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Lounev V, Groppe JC, Brewer N, Wentworth KL, Smith V, Xu M, Schomburg L, Bhargava P, Al Mukaddam M, Hsiao EC, Shore EM, Pignolo RJ, Kaplan FS. Matrix metalloproteinase-9 deficiency confers resilience in fibrodysplasia ossificans progressiva in a man and mice. J Bone Miner Res 2024; 39:382-398. [PMID: 38477818 DOI: 10.1093/jbmr/zjae029] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/14/2024]
Abstract
Single case studies of extraordinary disease resilience may provide therapeutic insight into conditions for which no definitive treatments exist. An otherwise healthy 35-year-old man (patient-R) with the canonical pathogenic ACVR1R206H variant and the classic congenital great toe malformation of fibrodysplasia ossificans progressiva (FOP) had extreme paucity of post-natal heterotopic ossification (HO) and nearly normal mobility. We hypothesized that patient-R lacked a sufficient post-natal inflammatory trigger for HO. A plasma biomarker survey revealed a reduction in total matrix metalloproteinase-9 (MMP-9) compared to healthy controls and individuals with quiescent FOP. Whole exome sequencing identified compound heterozygous variants in MMP-9 (c.59C > T, p.A20V and c.493G > A, p.D165N). Structural analysis of the D165N variant predicted both decreased MMP-9 secretion and activity that were confirmed by enzyme-linked immunosorbent assay and gelatin zymography. Further, human proinflammatory M1-like macrophages expressing either MMP-9 variant produced significantly less Activin A, an obligate ligand for HO in FOP, compared to wildtype controls. Importantly, MMP-9 inhibition by genetic, biologic, or pharmacologic means in multiple FOP mouse models abrogated trauma-induced HO, sequestered Activin A in the extracellular matrix (ECM), and induced regeneration of injured skeletal muscle. Our data suggest that MMP-9 is a druggable node linking inflammation to HO, orchestrates an existential role in the pathogenesis of FOP, and illustrates that a single patient's clinical phenotype can reveal critical molecular mechanisms of disease that unveil novel treatment strategies.
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Affiliation(s)
- Vitali Lounev
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A & M University College of Dentistry, Dallas, TX 75246-2013, United States
| | - Niambi Brewer
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kelly L Wentworth
- Department of Medicine, Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA 94143-0794, United States
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
| | | | - Meiqi Xu
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charite University Hospital, D-10115 Berlin, Germany
| | | | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Edward C Hsiao
- Department of Medicine, University of California, San Francisco, CA 94143-0794, United States
- Division of Endocrinology and Metabolism, The Institute for Human Genetics, the Program in Craniofacial Biology, University of California, San Francisco, CA 94143-0794, United States
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Genetics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- The Center for Research in FOP and Related Disorders, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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Lindborg CM, Al Mukaddam M, Baujat G, Cho TJ, De Cunto CL, Delai PLR, Eekhoff EMW, Haga N, Hsiao EC, Morhart R, de Ruiter R, Scott C, Seemann P, Szczepanek M, Tabarkiewicz J, Pignolo RJ, Kaplan FS. Most Fractures Treated Nonoperatively in Individuals With Fibrodysplasia Ossificans Progressiva Heal With a Paucity of Flareups, Heterotopic Ossification, and Loss of Mobility. Clin Orthop Relat Res 2023; 481:2447-2458. [PMID: 37156007 PMCID: PMC10642855 DOI: 10.1097/corr.0000000000002672] [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] [Received: 12/12/2022] [Revised: 02/05/2023] [Accepted: 03/30/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultrarare genetic disorder with episodic and progressive heterotopic ossification. Tissue trauma is a major risk factor for flareups, heterotopic ossification (HO), and loss of mobility in patients with FOP. The International Clinical Council on FOP generally recommends avoiding surgery in patients with FOP unless the situation is life-threatening, because soft tissue injury can trigger an FOP flareup. Surprisingly little is known about flareups, HO formation, and loss of mobility after fractures of the normotopic (occurring in the normal place, distinct from heterotopic) skeleton when treated nonoperatively in patients with FOP. QUESTIONS/PURPOSES (1) What proportion of fractures had radiographic evidence of union (defined as radiographic evidence of healing at 6 weeks) or nonunion (defined as the radiographic absence of a bridging callus at 3 years after the fracture)? (2) What proportion of patients had clinical symptoms of an FOP flareup because of the fracture (defined by increased pain or swelling at the fracture site within several days after closed immobilization)? (3) What proportion of patients with fractures had radiographic evidence of HO? (4) What proportion of patients lost movement after a fracture? METHODS We retrospectively identified 36 patients with FOP from five continents who sustained 48 fractures of the normotopic skeleton from January 2001 to February 2021, who were treated nonoperatively, and who were followed for a minimum of 18 months after the fracture and for as long