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Tripto-Shkolnik L, Szalat A, Tsvetov G, Rouach V, Sternberg C, Hoppe A, Burshtein G, Galitzer H, Toledano M, Harari G, Santora AC, Cosman F. Oral daily PTH(1-34) tablets (EB613) in postmenopausal women with low BMD or osteoporosis: a randomized, placebo-controlled, six-month, phase 2 study. J Bone Miner Res 2024:zjae057. [PMID: 38578978 DOI: 10.1093/jbmr/zjae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 02/21/2024] [Accepted: 04/03/2024] [Indexed: 04/07/2024]
Abstract
Anabolic treatment is indicated for high and very-high risk patients with osteoporosis, but acceptance is limited because current anabolic medications require subcutaneous injections. The purpose of this study was to assess the effects of a novel orally administered parathyroid hormone (PTH) tablet on serum markers of bone formation [N-terminal propeptide of Type I procollagen (PINP) and osteocalcin (OC)] and bone resorption [crosslinked C-telopeptide (CTX)], bone mineral density (BMD) and safety in postmenopausal women with low BMD or osteoporosis. In this 6-month, double-blind, placebo-controlled study, 161 patients were randomized to oral PTH tablets containing 0.5, 1.0, 1.5, or 2.5 mg or placebo daily. Biochemical markers were assessed at 1, 2, 3 and 6 months and BMD of lumbar spine, total hip and femoral neck was measured at 6 months. Biochemical marker changes were dose dependent with minimal or no effect at the two lowest doses. At the highest dose (2.5 mg once daily), serum PINP and OC levels increased 30% within 1 month after oral PTH initiation (p < 0.0001), remained elevated through 3 months and were back to baseline at 6 months. In contrast, serum CTX levels declined 16% and 21% below baseline at 3 and 6 months respectively (both p ≤ 0.02). At 6 months, 2.5 mg tablets increased mean BMD vs placebo of the lumbar spine by 2.7%, total hip by 1.8%, and femoral neck by 2.8% (all p ≤ 0.01). There were no drug-related serious adverse events. The most common adverse events were headache, nausea, and dizziness. In contrast to subcutaneous PTH, the oral PTH tablet appears to increase BMD rapidly by the dual mechanism of stimulating formation and inhibiting bone resorption. This might be the first effective oral anabolic alternative to subcutaneous administration for the treatment of low BMD or osteoporosis.
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Giveon S, Zacay G, Vered I, Foldes AJ, Tripto-Shkolnik L. Zoledronic acid sequential to teriparatide may promote greater inhibition of bone resorption than zoledronic acid alone. Ther Adv Endocrinol Metab 2023; 14:20420188231213639. [PMID: 38028331 PMCID: PMC10666713 DOI: 10.1177/20420188231213639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Teriparatide (TPTD) should be followed by an antiresorptive to maximize bone mineral density gain and anti-fracture protection. Infrequent zoledronic acid (ZOL) administration has demonstrated effectiveness. The duration of ZOL effect following TPTD is unknown. Objective To evaluate the effect of ZOL on bone resorption marker in a post-TPTD versus ZOL-alone scenario in osteoporotic patients. Design Retrospective cohort study. Methods Patients treated with TPTD followed by ZOL (TPTD-ZOL) or with a single ZOL infusion were identified in the database of a tertiary referral center. Clinical and laboratory data, including C-terminal telopeptide of type I collagen (CTX) following ZOL treatment, were compared. Results Twenty-six patients (93% women) treated with TPTD-ZOL and 41 with ZOL were comparable in age (median 70.1 versus 69.6 years, p = 0.6) and sex. Timing of CTX measurement post-ZOL was the same, median 1.0 year. CTX was lower following TPTD-ZOL (median 142.1 versus 184.2 pg/mL, p = 0.005). In a multivariable regression model (controlled for baseline characteristics), pretreatment with TPTD strongly predicted CTX <150 pg/mL, 1 year following ZOL (odds ratio = 7.5, 95% CI 1.3-58.1, p = 0.03). In a subgroup with sequential CTX measurements following one ZOL, significantly lower levels persisted in the TPTD-ZOL group for a median of 4.4 years follow-up. Conclusion ZOL-administered sequential to TPTD yielded deeper and more prolonged bone resorption suppression than ZOL alone. Prospective data are needed to confirm whether in a sequential treatment scenario, subsequent ZOL dosing interval should be less frequent.
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Affiliation(s)
- Sharon Giveon
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Sheba Road 2, Ramat Gan, Tel Hashomer 5262100, Israel
| | - Galia Zacay
- School of Medicine, Tel Aviv University, Israel
- Meuhedet Health Services, Tel Aviv, Israel
| | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Tel Aviv University, Israel
| | - A. Joseph Foldes
- Osteoporosis Center, Hadassah Mount-Scopus University Hospital, Jerusalem, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Tel Aviv University, Israel
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Aharon-Hananel G, Zacay G, Tau N, Levy-Shraga Y, Tirosh A, Vered I, Tripto-Shkolnik L. Trabecular Bone Score Change Is Not Predicted by Bone Turnover: Short-term Sequential Follow-up. Isr Med Assoc J 2023; 25:438-442. [PMID: 37381941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Trabecular bone score (TBS) reflects vertebrae microarchitecture and assists in fracture risk assessment. The International Society of Clinical Densitometry postulates that the role of TBS in monitoring antiresorptive therapy is unclear. Whether changes in TBS correlate with bone resorption measured by bone turnover markers is not known. OBJECTIVES To determine whether longitudinal changes in TBS correlate with C-terminal telopeptide (CTX) of type I collagen. METHODS Examinees with two bone mineral density (BMD) measurements were detected via the institutional database. Over 5.8% change in TBS was considered least significant and patients were grouped accordingly (increment, decrement, or unchanged). CTX, BMD, co-morbidities, incident fractures, and medication exposure were compared between the groups by Kruskal-Wallis. The correlation between TBS and BMD change and CTX in a continuous model was analyzed by Pearson's correlation coefficient. RESULTS In total, 110 patients had detailed medical records. In 74.5%, TBS change was below least significant change. Two other TBS categories, fracture incidence or medication exposure, did not differ by CTX. In the continuous model, BMD and TBS change was positively correlated (r = 0.225, P = 0.018). A negative correlation was observed between BMD change and CTX. The decrease in BMD level was associated with higher CTX (r = -0.335, P = 0.004). No correlation was observed between CTX and TBS. CONCLUSIONS No correlation between TBS dynamics and bone resorption marker was found. Clinical interpretation and implication of longitudinal TBS changes should be further explored.
