along with drug therapy and calcium intake. Even if widely used in clinical practice, vitamin D supplementation for OI individuals still needs a better characterization and harmonized frame for its use in the clinical setting, as well as further studies focusing on its effect on bone fragility.
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Affiliation(s)
- Maria Gnoli
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
| | - Evelise Brizola
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
| | - Morena Tremosini
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
| | - Alessia Di Cecco
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
| | - Luca Sangiorgi
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
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van Gemert MJC, Zwinderman AH, Koppen PJV, Neumann HAM, Vlaming M. Child Abuse, Misdiagnosed by an Expertise Center-Part II-Misuse of Bayes' Theorem. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050843. [PMID: 37238391 DOI: 10.3390/children10050843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
A newborn girl had, from two weeks on, small bruises on varying body locations, but not on her chest. Her Armenian grandmother easily bruised, too. Her mother was diagnosed with hypermobility-type Ehlers-Danlos-Syndrome (hEDS), an autosomal dominant connective tissue disorder, with a 50% inheritance probability. Referral to a University Medical Center located "Dutch Expertise Center for Child Abuse" resulted (prior to consultation) in physical abuse suspicion. Protocol-based skeletal X-rays showed three healed, asymptomatic rib fractures. A protocol-based Bayesian likelihood ratio guesstimation gave 10-100, erroneously used to suggest a 10-100 times likelier non-accidental-than-accidental cause. Foster care placement followed, even in a secret home, where she also bruised, suggesting hEDS inheritance. Correct non-accidental/accidental Bayes' probability of symptoms is (likelihood ratio) × (physical abuse incidence). From the literature, we derived an infant abuse incidence between about ≈0.0009 and ≈0.0026 and a likelihood ratio of <5 for bruises. For rib fractures, we used a zero likelihood ratio, arguing their cause was birth trauma from the extra delivery pressure on the chest, combined with fragile bones as the daughter of an hEDS-mother. We thus derived a negligible abuse/accidental probability between <5 × 0.0009 <0.005 and <5 × 0.0026 <0.013. The small abuse incidence implies that correctly using Bayes' theorem will also miss true infant physical abuse cases. Curiously, because likelihood ratios assess how more often symptoms develop if abuse did occur versus non-abuse, Bayes' theorem then implies a 100% infant abuse incidence (unwittingly) used by LECK. In conclusion, probabilities should never replace differential diagnostic procedures, the accepted medical method of care. Well-known from literature, supported by the present case, is that (child abuse pediatrics) physicians, child protection workers, and judges were unlikely to understand Bayesian statistics. Its use without statistics consultation should therefore not have occurred. Thus, Bayesian statistics, and certainly (misused) likelihood ratios, should never be applied in cases of physical child abuse suspicion. Finally, parental innocence follows from clarifying what could have caused the girl's bruises (inherited hEDS), and rib fractures (birth trauma from fragile bones).
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Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology & Bio-Statistics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Peter J van Koppen
- Department of Criminal Law and Criminology, Faculty of Law, VU University, 1081 HV Amsterdam, The Netherlands
| | | | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands
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Root AW, Levine MA. One half-century of advances in the evaluation and management of disorders of bone and mineral metabolism in children and adolescents. J Pediatr Endocrinol Metab 2023; 36:105-118. [PMID: 36636022 PMCID: PMC10406614 DOI: 10.1515/jpem-2022-0624] [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: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023]
Abstract
The past 50 years of research in pediatric bone and mineral metabolism have led to remarkable progress in the identification and characterization of disorders that affect the developing skeleton. Progress has been facilitated through advances in both technology and biology and this paper provides a brief description of some but not all of the key findings, including identification of the calcium sensing receptor and the polypeptides parathyroid hormone and parathyroid hormone-related protein as well as their shared receptor and signal generating pathways; the elucidation of vitamin D metabolism and actions; discovery of fibroblast growth factor 23 (FGF23), the sodium-phosphate co-transporters and the other components that regulate phosphate metabolism. Moreover, the past half-century of research has led to the delineation of the molecular bases for genetic forms of hypoparathyroidism, pseudohypoparathyroidism, and primary hyperparathyroidism as well as the determination of the genetic causes of osteogenesis imperfecta, osteopetrosis, hypophosphatasia, and other disorders of mineral/bone homeostasis. During the next decade we expect that many of these fundamental discoveries will lead to the development of innovative treatments that will improve the lives of children with these disorders.