as 20 years, depending on when they sustained their fracture during the study period. Five patients (seven fractures) were excluded from the analysis to minimize cotreatment bias because these patients were enrolled in palovarotene clinical trials (NCT02190747 and NCT03312634) at the time of their fractures. Thus, we analyzed 31 patients (13 male, 18 female, median age 22 years, range 5 to 57 years) who sustained 41 fractures of the normotopic skeleton that were treated nonoperatively. Patients were analyzed at a median follow-up of 6 years (range 18 months to 20 years), and none was lost to follow-up. Clinical records for each patient were reviewed by the referring physician-author and the following data for each fracture were recorded: biological sex, ACVR1 gene pathogenic variant, age at the time of fracture, fracture mechanism, fracture location, initial treatment modality, prednisone use at the time of the fracture as indicated in the FOP Treatment Guidelines for flare prevention (2 mg/kg once daily for 4 days), patient-reported flareups (episodic inflammatory lesions of muscle and deep soft connective tissue characterized variably by swelling, escalating pain, stiffness, and immobility) after the fracture, follow-up radiographs of the fracture if available, HO formation (yes or no) as a result of the fracture determined at a minimum of 6 weeks after the fracture, and patient-reported loss of motion at least 6 months after and as long as 20 years after the fracture. Postfracture radiographs were available in 76% (31 of 41) of fractures in 25 patients and were independently reviewed by the referring physician-author and senior author for radiographic criteria of fracture healing and HO. RESULTS Radiographic healing was noted in 97% (30 of 31) of fractures at 6 weeks after the incident fracture. Painless nonunion was noted in one patient who sustained a displaced patellar fracture and HO. In seven percent (three of 41) of fractures, patients reported increased pain or swelling at or near the fracture site within several days after fracture immobilization that likely indicated a site-specific FOP flareup. The same three patients reported a residual loss of motion 1 year after the fracture compared with their prefracture status. HO developed in 10% (three of 31) of the fractures for which follow-up radiographs were available. Patient-reported loss of motion occurred in 10% (four of 41) of fractures. Two of the four patients reported noticeable loss of motion and the other two patients reported that the joint was completely immobile (ankylosis). CONCLUSION Most fractures treated nonoperatively in individuals with FOP healed with few flareups, little or no HO, and preservation of mobility, suggesting an uncoupling of fracture repair and HO, which are two inflammation-induced processes of endochondral ossification. These findings underscore the importance of considering nonoperative treatment for fractures in individuals with FOP. Physicians who treat fractures in patients with FOP should consult with a member of the International Clinical Council listed in the FOP Treatment Guidelines ( https://www.iccfop.org ). LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Carter M. Lindborg
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
| | - Genevieve Baujat
- Département de Genetique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Carmen L. De Cunto
- Department of Pediatrics, Pediatric Rheumatology Section, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia L. R. Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, Brazil
| | - Elisabeth M. W. Eekhoff
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Nobuhiko Haga
- Rehabilitation Services Bureau, National Rehabilitation Center for Persons with Disabilities, Tokorozawa City, Japan
| | - Edward C. Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, the Institute for Human Genetics, the Ely and Edythe Broad Institute for Regeneration Medicine, the Program in Craniofacial Biology and the Department of Medicine, University of California, San Francisco, CA, USA
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Germany
| | - Ruben de Ruiter
- Department of Internal Medicine, Division of Endocrinology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Christiaan Scott
- Department of Orthopaedic Surgery, the University of Cape Town, Cape Town, South Africa and Department of Rheumatology, Red Cross Children’s Hospital, Cape Town, South Africa
| | - Petra Seemann
- Institute for Experimental Endocrinology, Charite University Hospital, Berlin, Germany
| | - Małgorzata Szczepanek
- Department of Pediatrics, Institute of Medical Sciences, Medical College of Rzeszow University, University of Rzeszow, Rzeszow, Poland
| | - Jacek Tabarkiewicz
- Department of Human Immunology, Institute of Medical Sciences, Medical College of Rzeszow University, University of Rzeszow, Rzeszow, Poland
| | - Robert J. Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederick S. Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA, USA
