1
|
Periasamy U, Chilutti M, Kaplan SL, Hickey CP, Hayes K, Pennington JW, Balamuth F, Fitzgerald JC, Weiss SL. Prevalence of and Associations With Avascular Necrosis After Pediatric Sepsis: A Single-Center Retrospective Study. Pediatr Crit Care Med 2022; 23:e153-e161. [PMID: 34991135 PMCID: PMC8897239 DOI: 10.1097/pcc.0000000000002880] [Citation(s) in RCA: 2] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Avascular necrosis (AVN) is a rare, but serious, complication after sepsis in adults. We sought to determine if sepsis is associated with postillness diagnosis of AVN, as well as potential-associated risk factors for AVN in children with sepsis. DESIGN Retrospective observational study. SETTING Single academic children's hospital. PATIENTS Patients less than 18 years treated for sepsis or suspected bacterial infection from 2011 to 2017. Patients who developed AVN within 3 years after sepsis were compared with patients who developed AVN after suspected bacterial infection and with patients with sepsis who did not develop AVN. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS AVN was determined using International Classification of Diseases, 9th Edition/10th Edition codes and confirmed by chart review. The prevalence of AVN after sepsis was 0.73% (21/2,883) and after suspected bacterial infection was 0.43% (53/12,276; risk difference, 0.30; 95% CI, 0.0-0.63; p = 0.05). Compared with 43 sepsis controls without AVN, AVN in the 21 sepsis cases was associated with being older, having sickle cell disease and malignancy, higher body mass index, unknown source of infection, and low platelet count in the first 7 days of sepsis. Half of sepsis patients were treated with corticosteroids, and higher median cumulative dose of steroids was associated with AVN (23.2 vs 5.4 mg/kg; p < 0.01). Older age at infection (odds ratio [OR], 1.3; 95% CI, 1.1-1.4), malignancy (OR, 8.8; 95% CI, 2.6-32.9), unknown site of infection (OR, 12.7; 95% CI, 3.3-48.6), and minimal platelet count less than 100,000/µL in first 7 days of sepsis (OR, 5.0; 95% CI, 1.6-15.4) were identified as potential risk factors for AVN after sepsis following adjustment for multiple comparisons. CONCLUSIONS Although rare, sepsis was associated with a higher risk of subsequent AVN than suspected bacterial infection in children. Older age, malignancy, unknown site of infection, and minimum platelet count were potential risk factors for AVN after sepsis.
Collapse
Affiliation(s)
- Uvaraj Periasamy
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston MA, USA
| | - Marianne Chilutti
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Summer L. Kaplan
- Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Christopher P. Hickey
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
| | - Katie Hayes
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
| | - Jeffrey W. Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Fran Balamuth
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Pediatrics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Julie C. Fitzgerald
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| |
Collapse
|
2
|
Krez A, Lane J, Heilbronner A, Park-Min KH, Kaneko K, Pannellini T, Mintz D, Hansen D, McMahon DJ, Kirou KA, Roboz G, Desai P, Bockman RS, Stein EM. Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis. Osteoporos Int 2021; 32:2095-2103. [PMID: 33877383 PMCID: PMC8056829 DOI: 10.1007/s00198-021-05947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/01/2021] [Indexed: 12/24/2022]
Abstract
UNLABELLED This study investigated risk factors for osteonecrosis involving multiple joints (MJON) among glucocorticoid-treated patients. The best predictor of MJON was cumulative oral glucocorticoid dose. Risk of MJON was 12-fold higher in patients who had a second risk factor for osteonecrosis. Further research is needed into strategies for prevention of MJON. INTRODUCTION Osteonecrosis (ON) is a debilitating musculoskeletal condition in which bone cell death can lead to mechanical failure. When multiple joints are affected, pain and disability are compounded. Glucocorticoid treatment is one of the most common predisposing factors for ON. This study investigated risk factors for ON involving multiple joints (MJON) among glucocorticoid-treated patients. METHODS Fifty-five adults with glucocorticoid-induced ON were prospectively enrolled. MJON was defined as ON in ≥ three joints. Route, dose, duration, and timing of glucocorticoid treatment were assessed. RESULTS Mean age of enrolled subjects was 44 years, 58% were women. Half had underlying conditions associated with increased ON risk: systemic lupus erythematosus (29%), acute lymphoblastic leukemia (11%), HIV (9%), and alcohol use (4%). Mean daily oral dose of glucocorticoids was 29 mg. Average cumulative oral dose was 30 g over 5 years. The best predictor of MJON was cumulative oral glucocorticoid dose. For each increase of 1,000 mg, risk of MJON increased by 3.2% (95% CI 1.03, 1.67). Glucocorticoid exposure in the first 6 months of therapy, peak dose (oral or IV), and mean daily dose did not independently increase risk of MJON. The risk of MJON was 12-fold in patients who had a second risk factor (95% CI 3.2, 44.4). CONCLUSIONS Among patients with glucocorticoid-induced ON, cumulative oral dose was the best predictor of multi-joint disease; initial doses of IV and oral glucocorticoids did not independently increase risk. Further research is needed to better define optimal strategies for prevention and treatment of MJON.