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Affiliation(s)
- Genya Aharon-Hananel
- Department of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Zacay
- Kupat Holim Meuhedet, Tel Aviv, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Tau
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Levy-Shraga
- Department of Pediatric Endocrinology and Diabetes, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Tirosh
- Department of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Vered
- Department of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Department of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Peltz-Sinvani N, Raz HM, Klein P, Ish-Shalom S, Vered I, Tripto-Shkolnik L. Pregnancy- and lactation-induced osteoporosis: a social-media-based survey. BMC Pregnancy Childbirth 2023; 23:311. [PMID: 37131133 PMCID: PMC10152747 DOI: 10.1186/s12884-023-05639-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/24/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Pregnancy- and lactation-induced osteoporosis (PLO) presenting as spinal fractures is rare, and the spectrum of clinical presentation, risk factors and pathophysiology are incompletely understood. The aim of this study was to delineate clinical parameters, risk factors and osteoporosis-related quality of life (QOL) of women with PLO. METHODS Participants of a social-media (WhatsApp) PLO group and mothers of a parents' WhatsApp group (control group) were offered to fill a questionnaire, including an osteoporosis-related QOL section. The groups were compared using the independent Students t test for numerical variables, and the Chi-square test or Fisher's exact test for categorical variables. RESULTS Twenty-seven women with PLO and 43 in the control group (aged 36.2 ± 4.7 and 38.8 ± 4.3 years, respectively, p = 0.04) participated. Among women with PLO, more than 5 vertebrae were involved in 13 (48%), 4 vertebrae in 6 (22%), and 3 or fewer vertebrae in 8 (30%). Among the 24 women with relevant data, 21 (88%) had nontraumatic fractures; 3 (13%) women had fractures during pregnancy, and the remaining during the early postpartum period. Diagnosis was delayed for over 16 weeks for 11 (41%) women; 16 (67%) received teriparatide. Significantly lower proportions of women in the PLO group engaged in physical activity over 2 hours/week, before and during pregnancy (37 vs. 67%, p < 0.015 and 11 vs. 44%, p < 0.003, respectively). A lower proportion of the PLO than the control group reported calcium supplementation during pregnancy (7% vs. 30%, p = 0.03) and a higher proportion reported treatment with low-molecular-weight-heparin during pregnancy (p = 0.03). Eighteen (67%) of the PLO group expressed fear of fractures and 15 (56%) fear of falls, compared to none and 2%, respectively, of the control group (p < 0.00001 for both). CONCLUSIONS Most of the women with PLO who responded to our survey reported spinal fractures involving multiple vertebrae, delayed diagnosis, and treatment with teriparatide. Compared to a control group, they reported less physical activity and impaired QOL. For this uncommon yet severe condition, a multidisciplinary effort should be exerted for early identification and treatment, to alleviate back pain, prevent subsequent fractures and improve QOL.
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Affiliation(s)
- Naama Peltz-Sinvani
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Hadar Milloh Raz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pinchas Klein
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Yosibash Z, Trabelsi N, Buchnik I, Myers KW, Salai M, Eshed I, Barash Y, Klang E, Tripto-Shkolnik L. Hip Fracture Risk Assessment in Elderly and Diabetic Patients: Combining Autonomous Finite Element Analysis and Machine Learning. J Bone Miner Res 2023. [PMID: 36970838 DOI: 10.1002/jbmr.4805] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
Autonomous finite element analyses (AFE) based on CT scans predict the biomechanical response of femurs during stance and sidewise fall positions. We combine AFE with patient data via a machine learning (ML) algorithm to predict the risk of hip fracture. An opportunistic retrospective clinical study of CT scans is presented, aimed at developing a ML algorithm with AFE for hip fracture risk assessment in type 2 diabetic mellitus (T2DM) and non-T2DM patients. Abdominal/pelvis CT scans of patients who experienced a hip fracture within 2 years after an index CT scan were retrieved from a tertiary medical center database. A control group of patients without a known hip fracture for at least 5 years after an index CT scan was retrieved. Scans belonging to patients with/without T2DM were identified from coded diagnoses. All femurs underwent an AFE under three physiological loads. AFE results, patient's age, weight, and height were input to the ML algorithm (support vector machine [SVM]), trained by 80% of the known fracture outcomes, with cross-validation, and verified by the other 20%. In total, 45% of available abdominal/pelvic CT scans were appropriate for AFE (at least 1/4 of the proximal femur was visible in the scan). The AFE success rate in automatically analyzing CT scans was 91%: 836 femurs we successfully analyzed, and the results were processed by the SVM algorithm. A total of 282 T2DM femurs (118 intact and 164 fractured) and 554 non-T2DM (314 intact and 240 fractured) were identified. Among T2DM patients, the outcome was: Sensitivity 92%, Specificity 88% (cross-validation area under the curve [AUC] 0.92) and for the non-T2DM patients: Sensitivity 83%, Specificity 84% (cross-validation AUC 0.84). Combining AFE data with a ML algorithm provides an unprecedented prediction accuracy for the risk of hip fracture in T2DM and non-T2DM populations. The fully autonomous algorithm can be applied as an opportunistic process for hip fracture risk assessment. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Zohar Yosibash
- School of Mechanical Engineering, The Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
- PerSimiO Ltd, Beer-Sheva, Israel
| | - Nir Trabelsi
- PerSimiO Ltd, Beer-Sheva, Israel
- Department of Mechanical Engineering, Shamoon College of Engineering, Beer-Sheva, Israel
| | - Itay Buchnik
- Department of Electrical and Computer Engineering, Ben Gurion University, Beer-Sheva, Israel
| | | | - Moshe Salai
- Orthopedic Department, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Iris Eshed
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
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Bilezikian JP, Fraenkel M, Tripto-Shkolnik L, Rizzoli R, Siris E. In Memoriam: Uri A. Liberman, 1935-2022. J Bone Miner Res 2023; 38:455-456. [PMID: 36772839 DOI: 10.1002/jbmr.4771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 12/31/2022] [Indexed: 02/12/2023]
Affiliation(s)
- John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | | | - Rene Rizzoli
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ethel Siris
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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8
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Schwarz Y, Goldshtein I, Friedman YE, Peltz-Sinvani N, Brodavka M, Kowal D, Vered I, Tripto-Shkolnik L. Bone mineral density of the ultra-distal radius: are we ignoring valuable information? Arch Osteoporos 2023; 18:28. [PMID: 36725758 DOI: 10.1007/s11657-023-01218-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
The current study explored the possible utilization in dual-X-ray-absorptiometry scanning (DXA) of the ultra-distal radius (UDR). This region of interest is currently unused and mostly unstudied in this context. The study findings suggest UDR as potential useful region of interest in DXA scanning and warrant further study of the site. PURPOSE Bone mineral density (BMD) measurement of a non-dominant arm is not routinely performed during dual-X-ray-absorptiometry (DXA) test, and the possible utility of ultra-distal (UDR) radius BMD is not well-studied. We evaluated in women, correlations of UDR BMD with fracture prevalence, fracture risk prediction by the fracture risk assessment tool (FRAX), and osteoporosis diagnosed by traditional sites. METHODS Women who underwent a routine DXA (including their non-dominant forearm and including UDR BMD) in a tertiary medical center were included. Risk factors relevant to FRAX calculation were assessed via a self-administered questionnaire. Spearman correlations of UDR BMD to 10-year risks of major osteoporotic and hip fractures (assessed by FRAX) were explored. The possible added value of UDR BMD in explaining prevalent osteoporotic fractures was assessed using a multivariable regression model incorporating age and traditional osteoporosis diagnosis. RESULTS The study included 1245 women with a median age of 66 years (interquartile range: 59-73), of whom 298 (24%) had UDR T-score ≤ - 2.5 and 154 (12%) reported prior fractures. UDR BMD was significantly negatively correlated with FRAX risk score for hip and major osteoporotic fractures (R = - 0.5 and R = - 0.41, respectively; P < 0.001). UDR T-score ≤ - 2.5 was associated with higher fracture prevalence (19% vs 10%; P < 0.001) and remained significant after adjusting for traditional BMD and age (OR 1.49, 1.01-2.19; P = 0.043). CONCLUSION UDR BMD correlates both with prior fractures and with predicted fracture risks and might pose added value over traditional DXA sites.