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Affiliation(s)
- Allen W. Root
- Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
| | - Michael A. Levine
- Corresponding author: Michael A. Levine, MD, The Center for Bone Health at the Children’s Hospital of Philadelphia, Philadelphia, PA, USA,
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Charoenngam N, Rittiphairoj T, Ponvilawan B, Jaroenlapnopparat A, Waitayangkoon P, Suppakitjanusant P, Prasitsumrit V, Pongchaiyakul C, Holick MF. Bone fragility in Hereditary Connective Tissue Disorders: a Systematic Review and Meta-analysis. Endocr Pract 2023:S1530-891X(23)00045-9. [PMID: 36804968 DOI: 10.1016/j.eprac.2023.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To investigate bone fragility in patients with hereditary connective tissue disorders (HCTD), including Ehlers-Danlos syndrome (EDS), Marfan's syndrome (MFS) and Loeys-Dietz syndrome (LDS). METHODS From inception to June 2022, potentially eligible studies were identified in the Medline and EMBASE databases using search strategy that included terms for "HCTD", "Fracture" and "Osteoporosis". Eligible studies must consist of a group of patients with HCTD and report prevalence/incidence of fracture/osteoporosis in their participants, with or without comparison with healthy individuals. Point estimates with standard errors were obtained from each study and combined using the generic inverse variance method. RESULTS Among the 4,206 articles identified, 19 studies were included. The pooled prevalence of fracture in EDS, MFS and LDS were 44% (95%CI, 25 - 65%, I2 88%), 17% (95%CI, 11 - 26%, I2 68%), 69% (95%CI, 47 - 85%, I2 83%), respectively. The pooled prevalence of osteoporosis in EDS was 17% (95%CI, 8 - 34%, I2 96%). EDS was associated with fracture [pooled odds ratio 4.90 (95%CI, 1.49 - 16.08, I2 86%)], but not osteoporosis [pooled odds ratio 1.34 (95%CI, 0.28 - 6.36, I2 87%). One study reported a 5% (95%CI, 3 - 8%) prevalence of osteoporosis in MFS, which was associated with fracture [incidence rate ratio 1.35 (95%CI, 1.18 - 1.55)] and osteoporosis [subhazard ratio 3.97 (95%CI, 2.53 - 6.25)]. CONCLUSION EDS was associated with fracture, which could be independent of osteoporosis status. MFS had a milder degree of increased risk of fracture and osteoporosis. Despite no data from cohort studies, there was a significantly higher rate of fracture in LDS.
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Affiliation(s)
- Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA; Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | | | - Ben Ponvilawan
- Department of Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | | | | | - Vitchapong Prasitsumrit
- Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
| | - Michael F Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Khromykh K, Dudnyk V, Korol T, Fedchishen O. MARBLE DISEASE (CASE REPORT). WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1694-1700. [PMID: 37622517 DOI: 10.36740/wlek202307127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
We present clinical case of marble disease in 5 yo girl. The management of this child was made in Vinnitsia Regional Children's Hospital (Vinnitsia, Ukraine). CBC, X-ray of bones, bone marrow biopsy, genetical testing, MRI of the brain and CT of the skull were done during this period. Marble disease is a very rare disease with very serious consequences, the prevention of which requires timely diagnosis and treatment, namely the prevention of infectious complications and early allogenic transplantation of stem cells. As it is a genetically determined disease, it is not possible to prevent the development of osteopetrosis. Genetic screening and proper treatment will allow the patient to lead an almost normal life.