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Pignolo RJ, Al Mukaddam M, Baujat G, Brown MA, De Cunto C, Hsiao EC, Keen R, Le Quan Sang KH, Grogan DR, Marino R, Strahs AR, Kaplan FS. Study methodology and insights from the palovarotene clinical development program in fibrodysplasia ossificans progressiva. BMC Med Res Methodol 2023; 23:269. [PMID: 37957586 PMCID: PMC10642058 DOI: 10.1186/s12874-023-02080-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The design of clinical trials in rare diseases is often complicated by a lack of real-world translational knowledge. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder characterized by skeletal malformations and progressive heterotopic ossification (HO). Palovarotene is a selective retinoic acid receptor gamma agonist. Here, we describe the methodology of three studies in the palovarotene clinical development program in FOP and discuss insights that could inform future research, including endpoint suitability and the impact of trial design. METHODS PVO-1A-001 (NCT02322255) was a prospective, protocol-specified, longitudinal FOP natural history study (NHS). PVO-1A-201 (NCT02190747) was a randomized, double-blind, placebo-controlled phase II trial; PVO-1A-202 (NCT02279095) was its open-label extension. Trial designs, including treatment regimens and imaging assessments, were refined between PVO-1A-201 and PVO-1A-202, and within PVO-1A-202, based on emerging data as the studies progressed. Palovarotene doses were administered using a flare-up treatment regimen (higher dose for 2/4 weeks, followed by lower dose for 4/≥8 weeks; from flare-up onset), with or without accompanying chronic (daily) treatment. Flare-up and disease progression outcomes were assessed, including incidence and volume of new HO during flare-ups and/or annually, as well as other clinical, patient-reported, and exploratory outcomes. Safety was monitored throughout all studies. RESULTS Overall, 114 and 58 individuals with FOP were enrolled in the NHS and phase II trials, respectively. Results of the NHS and PVO-1A-201 were published in 2022; complete results of PVO-1A-202 will be publicly available in due course. Together the studies yielded important information on endpoint suitability, including that low-dose whole-body computed tomography was the optimum imaging modality for assessing HO progression annually and that long study durations are needed to detect substantial changes in functional and patient-reported outcomes. CONCLUSIONS A flexible clinical development program is necessary for underexplored rare diseases to overcome the many challenges faced. Here, the NHS provided a longitudinal evaluation of FOP progression and interventional trials were based on emerging data. The studies described informed the design and endpoints implemented in the phase III MOVE trial (NCT03312634) and provide a foundation for future clinical trial development. TRIAL REGISTRATION NCT02322255 (registered 23/12/2014); NCT02190747 (registered 15/07/2014); NCT02279095 (registered 30/10/2014).
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Affiliation(s)
| | - Mona Al Mukaddam
- Departments of Orthopedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Geneviève Baujat
- Département de Génétique, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, Université Paris Cité, Paris, France
| | - Matthew A Brown
- Faculty of Life Sciences and Medicine, King's College London, and Genomics England Ltd, London, UK
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edythe Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California-San Francisco, San Francisco, CA, US
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Institut Imagine, Hôpital Universitaire Necker-Enfants Malades, Université Paris Cité, Paris, France
| | | | | | | | - Frederick S Kaplan
- Departments of Orthopedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
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4
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Di Rocco M, Forleo-Neto E, Pignolo RJ, Keen R, Orcel P, Funck-Brentano T, Roux C, Kolta S, Madeo A, Bubbear JS, Tabarkiewicz J, Szczepanek M, Bachiller-Corral J, Cheung AM, Dahir KM, Botman E, Raijmakers PG, Al Mukaddam M, Tile L, Portal-Celhay C, Sarkar N, Hou P, Musser BJ, Boyapati A, Mohammadi K, Mellis SJ, Rankin AJ, Economides AN, Trotter DG, Herman GA, O'Meara SJ, DelGizzi R, Weinreich DM, Yancopoulos GD, Eekhoff EMW, Kaplan FS. Garetosmab in fibrodysplasia ossificans progressiva: a randomized, double-blind, placebo-controlled phase 2 trial. Nat Med 2023; 29:2615-2624. [PMID: 37770652 PMCID: PMC10579054 DOI: 10.1038/s41591-023-02561-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 09/26/2022] [Accepted: 08/23/2023] [Indexed: 09/30/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare disease characterized by heterotopic ossification (HO) in connective tissues and painful flare-ups. In the phase 2 LUMINA-1 trial, adult patients with FOP were randomized to garetosmab, an activin A-blocking antibody (n = 20) or placebo (n = 24) in period 1 (28 weeks), followed by an open-label period 2 (28 weeks; n = 43). The primary end points were safety and for period 1, the activity and size of HO lesions. All patients experienced at least one treatment-emergent adverse event during period 1, notably epistaxis, madarosis and skin abscesses. Five deaths (5 of 44; 11.4%) occurred in the open-label period and, while considered unlikely to be related, causality cannot be ruled out. The primary efficacy end point in period 1 (total lesion activity by PET-CT) was not met (P = 0.0741). As the development of new HO lesions was suppressed in period 1, the primary efficacy end point in period 2 was prospectively changed to the number of new HO lesions versus period 1. No placebo patients crossing over to garetosmab developed new HO lesions (0% in period 2 versus 40.9% in period 1; P = 0.0027). Further investigation of garetosmab in FOP is ongoing. ClinicalTrials.gov identifier NCT03188666 .