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Affiliation(s)
- Yair Schwarz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Inbal Goldshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yehudit Eden Friedman
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Peltz-Sinvani
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Brodavka
- Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - David Kowal
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
| | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Schwarz Y, Tripto-Shkolnik L. Rapid Improvement of Osteitis Fibrosa Cystica Following Parathyroidectomy. JCEM Case Rep 2023; 1:luac005. [PMID: 37908257 PMCID: PMC10578371 DOI: 10.1210/jcemcr/luac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Indexed: 11/02/2023]
Affiliation(s)
- Yair Schwarz
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Ramat Gan 5266202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Ramat Gan 5266202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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10
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Gendelman O, Tripto-Shkolnik L, Vered I, Lidar M. Bisphosphonates Related Ocular Side Effects: A Case Series and Review of Literature. Ocul Immunol Inflamm 2022; 30:1995-1999. [PMID: 34014797 DOI: 10.1080/09273948.2021.1922705] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe the clinical features of patients with bisphosphonate related ocular side effects (BROSE). METHODS The medical records of all patients with BROSE between January 2009 and December 2019 were reviewed. RESULTS Nine cases with BROSE were identified. All subjects were female. Median age at diagnosis was of 69 years. The leading indication for bisphosphonate treatment was osteoporosis (n=7), Paget's disease of bone (n=1) and breast cancer (n=1). Six (66.67%) patients presented with uveitis, one (11%) episcleritis and two (22%) with orbital inflammation. Five events (55.5%) occurred within 10 days of initiating the bisphosphonate and the rest (44.44%) developed within 2 weeks to 3 years later. Four (44.44%) patients had concurrent thyroid disease. An association was found between underlying thyroid disease or autoimmunity. CONCLUSION BROSE is an uncommon complication of bisphosphonate therapy occurring more frequently in patients with an autoimmune predisposition.
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Affiliation(s)
- Omer Gendelman
- Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Liana Tripto-Shkolnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
| | - Iris Vered
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel Hashomer, Israel
| | - Merav Lidar
- Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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11
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Brandi ML, Ariceta G, Beck-Nielsen SS, Boot AM, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Nilsson O, Schnabel D, Tripto-Shkolnik L, Zillikens MC, Liu J, Tudor A, Mughal MZ. Post-authorisation safety study of burosumab use in paediatric, adolescent and adult patients with X-linked hypophosphataemia: rationale and description. Ther Adv Chronic Dis 2022; 13:20406223221117471. [PMID: 36082134 PMCID: PMC9445456 DOI: 10.1177/20406223221117471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: X-linked hypophosphataemia (XLH) is a rare, inherited, phosphate-wasting disorder that elevates fibroblast growth factor 23 (FGF23), causing renal phosphate-wasting and impaired active vitamin D (1,25(OH)2D) synthesis. Disease characteristics include rickets, osteomalacia, odontomalacia, and short stature. Historically, treatment has been oral phosphate and 1,25(OH)2D supplements. However, these treatments do not correct the primary pathogenic mechanism or treat all symptoms and can be associated with adverse effects. Burosumab is a recombinant human immunoglobulin G1 monoclonal antibody against FGF23, approved for treating XLH in several geographical regions, including Europe and Israel. Burosumab restores normal serum phosphate levels, minimising the clinical consequences of XLH. Safety data on long-term treatment with burosumab are lacking owing to the rarity of XLH. This post-authorisation safety study (PASS) aims to evaluate the safety outcomes in patients aged >1 year. Methods: The PASS is a 10-year retrospective and prospective cohort study utilising data from the International XLH Registry (NCT03193476), which includes standard diagnostic and monitoring practice data at participating centres. The PASS aims to evaluate frequency and severity of safety outcomes, frequency and outcomes of pregnancies in female patients, and safety outcomes in patients with mild to moderate kidney disease at baseline, in children, adolescents and adults treated with burosumab for XLH. It is expected that there will be at least 400 patients who will be administered burosumab. Results: Data collection started on 24 April 2019. The expected date of the final study report is 31 December 2028, with two interim reports. Conclusion: This PASS will provide data on the long-term safety of burosumab treatment for XLH patients and describe safety outcomes for patients receiving burosumab contrasted with those patients receiving other XLH treatments, to help inform the future management of XLH patients. The PASS will be the largest real-world safety study of burosumab. Registry identification: The International XLH Registry is registered with clinicaltrials.gov as NCT03193476 (https://clinicaltrials.gov/ct2/show/NCT03193476), and the PASS is registered with the European Union electronic Register of Post-Authorisation Studies as EUPAS32190 (http://www.encepp.eu/encepp/viewResource.htm?id=32191).
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Affiliation(s)
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatric Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karine Briot
- APHP, Department of Rheumatology, Cochin Hospital, Université de Paris, Paris, France
| | - Carmen de Lucas Collantes
- Department of Nephrology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Metabolic Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Pediatric Endocrinology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Department of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronic Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC Bone Center - Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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12
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Modan-Moses D, Megnazi O, Tripto-Shkolnik L, Talmor H, Toledano A, Shilton T, Enoch-Levy A, Stein D, Levy-Shraga Y. Changes in trabecular bone score and bone density in female adolescents with anorexia nervosa: a longitudinal study. J Clin Densitom 2022; 25:416-423. [PMID: 34933783 DOI: 10.1016/j.jocd.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 10/23/2021] [Accepted: 11/08/2021] [Indexed: 12/25/2022]
Abstract
Impaired bone health is a common complication of anorexia nervosa (AN). We aimed to assess longitudinal changes in bone mineral density (BMD) and trabecular bone score (TBS), a measure of bone quality, in female adolescents with anorexia nervosa (AN). We conducted a retrospective longitudinal study of 41 female adolescents with AN who underwent two dual-energy X-ray absorptiometry (DXA) scans. Clinical data, including age, weight, height, body mass index (BMI), and DXA measurements were retrieved from the medical charts. Lumbar bone mineral apparent density (BMAD) was calculated to correct for size. Changes (Δ) in BMD, BMAD, and TBS were examined for correlations with clinical characteristics. Mean ages at the time of DXA scans were 14.8±1.9 and 16.8±2.0 years. There was a significant improvement in anthropometric parameters and DXA measurements at the second DXA scan. However, these values were still significantly lower than expected in the general population. The Δlumbar BMD Z-score was 0.3±0.7, the Δlumbar BMAD Z-score was 0.2±0.7 and the ΔTBS Z-score was 0.5±0.7. ΔTBS Z-score was positively correlated with Δheight Z-score, Δweight Z-score and ΔBMI Z-scores, and negatively correlated height Z-score, weight Z-score and TBS Z-scores at the first DXA scan (p<0.05). Δheight Z-score, ΔBMI Z-score and the progression from early to late puberty were identified as significant independent predictors of Δlumbar BMAD Z-score (p<0.05). During two years of treatment, both BMD and TBS increased significantly. Improvement in height and in weight status, and progression in puberty are predictors of improvement in BMD and TBS.
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Affiliation(s)
- Dalit Modan-Moses
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israe; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv
| | - Ophir Megnazi
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv
| | - Liana Tripto-Shkolnik
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israe
| | - Helit Talmor
- Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Anat Toledano
- Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Tal Shilton
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Enoch-Levy
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Daniel Stein
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv; Pediatric Psychosomatic Department, Division of Child and Adolescent Psychiatry, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yael Levy-Shraga
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israe; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv.