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Affiliation(s)
| | - Veronika Dudnyk
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | - Tetiana Korol
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
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9
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Charoenngam N, Nasr A, Shirvani A, Holick MF. Hereditary Metabolic Bone Diseases: A Review of Pathogenesis, Diagnosis and Management. Genes (Basel) 2022; 13:genes13101880. [PMID: 36292765 PMCID: PMC9601711 DOI: 10.3390/genes13101880] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 11/20/2022] Open
Abstract
Hereditary metabolic bone diseases are characterized by genetic abnormalities in skeletal homeostasis and encompass one of the most diverse groups among rare diseases. In this review, we examine 25 selected hereditary metabolic bone diseases and recognized genetic variations of 78 genes that represent each of the three groups, including sclerosing bone disorders, disorders of defective bone mineralization and disorder of bone matrix and cartilage formation. We also review pathophysiology, manifestation and treatment for each disease. Advances in molecular genetics and basic sciences has led to accurate genetic diagnosis and novel effective therapeutic strategies for some diseases. For other diseases, the genetic basis and pathophysiology remain unclear. Further researches are therefore crucial to innovate ways to overcome diagnostic challenges and develop effective treatment options for these orphan diseases.
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Affiliation(s)
- Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA 02138, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Aryan Nasr
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Arash Shirvani
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Michael F. Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- Correspondence: ; Tel.: +1-617-358-6139
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10
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Charoenngam N, Ayoub D, Holick MF. Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention. Expert Rev Endocrinol Metab 2022; 17:1-14. [PMID: 35852141 DOI: 10.1080/17446651.2022.2099374] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Rickets is typically characterized by bone deformities due to defective bone mineralization and chondrocyte maturation in growing bones. However, infantile rickets often goes unrecognized, because the skeletal abnormalities are more subtle and often can only be detected radiologically. Nutritional rickets is a major public health concern in several regions worldwide. It is most commonly caused by vitamin D and/or calcium deficiency. AREA COVERED We provide an overview of historical perspective, epidemiology, and pathophysiology of nutritional rickets. Additionally, we outline diagnostic approaches and highlight challenges in radiographic diagnosis of rickets. Finally, we present strategies for prevention and treatment of rickets. EXPERT OPINION Despite the evidence from clinical databases that rickets is a rare disease, it is likely that rickets is clinically underdiagnosed as studies designed to screen healthy children for radiographic evidence of rickets reported surprisingly much higher prevalence. It has been reported that some of the radiologic features of rickets can be misinterpreted as fractures. To prevent nutritional rickets, most if not all infants and young children, should receive vitamin D from formulas and foods that are fortified with vitamin D or supplementation to achieve a serum 25-hydroxyvitamin D of at least 20 ng/mL as recommended by the Institute of Medicine. It has been recommended by the Endocrine Society that to achieve maximum bone health for children and adults, a serum concentration of 25-hydroxyvitamin D should be at least 30 ng/mL and preferably 40-60 ng/mL. Pregnant women who are unable to obtain an adequate amount of vitamin D from sunlight exposure and natural and fortified diets should take a vitamin D supplement of 1500-2000 IUs daily as recommended by the Endocrine Society since it has been demonstrated that 600 IUs daily will not maintain a circulating 25-hydroxyvitamin D of at least 20 ng/mL and most pregnant women. If lactating women take approximately 6400 IUs of vitamin D daily, they provide enough vitamin D in their milk to satisfy their infant's requirement thereby preventing rickets.