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Affiliation(s)
- Maja Di Rocco
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | | | - Richard Keen
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Philippe Orcel
- Department of Rheumatology - DMU Locomotion, Assistance Publique - Hôpitaux de Paris, Paris, France
- INSERM Université Paris Cité, Paris, France
| | - Thomas Funck-Brentano
- Department of Rheumatology - DMU Locomotion, Assistance Publique - Hôpitaux de Paris, Paris, France
- INSERM Université Paris Cité, Paris, France
| | - Christian Roux
- Department of Rheumatology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sami Kolta
- Department of Rheumatology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Annalisa Madeo
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Judith S Bubbear
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Jacek Tabarkiewicz
- Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów University, Rzeszów, Poland
| | - Małgorzata Szczepanek
- Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów University, Rzeszów, Poland
| | | | - Angela M Cheung
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Dahir
- Vanderbilt University Medical Center, Program for Metabolic Bone Disorders, Nashville, TN, USA
| | - Esmée Botman
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC), Vrije Universiteit, Amsterdam UMC Expert Center in Rare Bone Disease, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Pieter G Raijmakers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mona Al Mukaddam
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lianne Tile
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Peijie Hou
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - E Marelise W Eekhoff
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC), Vrije Universiteit, Amsterdam UMC Expert Center in Rare Bone Disease, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Frederick S Kaplan
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Jones BC, Wehrli FW, Kamona N, Deshpande RS, Vu BTD, Song HK, Lee H, Grewal RK, Chan TJ, Witschey WR, MacLean MT, Josselyn NJ, Iyer SK, Al Mukaddam M, Snyder PJ, Rajapakse CS. Automated, calibration-free quantification of cortical bone porosity and geometry in postmenopausal osteoporosis from ultrashort echo time MRI and deep learning. Bone 2023; 171:116743. [PMID: 36958542 PMCID: PMC10121925 DOI: 10.1016/j.bone.2023.116743] [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: 01/25/2023] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Assessment of cortical bone porosity and geometry by imaging in vivo can provide useful information about bone quality that is independent of bone mineral density (BMD). Ultrashort echo time (UTE) MRI techniques of measuring cortical bone porosity and geometry have been extensively validated in preclinical studies and have recently been shown to detect impaired bone quality in vivo in patients with osteoporosis. However, these techniques rely on laborious image segmentation, which is clinically impractical. Additionally, UTE MRI porosity techniques typically require long scan times or external calibration samples and elaborate physics processing, which limit their translatability. To this end, the UTE MRI-derived Suppression Ratio has been proposed as a simple-to-calculate, reference-free biomarker of porosity which can be acquired in clinically feasible acquisition times. PURPOSE To explore whether a deep learning method can automate cortical bone segmentation and the corresponding analysis of cortical bone imaging biomarkers, and to investigate the Suppression Ratio as a fast, simple, and reference-free biomarker of cortical bone porosity. METHODS In this retrospective study, a deep learning 2D U-Net was trained to segment the tibial cortex from 48 individual image sets comprised of 46 slices each, corresponding to 2208 training slices. Network performance was validated through an external test dataset comprised of 28 scans from 3 groups: (1) 10 healthy, young participants, (2) 9 postmenopausal, non-osteoporotic women, and (3) 9 postmenopausal, osteoporotic women. The accuracy of automated porosity and geometry quantifications were assessed with the coefficient of determination and the intraclass correlation coefficient (ICC). Furthermore, automated MRI biomarkers were compared between groups and to dual energy X-ray absorptiometry (DXA)- and peripheral quantitative CT (pQCT)-derived BMD. Additionally, the Suppression Ratio was compared to UTE porosity techniques based on calibration samples. RESULTS The deep learning model provided accurate labeling (Dice score 0.93, intersection-over-union 0.88) and similar results to manual segmentation in quantifying cortical porosity (R2 ≥ 0.97, ICC ≥ 0.98) and geometry (R2 ≥ 0.82, ICC ≥ 0.75) parameters in vivo. Furthermore, the Suppression Ratio was validated compared to established porosity protocols (R2 ≥ 0.78). Automated parameters detected age- and osteoporosis-related impairments in cortical bone porosity (P ≤ .002) and geometry (P values ranging from <0.001 to 0.08). Finally, automated porosity markers showed strong, inverse Pearson's correlations with BMD measured by pQCT (|R| ≥ 0.88) and DXA (|R| ≥ 0.76) in postmenopausal women, confirming that lower mineral density corresponds to greater porosity. CONCLUSION This study demonstrated feasibility of a simple, automated, and ionizing-radiation-free protocol for quantifying cortical bone porosity and geometry in vivo from UTE MRI and deep learning.