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13
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Zacay G, Dubnov-Raz G, Modan-Moses D, Tripto-Shkolnik L, Levy-Shraga Y. Epidemiology of childhood fractures in Israel during 2000-2019. Bone Rep 2022. [DOI: 10.1016/j.bonr.2022.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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14
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Zacay G, Modan-Moses D, Tripto-Shkolnik L, Levy-Shraga Y. Decreases in pediatric fractures during the COVID-19 pandemic – a nationwide epidemiological cohort study. Bone Rep 2022. [PMCID: PMC9212933 DOI: 10.1016/j.bonr.2022.101247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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15
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Zacay G, Modan-Moses D, Tripto-Shkolnik L, Levy-Shraga Y. Decreases in pediatric fractures during the COVID-19 pandemic - a nationwide epidemiological cohort study. Eur J Pediatr 2022; 181:1473-1480. [PMID: 34993624 PMCID: PMC8739001 DOI: 10.1007/s00431-021-04323-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/12/2021] [Accepted: 11/15/2021] [Indexed: 01/05/2023]
Abstract
The COVID-19 pandemic led to fundamental changes in daily routines of children. Our aim was to evaluate the incidence and characteristics of fractures among Israeli children during 2020 compared with 2015-2019. Demographic, clinical data, and incidence rates of fractures in individuals aged < 18 years were derived from the electronic database of Meuhedet Health Services, which provides healthcare services to 1.2 million people in Israel. We further subdivided the year to five periods according to government regulations of lockdown and isolation at each period. Fracture sites were determined according to ICD9 definitions. During 2020, 10,701 fractures occurred compared with 12,574 ± 599 fractures per year during 2015-2019 (p-value < 0.001). Fracture rates were lower during all periods in 2020. The largest decline was observed during the first lockdown for both boys (56% decline, 95% confidence interval [CI] 52-60%) and girls (47% decline CI 41-53%). While the fracture rate declined for most age groups, the largest decline was recorded for the age group 11-14 years, with significant reduction rates of 66% (CI 59-71%) for boys and 65% (CI 54-73%) for girls. The most prominent declines were of fractures of the hand bones of both boys and girls (64% and 59%, respectively). Conclusions: Our data showed a significant decrease in fracture rate in 2020 compared to the previous 5 years, as well as differences between periods within that year. What is New: •The COVID-19 pandemic led to fundamental change in daily routines of children with significant decrease in school attendance and sport activities. •Consequent to these public health measures, the incidence rate of pediatric fractures decreased significantly. What is New: •This study demonstrates declines in fracture rates during lockdown periods, with only partial reversing of the trends between the lockdown periods. •The most pronounced decline was observed during the first lockdown period. •The decline was most prominent in children aged 11-14 years; there was no significant change in fracture incidence of children aged <3 years.
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Affiliation(s)
- Galia Zacay
- Meuhedet Health Services, Tel Aviv, Israel
- Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel
| | - Dalit Modan-Moses
- Meuhedet Health Services, Tel Aviv, Israel
- Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Liana Tripto-Shkolnik
- Meuhedet Health Services, Tel Aviv, Israel
- Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Levy-Shraga
- Meuhedet Health Services, Tel Aviv, Israel.
- Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel.
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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16
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Zacay G, Dubnov-Raz G, Modan-Moses D, Tripto-Shkolnik L, Levy-Shraga Y. Epidemiology of childhood fractures in Israel during 2000-2019. Bone 2022; 154:116174. [PMID: 34508878 DOI: 10.1016/j.bone.2021.116174] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/19/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Differences have been reported in incidence rates of fractures in the pediatric population, between countries and over time. The aim of this study was to evaluate the incidence and characteristics of fractures over 20 years among Israeli children. METHODS Incidence rates of fractures were derived from the electronic database of Meuhedet Health Services, a health maintenance organization providing healthcare services to 1.2 million people in Israel. Demographic and clinical data were extracted of all the fractures in individuals aged <18 years during 2000-2019. Fracture sites were determined according to ICD9 definitions. Fracture data were analyzed by age, sex, season and sector (general Jewish population, ultra-orthodox Jews and Arabs). RESULTS During the study period 188,283 fractures occurred in 142,049 individuals. The most common were fractures of the upper limb (65%), followed by fractures of the lower limb [20%]. The overall fracture rate was 251 per 10,000 person- years (PY), and was higher for boys than girls (319 vs. 180 per 10,000 PY, p < 0.001). During 20 years, standardized fracture rates decreased significantly in the general Jewish population, among both boys (from 457 to 325 per 10,000 PY, p < 0.001) and girls (from 244 to 196 per 10,000 PY, p < 0.001); increased among ultra-orthodox Jewish boys (from 249 to 285 per 10,000 PY, p = 0.002) and girls (from 147 to 194 per 10,000 PY, p < 0.001); and did not change significantly among Arab boys and girls. The fracture rate peaked among girls aged 10-11 years and among boys aged 12-13 years. Seasonal variation showed a bimodal distribution with peaks during spring and autumn. CONCLUSIONS The incidence of pediatric fractures is affected by age, gender, sector and season. Recognition of fracture characteristics may help identify specific populations and conditions for targeted prevention strategies.
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Affiliation(s)
- Galia Zacay
- Meuhedet Health Services, Tel Aviv, Israel; Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel
| | - Gal Dubnov-Raz
- Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel; Exercise, Nutrition and Lifestyle Clinic, Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Dalit Modan-Moses
- Meuhedet Health Services, Tel Aviv, Israel; Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel; Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Liana Tripto-Shkolnik
- Meuhedet Health Services, Tel Aviv, Israel; Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel; Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yael Levy-Shraga
- Meuhedet Health Services, Tel Aviv, Israel; Sackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel; Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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17
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Tripto-Shkolnik L, Vered I, Peltz-Sinvani N, Kowal D, Goldshtein I. Bone Mineral Density of the 1/3 Radius Refines Osteoporosis Diagnosis, Correlates With Prevalent Fractures, and Enhances Fracture Risk Estimates. Endocr Pract 2021; 27:408-412. [PMID: 33934751 DOI: 10.1016/j.eprac.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To investigate the added value of 1/3 radius (1/3R) for the diagnosis of osteoporosis by spine and hip sites and its correlation with prevalent fractures and predicted fracture risk. METHODS Fracture Risk Assessment Tool (FRAX) scores for hip and major osteoporotic fractures (MOF) with/without trabecular bone score were considered proxy for fracture risk. The contribution of 1/3R to risk prediction was depicted via linear regression models with FRAX score as the dependent variable-first only with central and then with radius T-score as an additional covariate. Significance of change in the explained variance was compared by F-test. RESULTS The study included 1453 patients, 86% women, aged 66 ± 10 years. A total of 32% (n = 471) were osteoporotic by spine/hip and 8% (n = 115) by radius only, constituting a 24.4% increase in the number of subjects defined as osteoporotic (n = 586, 40%). Prior fracture prevalence was similar among patients with osteoporosis by spine/hip (17.4%) and radius only (19.1%) (P = .77). FRAX prediction by a regression model using spine/hip T-score yielded explained variance of 51.8% and 49.9% for MOF and 39.8% and 36.4% for hip (with/without trabecular bone score adjustment, respectively). The contribution of 1/3R was statistically significant (P < .001) and slightly increased the explained variance to 52.3% and 50.4% for MOF and 40.9% and 37.4% for hip, respectively. CONCLUSION Reclassification of BMD results according to radius measurements results in higher diagnostic output. Prior fractures were equally prevalent among patients with radius-only and classic-site osteoporosis. FRAX tool performance slightly improved by incorporating radius BMD. Whether this approach may lead to a better fracture prediction warrants further prospective evaluation.