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Affiliation(s)
- Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
| | | | - Michael F Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Hildebrandt C, Wilson CR, Kritzer A. Standardizing genetic and metabolic consults for non-accidental trauma at a large pediatric academic center. CHILD ABUSE & NEGLECT 2022; 125:105480. [PMID: 35033936 DOI: 10.1016/j.chiabu.2021.105480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Evaluations of suspected non-accidental trauma (NAT) often include consultation with genetic and metabolic teams to assess patients for rare genetic conditions that can mimic or exacerbate child abuse. Diagnoses that may be questioned during court proceedings include osteogenesis imperfecta (OI) and glutaric aciduria type 1 (GA1). Currently there are no official society guidelines for the genetic or metabolic workup of suspected NAT. OBJECTIVE To standardize consult recommendations for suspected NAT through collaboration between the Genetics and Genomics Division and the Child Protection Team (CPT). PARTICIPANTS AND SETTINGS Children evaluated for suspected NAT at a single pediatric referral center. METHODS A year of inpatient consult requests for suspected NAT to the genetics division were reviewed. The most common indications for consult were fractures and subdural hematoma. Consult recommendations for similar indications varied between providers. A standard operating procedure (SOP) with specific recommendations for suspected NAT consults for fractures, intracranial hemorrhage, and other indications was created based on expert reviews and other relevant literature. A questionnaire assessing division practice patterns for these consults was distributed both pre (n = 17) and post-introduction of the SOP (n = 11). RESULTS Adherence to the SOP and impact on suspected NAT consult recommendations were assessed at 18 months after SOP introduction. Consult recommendations were in line with the SOP for 7/11 consults pre-intervention and 6/7 consults post-intervention. Providers were more likely to report feeling extremely or very confident they were using evidence-based medicine for NAT consults post-intervention.
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Affiliation(s)
- Clara Hildebrandt
- Boston Children's Hospital, Metabolism Program, Division of Genetics and Genomics, 300 Longwood Ave, Boston, MA, USA
| | - Celeste R Wilson
- Boston Children's Hospital, Child Protection Program, Division of General Pediatrics, 300 Longwood Ave, Boston, MA, USA
| | - Amy Kritzer
- Boston Children's Hospital, Metabolism Program, Division of Genetics and Genomics, 300 Longwood Ave, Boston, MA, USA.
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12
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Holick MF, Shirvani A, Charoenngam N. Fetal Fractures in an Infant with Maternal Ehlers-Danlos Syndrome, CCDC134 Pathogenic Mutation and a Negative Genetic Test for Osteogenesis Imperfecta. CHILDREN-BASEL 2021; 8:children8060512. [PMID: 34204301 PMCID: PMC8235512 DOI: 10.3390/children8060512] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
Intrauterine fractures are a rare clinical finding caused by abnormal early-life osteogenesis. In this case report, we reported a male infant with twenty-three intrauterine/fetal fractures resembling osteogenesis imperfecta and tested negative for COL1A1 and COL1A2 mutations. The infant’s mother had Ehlers–Danlos syndrome, hypermobility type. Whole-genome sequencing revealed that there were no pathologic mutations previously documented to be associated with intrauterine fracture. Genetic mutations reported to be associated with fragility fractures were identified. These include the pathogenic homozygous mutation in the CCDC134 gene. Other genetic variants that might be responsible for variable expressivity of the skeletal manifestation include the homozygous variants of the genes CCDC134, COL15A1 and ZFPM1, and the heterozygous variants of the genes MYH3, BCHE, AUTS2. This is the first reported case of in utero fractures, that was confirmed by X-ray after birth, in an infant who had no genetic evidence for osteogenesis imperfecta, had a homozygous pathogenic mutation of an osteogenesis gene and whose mother had Ehlers-Danlos syndrome hypermobility type. Therefore, we have identified a new genetic cause for in utero fractures. If after birth, this infant were found to have these fractures in various stages of healing with a negative genetic test for osteogenesis imperfecta he would have been misdiagnosed as due to nonaccidental trauma.
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Affiliation(s)
- Michael F. Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
- Correspondence: ; Tel.: +1-617-358-6139
| | - Arash Shirvani
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
| | - Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Editorial: Medical genetics, expert medical testimony, and suspected child abuse cases: a call for evidence-based standards in clinic and the courtroom. Curr Opin Pediatr 2021; 33:1-2. [PMID: 33337605 DOI: 10.1097/mop.0000000000000987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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