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Affiliation(s)
- Brandon C Jones
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, 210 South 33(rd) St, Philadelphia, PA 19104, United States of America.
| | - Felix W Wehrli
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
| | - Nada Kamona
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, 210 South 33(rd) St, Philadelphia, PA 19104, United States of America.
| | - Rajiv S Deshpande
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, 210 South 33(rd) St, Philadelphia, PA 19104, United States of America.
| | - Brian-Tinh Duc Vu
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, 210 South 33(rd) St, Philadelphia, PA 19104, United States of America.
| | - Hee Kwon Song
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
| | - Hyunyeol Lee
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; School of Electronics Engineering, Kyungpook National University, 80 Daehakro, Bukgu, Daegu 41566, Republic of Korea.
| | - Rasleen Kaur Grewal
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
| | - Trevor Jackson Chan
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, 210 South 33(rd) St, Philadelphia, PA 19104, United States of America.
| | - Walter R Witschey
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
| | - Matthew T MacLean
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
| | - Nicholas J Josselyn
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America; Department of Data Science, Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, United States of America.
| | - Srikant Kamesh Iyer
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America
| | - Mona Al Mukaddam
- Department of Medicine, Division of Endocrinology, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States of America.
| | - Peter J Snyder
- Department of Medicine, Division of Endocrinology, Perelman School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States of America.
| | - Chamith S Rajapakse
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 1 Founders Building, 3400 Spruce St, Philadelphia, PA 19104, United States of America.
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6
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Pignolo RJ, Hsiao EC, Al Mukaddam M, Baujat G, Berglund SK, Brown MA, Cheung AM, De Cunto C, Delai P, Haga N, Kannu P, Keen R, Le Quan Sang KH, Mancilla EE, Marino R, Strahs A, Kaplan FS. Reduction of New Heterotopic Ossification (HO) in the Open-Label, Phase 3 MOVE Trial of Palovarotene for Fibrodysplasia Ossificans Progressiva (FOP). J Bone Miner Res 2023; 38:381-394. [PMID: 36583535 DOI: 10.1002/jbmr.4762] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 08/10/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, severely disabling genetic disorder of progressive heterotopic ossification (HO). The single-arm, open-label, phase 3 MOVE trial (NCT03312634) assessed efficacy and safety of palovarotene, a selective retinoic acid receptor gamma agonist, in patients with FOP. Findings were compared with FOP natural history study (NHS; NCT02322255) participants untreated beyond standard of care. Patients aged ≥4 years received palovarotene once daily (chronic: 5 mg; flare-up: 20 mg for 4 weeks, then 10 mg for ≥8 weeks; weight-adjusted if skeletally immature). The primary endpoint was annualized change in new HO volume versus NHS participants (by low-dose whole-body computed tomography [WBCT]), analyzed using a Bayesian compound Poisson model (BcPM) with square-root transformation. Twelve-month interim analyses met futility criteria; dosing was paused. An independent Data Monitoring Committee recommended trial continuation. Post hoc 18-month interim analyses utilized BcPM with square-root transformation and HO data collapsed to equalize MOVE and NHS visit schedules, BcPM without transformation, and weighted linear mixed-effects (wLME) models, alongside prespecified analysis. Safety was assessed throughout. Eighteen-month interim analyses included 97 MOVE and 101 NHS individuals with post-baseline WBCT. BcPM analyses without transformation showed 99.4% probability of any reduction in new HO with palovarotene versus NHS participants (with transformation: 65.4%). Mean annualized new HO volume was 60% lower in MOVE versus the NHS. wLME results were similar (54% reduction fitted; nominal p = 0.039). All palovarotene-treated patients reported ≥1 adverse event (AE); 97.0% reported ≥1 retinoid-associated AE; 29.3% reported ≥1 serious AE, including premature physeal closure (PPC)/epiphyseal disorder in 21/57 (36.8%) patients aged <14 years. Post hoc computational analyses using WBCT showed decreased vertebral bone mineral density, content, and strength, and increased vertebral fracture risk in palovarotene-treated patients. Thus, post hoc analyses showed evidence for efficacy of palovarotene in reducing new HO in FOP, but high risk of PPC in skeletally immature patients. © 2022 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)