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Affiliation(s)
- Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
| | - Iris Vered
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Naama Peltz-Sinvani
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Kowal
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Inbal Goldshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Israel
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18
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Levy-Shraga Y, Megnazi O, Modan-Moses D, Tripto-Shkolnik L, Gruber N, Haberman Y, Shouval DS, Weiss B. Trabecular Bone Score in Children and Adolescents With Inflammatory Bowel Diseases. J Clin Densitom 2021; 24:243-251. [PMID: 33189561 DOI: 10.1016/j.jocd.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Trabecular bone score (TBS) is a textural index that evaluates bone microarchitecture of the lumbar spine. Our aim was to assess TBS in children with inflammatory bowel diseases and to evaluate correlations with clinical, laboratory and densitometric variables. METHODS A retrospective study of TBS and areal bone mineral density measurements by dual-energy X-ray absorptiometry (DXA) of children with either Crohn's disease (CD) or ulcerative colitis (UC). Bone mineral apparent density was calculated for size adjustment. TBS Z-score for each child were calculated based on data from a healthy population of similar age and gender distribution. Variables significantly associated with TBS were included in stepwise linear regression models to examine independent predictors of TBS. RESULTS Fifty patients (age at DXA scan 13.8 ± 3.0 years, 29 males) were included. No significant differences were observed between the patients with CD and UC, in age at diagnosis, age at DXA scan and disease duration. The mean TBS of patients with CD (n = 35) was lower than of patients with UC (n = 15): 1.340 ± 0.080 vs 1.395 ± 0.092, p = 0.040. The mean TBS Z-score of patients with CD, -0.443 ± 0.788, was significantly lower than expected in healthy children (p = 0.002), while the mean TBS Z-score of patients with UC, 0.231 ± 0.685, was similar to that of healthy children (p = 0.212). In the stepwise linear regression analysis, BMI Z-score at diagnosis, phosphorus level at diagnosis and age at the time of the DXA scan were significant independent predictors of TBS (r² = 0.604; β = 0.037, 95% confidence interval (CI) for β 0.022-0.051, p < 0.001; β = 0.045, 95% CI: 0.017-0.073, p = 0.002; and β = 0.031, 95% CI: 0.005-0.021, p < 0.002, respectively). CONCLUSIONS TBS is significantly reduced in pediatric patients with CD but not in patients with UC. This finding likely reflects the effect of CD on bone microarchitecture.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Ophir Megnazi
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dalit Modan-Moses
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liana Tripto-Shkolnik
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Noah Gruber
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel; The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Haberman
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Dror S Shouval
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Batia Weiss
- The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
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Tripto-Shkolnik L, Liel Y, Yekutiel N, Goldshtein I. Long-Term Follow-Up of Denosumab Discontinuers with Multiple Vertebral Fractures in the Real-World: A Case Series. Horm Metab Res 2021; 53:185-190. [PMID: 33588445 DOI: 10.1055/a-1368-4218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Denosumab discontinuation is associated with rapid reversal of bone turnover suppression and with a considerable increase in fracture risk, including a risk for multiple vertebral fractures (MVF). Long-term follow-up of patients who sustained MVF after denosumab discontinuation has not been reported. This case-series was aimed to provide a long-term follow-up on the management and outcome of denosumab discontinuers who initially presented with multiple vertebral fractures. Denosumab discontinuers were identified from a computerized database of a large healthcare provider. Baseline and follow-up clinical, laboratory, and imaging data were obtained from the computerized database and electronic medical records. The post-denosumab discontinuers MVF patients consisted of 12 women aged 71±12. Osteoporotic fractures were prevalent before denosumab discontinuation in 6 of the patients. The majority received bisphosphonates before denosumab. MVF occurred 134±76 days after denosumab discontinuation. The patients were followed for a median of 36.5 (IQR 28.2, 42.5) months after MVF. Two patients passed-away. Two patients suffered recurrent vertebral fractures. Following MVF, patients were treated inconsistently with denosumab, teriparatide, oral, and intravenous bisphosphonates, in various sequences. Two patients underwent vertebroplasty/kyphoplasty. This long-term follow-up of real-world patients with MVF following denosumab discontinuation reveals that management is inconsistent, and recurrent fractures are not uncommon. It calls for clear management guidelines for patients with MVF after denosumab discontinuation and for special attention to this high-risk group.
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Affiliation(s)
- Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center at Tel Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Liel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Naama Yekutiel
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Inbal Goldshtein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
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Affiliation(s)
- L Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Liel
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Shalit R, Tripto-Shkolnik L. SEIZURES ASSOCIATED WITH ZOLEDRONIC ACID (ZA) THERAPY: A CASE REPORT AND REVIEW OF THE LITERATURE. AACE Clin Case Rep 2020; 6:e315-e318. [PMID: 33244492 DOI: 10.4158/accr-2020-0234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/17/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Seizures following administration of potent bisphosphonates have been reported only sporadically in the medical literature. The rare cases described were often attributed to other precipitating factors such as hypoglycemia, acute infection, or predisposition to post-bisphosphonate hypocalcemia. We review the previous cases and present a new case of suspected seizure episode following zoledronic acid therapy. Methods We describe a case of a 63-year-old woman with a history of well-controlled epileptic disorder with no seizure activity in recent years. She was treated with intravenous zoledronic acid due to osteoporosis. Twelve hours after treatment, she suffered an episode of loss of consciousness with urinary incontinence suspected to be seizure-related. Results Unlike previously reported cases, our patient had a low risk for postinfusion hypocalcemia as her creati-nine, calcium, parathyroid hormone, and vitamin D were all within normal limits prior to the infusion. Conclusion Our interpretation of the scenario described is based on clinical judgment and not supported by ancillary studies. Nevertheless, our case, along with the limitations described, joins other reports, and raises questions about possible interaction between a convulsion disorder and a potent bone resorption inhibition administration, leading to a relative hypocalcemia and possible seizure threshold reduction. This question should be further explored by other studies.
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Landau N, Hamiel U, Tokatly Latzer I, Mauda E, Levek N, Tripto-Shkolnik L, Pinhas-Hamiel O. Paediatricians' attitudes and beliefs towards transgender people: a cross-sectional survey in Israel. BMJ Open 2020; 10:e031569. [PMID: 32341041 PMCID: PMC7204925 DOI: 10.1136/bmjopen-2019-031569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The number of transgender and gender non-conforming children is on the rise. For these children, the timing of medical intervention is crucial, yet transgender children report poorer overall physical and mental health outcomes compared with their cisgender peers. We aim to describe how paediatricians perceive transgender people. SETTING The 'Transgender Attitudes and Beliefs Scale', which consists of 29 items in three domains-human value, interpersonal comfort and sex/gender beliefs-was administered to 391 senior and resident paediatricians in Israel. The responses on a 7-point Likert scale were collapsed into two categories: a mean score of ≥6 for each domain was a 'Favourable' perception and <6 'Unfavourable'. RESULTS Of 355 respondents (91% response rate), 221 (62%) were females, 132 (37%) were males and 2 identified as 'other'; 290 (82%) were born in 'trans-respect countries', 274 (77%) identified as secular, 223 (63%) were senior physicians and 132 (27%) were residents. Overall, 90% of the cohort scored favourably on the 'Human value' domain, 68% on 'Interpersonal comfort' and 40% on 'Sex/gender beliefs'. In the 'Interpersonal comfort' domain, being a man, birthplace in a transphobic country, identification as religious and being a senior physician were all associated with increased ORs for an unfavourable score: 2.1 (95% CI 1.3 to 3.4), 3.4 (95% CI 1.9 to 6.3), 2.4 (95% CI 1.4 to 4.2) and 1.8 (95% CI 1.1 to 3.0), respectively. In the 'Sex/gender beliefs' domain, being a man and identifying as religious had significantly increased ORs for unfavourable scores: 2.2 (95% CI 1.3 to 3.5) and 10.6 (95% CI 4.7 to 24.1), respectively. CONCLUSIONS Negative attitudes towards transgender people are still widespread among paediatricians. Interventions are warranted to positively impact these attitudes.