Collapse
Affiliation(s)
- A Krez
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - J Lane
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - A Heilbronner
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - K-H Park-Min
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomic Research Center, Hospital for Special Surgery, New York, NY, USA
| | - K Kaneko
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomic Research Center, Hospital for Special Surgery, New York, NY, USA
| | - T Pannellini
- Research Division, Hospital for Special Surgery, New York, NY, USA
| | - D Mintz
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - D Hansen
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - D J McMahon
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - K A Kirou
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - G Roboz
- Department of Hematology and Oncology, Weill Cornell Medical Center, New York, NY, USA
| | - P Desai
- Department of Hematology and Oncology, Weill Cornell Medical Center, New York, NY, USA
| | - R S Bockman
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - E M Stein
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA.
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA.
| |
Collapse
|
3
|
Barzilai-Birenboim S, Yacobovich J, Zalcberg Y, Arad-Cohen N, Avrahami G, Gilad G, Litichever N, Izraeli S, Elitzur S. Bone pain at leukemia diagnosis and other risk factors for symptomatic osteonecrosis in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29033. [PMID: 33788395 DOI: 10.1002/pbc.29033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/25/2021] [Accepted: 03/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Osteonecrosis is a major cause of acute and long-lasting complications of acute lymphoblastic leukemia (ALL) therapy in children. Our study aimed to evaluate the prevalence, characteristics, risk factors, and outcome of osteonecrosis in children with ALL. PROCEDURE The cohort included 559 children aged 1-20 years diagnosed with ALL between 2003 and 2018 at two tertiary medical centers in Israel and enrolled in two consecutive protocols: ALL-IC BFM 2002 and AIEOP-BFM ALL 2009. Symptomatic osteonecrosis was prospectively captured as an adverse event. RESULTS Osteonecrosis occurred in 51 patients (9.1%). Ninety-four percent of the events were graded as moderate or severe (grades 3-4, Ponte di Legno Toxicity Working Group classification) and multiple bone involvement was common. Full resolution of osteonecrosis was documented in only 16% of the children (median follow-up 4.2 years). Stepwise logistic regression identified five risk factors for osteonecrosis, with a high predictive value (AUC = 0.88): older ageat ALL diagnosis, high-risk ALL group, T-cell immunophenotype, female gender, and a novel risk factor: bone pain at the time of leukemia diagnosis. In addition, osteonecrosis was less common among children of Arab ethnicity. Thrombophilia and an elevated age-adjusted body mass index were not confirmed as risk factors for osteonecrosis. CONCLUSION Due to the low rates of osteonecrosis resolution and its debilitating long-term impact, the identification of patients at high risk for osteonecrosis is important for their inclusion in further studies evaluating potential therapeutic adjustments.