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Affiliation(s)
- Nitsan Landau
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Ramat-Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Hamiel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Itay Tokatly Latzer
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Ramat-Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elinor Mauda
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Ramat-Gan, Israel
| | - Noah Levek
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Ramat-Gan, Israel
| | - Liana Tripto-Shkolnik
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Orit Pinhas-Hamiel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Ramat-Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Affiliation(s)
- L Tripto-Shkolnik
- Sheba Medical Center at Tel Hashomer, Division of Endocrinology, Diabetes and Metabolism, Ramat-Gan, Israel
| | - V Rouach
- Tel Aviv Sourasky Medical Center, Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv, Israel
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Tripto-Shkolnik L, Fund N, Rouach V, Chodick G, Shalev V, Goldshtein I. Fracture incidence after denosumab discontinuation: Real-world data from a large healthcare provider. Bone 2020; 130:115150. [PMID: 31715340 DOI: 10.1016/j.bone.2019.115150] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/25/2019] [Accepted: 11/07/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vertebral fractures (VF) upon Denosumab (DMAB) discontinuation were first described as a distinct phenomenon in 2015, yet the magnitude of this event remains undetermined. OBJECTIVES To estimate fracture risk after DMAB discontinuation, in a real-world setting. METHODS The computerized database of a 2.3-million members' state-mandated health organization was utilized to detect osteoporotic patients with at least two DMAB dispenses. Treatment discontinuation was defined as a refill gap of 3 months or more, while the discontinuation date was defined as an anticipated missed purchase date. Fractures were identified by an osteoporosis registry and individually adjudicated by an expert's review. Fractures occurring within one year from discontinuation among DMAB discontinuers (DD) and from the 2nd year of treatment onwards for persistent users (PU) were included. RESULTS A total of 1500 DD (92% females, mean ± SD age = 71.8 ± 9.5y), and 1610 PU (91%, 71.7 ± 8.8) were identified. At baseline, the groups were comparable in fracture- history, bisphosphonate exposure, smoking, and bone density. Multiple VF occurred in 12 (0.8%) DD vs. 2 (0.1%) PU (p = 0.006). The overall rate of fractures per 100 patient-years of follow-up was significantly higher in DD than PU (RR 3.2, 95% CI 2.2-4.8), as well as the rate of VF (RR 4.7, 95% CI 2.3-9.6) and multiple VF (RR 14.6, 95% CI 3.3-65.3, effect size 1.06). CONCLUSIONS Patients who discontinue DMAB are at greater risk of major OP fractures than those who persist with treatment. Same is true for clinical multiple vertebral fractures, yet the incidence of the latter was low. These findings demonstrate a need for greater awareness and thoughtful management of DMAB discontinuation.
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Affiliation(s)
- Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel.
| | - Naama Fund
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Israel
| | - Vanessa Rouach
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Israel
| | - Gabriel Chodick
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Varda Shalev
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Inbal Goldshtein
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Israel
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Tripto-Shkolnik L. [TRANSGENDER ENDOCRINOLOGY]. Harefuah 2019; 158:556-558. [PMID: 31507102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinical encounters with transgender people seeking hormonal treatment for gender reaffirmation, provide an opportunity, besides engagement in the endocrine dilemmas, to challenge the binary pattern of thinking and reveal many fascinating and complex matters of transgender medicine: human, philosophical and political. The current review of the subject is presented by an endocrinologist engaged in hormonal treatment of transgender people.
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Affiliation(s)
- Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer
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Levy-Shraga Y, Tripto-Shkolnik L, David D, Vered I, Stein D, Modan-Moses D. Low trabecular bone score in adolescent female inpatients with anorexia nervosa. Clin Nutr 2019; 38:1166-1170. [DOI: 10.1016/j.clnu.2018.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 01/09/2023]
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Tripto-Shkolnik L, Rouach V, Marcus Y, Rotman-Pikielny P, Benbassat C, Vered I. Vertebral Fractures Following Denosumab Discontinuation in Patients with Prolonged Exposure to Bisphosphonates. Calcif Tissue Int 2018; 103:44-49. [PMID: 29396698 DOI: 10.1007/s00223-018-0389-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/07/2018] [Indexed: 12/23/2022]
Abstract
Denosumab (DMAB) efficacy for treatment of osteoporosis was demonstrated in a pivotal trial with a reduction in vertebral and hip fractures during 3 years, and fracture risk reduction was sustained up to 10 years in an extension study. DMAB causes potent yet reversible inhibition of bone resorption. Bone density declines rapidly upon discontinuation and bone turnover markers increase above baseline in a rebound fashion. Spontaneous multiple vertebral fractures after DMAB discontinuation were recently reported. Prior treatment with bisphosphonates (BP) was postulated to decrease the risk for this alarming phenomenon. We aimed to describe our experience of fractures following DMAB withdrawal with special attention to past history of osteoporosis treatment. A phone survey of physicians engaged in bone metabolism from nine hospitals in Israel was performed. Clinical data of the patients presenting with vertebral fractures upon DMAB discontinuation were summarized and compared to the previously published cases. Nine elderly (74.2 ± 5.3 years) female patients were identified. Most patients had a prolonged prior exposure to BP (7.4 ± 3.2 years). All but one sustained osteoporotic fractures prior to DMAB initiation and their FRAX scores were high. Thirty-six vertebral fractures were identified in nine patients. Eight patients presented with multiple fractures, and most fractures were spontaneous. In line with the previous reports, the timing and severity of the fractures raise concern of DMAB discontinuation effect. Prolonged BP exposure in most of our patients challenges the protective effect hypothesis. Care providers, patients, and regulatory authorities should be aware of the possible risk of DMAB treatment interruption.
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Affiliation(s)
| | - Vanessa Rouach
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | - Yonit Marcus
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
| | | | - Carlos Benbassat
- Institute of Endocrinology, Assaf Harofeh Medical Center, Tel Aviv, Israel
| | - Iris Vered
- Endocrine Institute, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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Tripto-Shkolnik L, Jaffe A, Liel Y. The impact of vitamin D status and parameters of calcium metabolism in patients with primary hyperparathyroidism. QJM 2018; 111:97-101. [PMID: 29462468 DOI: 10.1093/qjmed/hcx200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is ample evidence associating vitamin D deficiency in primary hyperparathyroidism (PHP) patients with more severe disease manifestations and increased risk of postoperative hypocalcemia. Yet, there is limited data regarding the safety of vitamin D repletion in these patients. AIM To assess the safety of vitamin D repletion in PHP patients in a real-world setting. DESIGN We included patients with asymptomatic PHP and few symptomatic patients who declined surgery, followed in our clinic, and treated on a routine basis with 2000 IU/day of vitamin D3. METHODS Serum calcium (sCa), PTH, 25-hydroxyvitamin D, and 24 h urinary calcium (uCa) and creatinine collections were compared between the lowest and the highest vitamin D time points. RESULTS There were 40 patients of a mean age was 63 ± 10 years. 25(OH)D at lowest and highest vitamin D time points was 15.5 ± 6.2 ng/ml and 33.2 ± 8, respectively (P < 0.001). Serum calcium was not affected by the changes in vitamin D levels. In none of the patients did sCa exceed 11.5 mg/dL. uCa was 220 ± 110 mg/24 h at the lowest vitamin D time point and 260 ± 140 at the highest vitamin D time point (P = 0.14). uCa exceeded 400 mg/24 h in two vs. five patients (P = 0.23) at the lowest and highest vitamin D time points, respectively. PTH was not significantly different between the different vitamin D time points. DISCUSSION/CONCLUSION Vitamin D repletion in PHP seems safe. Considering the documented adverse influence of vitamin D deficiency in PHP, particularly on skeletal manifestations and on the postoperative course, vitamin D repletion is warranted.
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Affiliation(s)
| | - A Jaffe
- Endocrine Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Y Liel
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Dubnov-Raz G, Steinacker JM, Marcus Y, Dipla K, Dicker D, Hoffman JR, Shimon I, Greenman Y, Tripto-Shkolnik L, Hirsch D, Buch A, Arieli M, Constantini NW. Meeting Reports: Exercise is Medicine Israel 5th Annual Conference - Endocrine Aspects Tel Aviv, Israel, May 10th, 2017. Pediatr Endocrinol Rev 2017; 15:57-59. [PMID: 28845629 DOI: 10.17458/per.vol15.2017.rsm.mr.exerciseismedicine] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gal Dubnov-Raz
- Exercise, Nutrition and Lifestyle Clinic, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel, 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 3Exercise is Medicine Israel, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jürgen M Steinacker
- Division of Sports and Rehabilitation Medicine, Ulm University, Ulm, Germany
| | - Yonit Marcus
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Konstantina Dipla
- Laboratory of Exercise Physiology and Biochemistry, Department of Physical Education and Sports Science at Serres, Aristotle University of Thessaloniki, Greece
| | - Dror Dicker
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Dept. of Internal Medicine D and Obesity Clinic, Rabin Medical Center, Hasharon Campus, Petah-Tiqva, Israel
| | - Jay R Hoffman
- Institute of Exercise Physiology and Wellness, Sport and Exercise Science, Burnett School of Biomedical Sciences, University of Central Florida, USA
| | - Ilan Shimon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 9Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
| | - Yona Greenman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Liana Tripto-Shkolnik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 10Endocrine Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Dania Hirsch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
| | - Assaf Buch
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Mickey Arieli
- International Institute for Counter-Terrorism, Herzliya, Israel
| | - Naama W Constantini
- Exercise is Medicine Israel, The Hebrew University of Jerusalem, Jerusalem, Israel, Sport Medicine Center, Shaare Zedek Medical Center, Jerusalem, Israel
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Szalat A, Shpitzen S, Tsur A, Zalmon Koren I, Shilo S, Tripto-Shkolnik L, Durst R, Leitersdorf E, Meiner V. Stepwise CaSR, AP2S1, and GNA11 sequencing in patients with suspected familial hypocalciuric hypercalcemia. Endocrine 2017; 55:741-747. [PMID: 28176280 DOI: 10.1007/s12020-017-1241-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/17/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE Patients with familial hyperparathyroidism and low urinary calcium excretion may have familial hypocalciuric hypercalcemia (FHH) with mutations in one of three genes: the calcium-sensing receptor (CaSR) defining FHH-type 1, the adaptor-related protein complex 2 (AP2S1) related to FHH-type 3 or the G-protein subunit alpha11 (GNA11) associated with FHH-type 2. We aimed to evaluate the presence of mutations in these genes and to identify phenotypic specificities and differences in these patients. SUBJECTS AND METHODS Selected patients were recruited for genetic evaluation. After informed consent was signed, blood for DNA extraction was obtained and genetic sequencing of CaSR was done. In negative cases, we further performed sequencing of AP2S1 and GNA11. RESULTS A total of 10 index cases were recruited. CaSR sequencing yielded three missense heterozygous mutations (30%): c.554G > A (p.I32V) previously characterized by our team, c.1394 G > A (p.R465Q) and a novel expected disease-causing mutation c.2479 A > C (p.S827R). We identified 2 additional patients (20%) carrying the deleterious recurrent mutation c.44G > T (p.R15L) in the AP2S1 gene. No GNA11 mutation was found. Clinically, patients with AP2S1 mutations had significant cognitive and behavioral disorders, and higher blood calcium and magnesium levels than patients with FHH1. CONCLUSION CaSR and AP2S1 sequencing is worthwhile in patients with familial hyperparathyroidism and phenotype suggesting FHH as it can diagnose up to 50% of cases. GNA11 mutations seem much rarer. Learning disabilities in these patients, associated with higher serum calcium and magnesium levels may suggest the presence of AP2S1 rather than CaSR mutation and may guide the first step in the genetic evaluation.
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Affiliation(s)
- Auryan Szalat
- Endocrinology and Metabolism Service, Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Shoshana Shpitzen
- Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Anat Tsur
- Endocrinology and Metabolism Service, Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ilana Zalmon Koren
- Pediatric Endocrinology, Armon Child Center, Carmel Hospital, Clalit Health Service, Haifa, Israel
| | - Shmuel Shilo
- Endocrinology and Metabolism Service, Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Liana Tripto-Shkolnik
- Endocrinology Department, Chaim Sheba Medical Center, Tel Ha Shomer, Ramat Gan, Israel
| | - Ronen Durst
- Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eran Leitersdorf
- Center for Research, Prevention and Treatment of Atherosclerosis, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Vardiella Meiner
- Department of Genetics and Metabolic diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Tripto-Shkolnik L, Segal E, Jaffe A, Ish-Shalom S, Bachrach R, Nachtigal A, Militianu D. Atypical Femoral Fractures: Radiological Evaluation and Bisphosphonate Exposure. Isr Med Assoc J 2015; 17:554-558. [PMID: 26625545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Evidence suggests that prolonged bisphosphonate (BP) treatment predisposes to atypical fractures (AF), but the etiology has yet to be determined. Addressing causality begins with case identification, which requires radiological adjudication. However, many trials based their case findings on coded diagnoses. OBJECTIVES To investigate the feasibility of case findings by the coding system and the reproducibility of radiological evaluations in two hospitals in Israel, and to compare BP exposure of AF patients to a control group with typical (intertrochanteric of femoral neck) fractures. METHODS Diagnostic databases from 2007 to 2010 were reviewed and admission X-rays of patients were examined in two steps by two radiologists. Fractures were classified as atypical or not atypical according to published criteria. A 2:1 control group was created. Ambulatory drug acquisition was reviewed. RESULTS Of the 198 patients who fulfilled the search criteria, 38 were classified by initial radiological opinion as AF. Subsequent radiological opinion judged 16 as not atypical. Of the AF patients, 80% were exposed to BP. Of those, 81% continued to receive BP treatment for 2.4 years after AF. Only one AF patient was discharged with suspected AF diagnosis. In the control group, 27% were exposed to BP prior to fracture (P < 0.001). CONCLUSIONS Thorough radiological revision is mandatory for proper classification of AF, and even when performed there is significant inconsistency in interpretation. Conclusions drawn from trials based solely on coded diagnoses lead to significant bias. BP exposure was significantly higher in the AF group. Caregiver unawareness of AF leads to improper management.