Collapse
Affiliation(s)
- Shlomit Barzilai-Birenboim
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Zalcberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Pediatric Hematology, Oncology, and Bone Marrow Transplantation, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Nira Arad-Cohen
- Department of Pediatric Hematology-Oncology, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, and Technion-Israel Institute of Technology, Haifa, Israel
| | - Galia Avrahami
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Gilad
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naomi Litichever
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Shai Izraeli
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Elitzur
- The Rina Zaizov Division of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
4
|
Genetic ancestry and skeletal toxicities among childhood acute lymphoblastic leukemia patients in the DFCI 05-001 cohort. Blood Adv 2021; 5:451-458. [PMID: 33496737 DOI: 10.1182/bloodadvances.2020003060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/17/2020] [Indexed: 11/20/2022] Open
Abstract
Hispanic children have a higher incidence of acute lymphoblastic leukemia (ALL) and inferior treatment outcomes relative to non-Hispanic White children. We previously reported that Hispanic children with ALL had lower risk of fracture and osteonecrosis. To unravel the genetic root of such ethnic differences, we genotyped 449 patients from the DFCI 05-001 cohort and analyzed their ancestry. Patients with discordant clinical and genetic ancestral groups were reclassified, and those with unknown ancestry were reassigned on the basis of genetic estimates. Both clinical and genetic ancestries were analyzed in relation to risk of bone toxicities and survival outcomes. Consistent with clinically reported race/ethnicity, genetically defined Hispanic and Black patients had significantly lower risk of fracture (Hispanic: subdistribution hazard ratio [SHR], 0.42; 95% confidence interval [CI], 0.22-0.81; P = .01; Black: SHR, 0.28; 95% CI, 0.10-0.75; P = .01), and osteonecrosis (Hispanic: SHR, 0.12; 95% CI, 0.02-0.93; P = .04; Black: SHR, 0.24; 95% CI, 0.08-0.78; P = .02). The lower risk was driven by African but not Native American or Asian ancestry. In addition, patients with a higher percentage of Native American ancestry had significantly poorer overall survival and event-free survival. Our study revealed that the lower risk of bone toxicities among Black and Hispanic children treated for ALL was attributed, in part, to the percentage of African ancestry in their genetic admixture. The findings provide suggestive evidence for the protective effects of genetic factors associated with African decent against bone damage caused by ALL treatment and clues for future studies to identify underlying biological mechanisms.
Collapse
|
5
|
Amin N, Kraft J, Fishlock A, White A, Holton C, Kinsey S, Feltbower R, James B. Surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003. Bone Joint J 2021; 103-B:589-596. [PMID: 33641424 DOI: 10.1302/0301-620x.103b3.bjj-2020-0239.r3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON. METHODS UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management. RESULTS Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention. CONCLUSION There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589-596.
Collapse
Affiliation(s)
| | | | | | | | | | - Sally Kinsey
- Leeds Children's Hospital, Leeds, UK.,University of Leeds, Leeds, UK
| | | | | |
Collapse
|
6
|
An YS, Park S, Jung JY, Suh CH, Kim HA. Clinical characteristics and role of whole-body bone scan in multifocal osteonecrosis. BMC Musculoskelet Disord 2019; 20:23. [PMID: 30646869 PMCID: PMC6334418 DOI: 10.1186/s12891-019-2401-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/02/2019] [Indexed: 01/04/2023] Open
Abstract
Background Multifocal osteonecrosis (ON) is defined as ON involving three or more distinct anatomical sites. We investigated the clinical characteristics and utility of whole-body bone scans (WBBS) in patients with multifocal ON. Methods A total of 254 patients with ON confirmed by magnetic resonance imaging (MRI) or X-rays of the hips or other anatomic regions were evaluated using WBBS and divided into those with multifocal disease and those with oligofocal disease; their clinical characteristics were then compared. All data were analyzed retrospectively both visually and quantitatively (via uptake grading and defect scoring). Associations between the MRI Association Research Circulation Osseous (ARCO) classification and bone scan photon defects and uptake grade were assessed. Factors associated with multifocal ON were identified using logistic regression. Results Of the 254 ON patients, 26 (10.2%) had multifocal ON. Their mean age (42.8 ± 14.3 years) was less than that of patients with oligofocal ON (50.9 ± 15.4 years; p = 0.011). Comorbidities, corticosteroid use, and treatment with immunosuppressive agents were more frequent in patients with multifocal ON. Age (odds ratio [OR] = 0.964, p = 0.013), the presence of a comorbidity (OR = 3.387, p = 0.006), present corticosteroid use (OR = 5.696, p < 0.001), and treatment with immunosuppressive agents (OR = 3.447, p = 0.004) were significantly associated with multifocal ON. The MRI ARCO classification was not associated with photon defects in the bone scans of those with femoral ON. However, the ARCO classification was significantly associated with uptake grade. Conclusions WBBS may be an additional tool for evaluating ON patients with risk factors for multiple ON, such as younger age, corticosteroid use, and comorbidities.
Collapse
Affiliation(s)
- Young-Sil An
- Department of Nuclear Medicine and Molecular Imaging, Ajou University School of Medicine, Suwon, Korea
| | - Sunghoon Park
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea.
| |
Collapse
|