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Jaffe A, Yoselis A, Tripto-Shkolnik L. Better together: a community- hospital integrative model of healthcare as a practical solution for providing excellence in endocrinology care in an era of limited resources. Isr J Health Policy Res 2015; 4:28. [PMID: 26140191 PMCID: PMC4488130 DOI: 10.1186/s13584-015-0024-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 06/01/2015] [Indexed: 11/29/2022] Open
Abstract
Background The demand for endocrinology services is growing worldwide, particularly among minority and underserved populations, mainly due to the rapid global increase of diabetes. The medical education of endocrinologists is a resource consuming process and is mainly hospital-based. Yet, given the chronic nature of endocrine morbidity, the greatest demand for endocrinology services is in the community. However, an isolated endocrinologist cannot cope with the rapid changes in the field. Limited funding of hospital facilities does not allow for the establishment of a freestanding endocrine-center; thus, the Community- Hospital Integrative Model of Healthcare (Co-HIMH) was developed and implemented in an Israeli government hospital and is presented as an approach for achieving excellence in endocrinology care. Aim To describe the design, function and challenges of the Co-HIMH. Model description Originally, three pillars: 1) the hospital unit as a regional expertise resource, 2) Co-HIMH endocrine providers participating in both community and hospital services, and 3) integrated information flow between health-care providers, supported the integration between hospital and community networks. Results The community and hospital endocrine human resources were increased to create attainable and accessible endocrine services in the community and hospital. Collaborative interaction between healthcare providers increased both continuity of care and efficient patient navigation. Endocrine hospital referrals for specialized procedures have grown. Within this area of low socioeconomic status, continued medical endocrine education was conducted introducing state-of-the-art treatments. The essence of these achievements was maintained by continuous training of fellows. During the years that the Co-HIMH operated, it certified 14 % of all endocrinology fellows in Israel. Unresolved issues regarding employee rights and formalization of the Co-HIMH status are significant challenges. Conclusions In the era of limited resources and increased healthcare demand, creative infrastructures are required. This article provides a successful example of a preliminary model and proposes future needed modifications.
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Affiliation(s)
- Anat Jaffe
- Endocrinology and Diabetes Unit Hillel Yaffe Medical Center Hadera, Hadera, Israel
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Hendy GN, Canaff L, Newfield RS, Tripto-Shkolnik L, Wong BYL, Lee BSP, Cole DEC. Codon Arg15 mutations of the AP2S1 gene: common occurrence in familial hypocalciuric hypercalcemia cases negative for calcium-sensing receptor (CASR) mutations. J Clin Endocrinol Metab 2014; 99:E1311-5. [PMID: 24731014 DOI: 10.1210/jc.2014-1120] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Familial hypocalciuric hypercalcemia (FHH) is an autosomal dominant disorder with three known subtypes: FHH1, FHH2, and FHH3. About 65% of FHH cases are FHH1, caused by inactivating mutations of the calcium-sensing receptor (CASR) gene. FHH3 was recently found to be caused by codon Arg15 (p.R15) mutations in the adaptor-related protein complex 2, σ-2 subunit that interacts with the CaSR and is encoded by the AP2S1 gene. OBJECTIVE The objective of the study was to assess the prevalence of AP2S1 mutations, and describe the phenotype of FHH3, in an independent cohort of FHH subjects lacking CASR mutations. PATIENTS AND METHODS Thirty-nine patients presenting with some combination of hypercalcemia, hypermagnesemia, nonsuppressed serum PTH levels, and reduced urinary calcium excretion were studied. Exon 2 of the AP2S1 gene was PCR amplified from patient genomic DNA and Sanger sequenced. The presence of p.R15 mutations was confirmed by restriction enzyme analysis. RESULTS Five of the 39 subjects had AP2S1 p.R15 mutations, a frequency of 13%. The three recurrent mutations reported previously were all found in our cohort (p.R15C in two, p.R15L in two, and p.R15H in one subject). The FHH3 phenotype did not differ materially from that of FHH1 due to CASR mutations. CONCLUSIONS The results affirm that a significant number of patients suspected of having FHH but proven negative for CASR mutation have AP2S1 p.R15 mutations. Screening for AP2S1 p.R15 mutations in such cases should be considered, given the clinical benefits (avoiding unnecessary parathyroidectomy) that have already been demonstrated for CASR screening in FHH1.
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Affiliation(s)
- Geoffrey N Hendy
- Departments of Medicine, Physiology, and Human Genetics (G.N.H., L.C.), McGill University, and Calcium Research Laboratory and Hormones and Cancer Research Unit (G.N.H., L.C.), Royal Victoria Hospital, Montreal, Québec, Canada H3A 1A1; Department of Pediatrics (R.S.N.), University of California, San Diego, and Rady Children's Hospital San Diego, San Diego, California 92123; Diabetes and Endocrinology Unit (L.T.-S.), Hillel Yaffe Medical Center, Hadera 38100, Israel; and Departments of Laboratory Medicine and Pathobiology, Medicine, and Genetics (B.Y.L.W, B.S.P.L., D.E.C.C.), University of Toronto, Toronto, Ontario, Canada M4N 3M5
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Tripto-Shkolnik L. Atypical femoral fractures and their relation to bisphosphonate use. Isr Med Assoc J 2013; 15:447-450. [PMID: 24079069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Liana Tripto-Shkolnik
- Osteoporosis Clinic, Endocrinology and Diabetes Unit, Hillel Yaffe Medical Center, Hadera, Israel.
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Tripto-Shkolnik L, Blumenfeld Z, Bronshtein M, Salmon A, Jaffe A. Pregnancy in a patient with adrenal carcinoma treated with mitotane: a case report and review of literature. J Clin Endocrinol Metab 2013; 98:443-7. [PMID: 23275528 DOI: 10.1210/jc.2012-2839] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Adrenocortical carcinoma (ACC) affects patients in a broad age group, including young women. Mitotane, an adrenolytic agent, is the mainstay of treatment after surgical removal of the tumor. There is extreme paucity of information regarding the effect of mitotane on childbearing potential and pregnancy outcome. OBJECTIVE The aim of the study was to describe and discuss the case of an ACC patient who conceived while on mitotane treatment. Current literature is reviewed. PATIENT AND METHODS A 33-year-old woman received mitotane treatment for 4 years due to metastatic ACC. Despite nearly therapeutic blood levels of the drug, the patient had regular menstruation and was able to conceive. Mitotane was stopped at gestation week 6. Although the drug continued to be detected in considerable amounts, the fetus developed normally, including morphologically intact adrenal glands. At gestation week 21, pregnancy was terminated due to ACC recurrence. Mitotane levels were undetectable in fetal cord blood and amniotic fluid. CONCLUSION Our report suggests that mitotane, despite its action as an endocrine disruptor, does not affect normal gonadal function or an ability to conceive. The concern of placental transfer by this hydrophobic compound is not supported by our findings. However, we do not recommend drawing conclusions regarding the safety of mitotane in pregnancy, based on 1 or several case reports. Until more data are available, pregnancy should be avoided in women being treated with mitotane for ACC.
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Affiliation(s)
- Liana Tripto-Shkolnik
- Diabetes and Endocrinology Unit, Hillel Yaffe Medical Center, POB 169, Hadera 38100, Israel.
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Ness-Abramof R, Nabriski DA, Shapiro MS, Tripto-Shkolnik L, Katz B, Weiss E, Shenkman L. Cardiac troponin T is not increased in patients with hypothyroidism. Intern Med J 2009; 39:117-20. [DOI: 10.1111/j.1445-5994.2008.01856.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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