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edythe Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California-San Francisco, San Francisco, CA, USA
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geneviève Baujat
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Staffan K Berglund
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Matthew A Brown
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Genomics England Ltd, London, UK
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Delai
- Centro de Pesquisa Clinica, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Peter Kannu
- Hospital for Sick Children, Toronto, ON, Canada
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Institut IMAGINE and Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Edna E Mancilla
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Hsiao EC, Keen R, Al Mukaddam M, Le Quan Sang KH, Wilson A, Marino R, Strahs A, Kaplan FS. The natural history of fibrodysplasia ossificans progressiva: A prospective, global 36-month study. Genet Med 2022; 24:2422-2433. [PMID: 36152026 DOI: 10.1016/j.gim.2022.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 06/17/2022] [Revised: 08/16/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE We report the first prospective, international, natural history study of the ultra-rare genetic disorder fibrodysplasia ossificans progressiva (FOP). FOP is characterized by painful, recurrent flare-ups, and disabling, cumulative heterotopic ossification (HO) in soft tissues. METHODS Individuals aged ≤65 years with classical FOP (ACVR1R206H variant) were assessed at baseline and over 36 months. RESULTS In total, 114 individuals participated; 33 completed the study (mean follow up: 26.8 months). Median age was 15.0 (range: 4-56) years; 54.4% were male. During the study, 82 (71.9%) individuals reported 229 flare-ups (upper back: 17.9%, hip: 14.8%, shoulder: 10.9%). After 84 days, 14 of 52 (26.9%) imaged flare-ups had new HO at the flare-up site (mean new HO volume: 28.8 × 103 mm3). Mean baseline low-dose whole-body computed tomography (excluding head) HO volume was 314.4 × 103 mm3; lowest at 2 to <8 years (68.8 × 103 mm3) and increasing by age (25-65 years: 575.2 × 103 mm3). The mean annualized volume of new HO was 23.6 × 103 mm3/year; highest at 8 to <15 and 15 to <25 years (21.9 × 103 and 41.5 × 103 mm3/year, respectively) and lowest at 25 to 65 years (4.6 × 103 mm3/year). CONCLUSION Results from individuals receiving standard care for up to 3 years in this natural history study show the debilitating effect and progressive nature of FOP cross-sectionally and longitudinally, with greatest progression during childhood and early adulthood.
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Affiliation(s)
| | - Geneviève Baujat
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | - Matthew A Brown
- Department of Medicine and Molecular Genetics, Faculty of Life Sciences and Medicine, School of Basic and Medical Biosciences, King's College London, London, United Kingdom; Genomics England, London, United Kingdom
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Eli and Edyth Broad Institute for Regeneration Medicine, and the Institute of Human Genetics, Department of Medicine, and the UCSF Program in Craniofacial Biology, University of California San Francisco, San Francisco, CA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim-Hanh Le Quan Sang
- Département de Génétique, Hôpital Universitaire Necker-Enfants Malades, Institut Imagine, Université Paris Cité, Paris, France
| | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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8
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Al Mukaddam M, Toder KS, Davis M, Cali A, Liljesthröm M, Hollywood S, Croskery K, Grandoulier AS, Böing EA, Whalen JD, Kaplan FS. The impact of fibrodysplasia ossificans progressiva (FOP) on patients and their family members: results from an international burden of illness survey. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1199-1213. [PMID: 36017643 DOI: 10.1080/14737167.2022.2115360] [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] [Indexed: 11/04/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, genetic disorder of heterotopic ossification, which transforms soft, connective tissues into bone, resulting in limited joint function and severe disability. We present results from an international burden of illness survey (NCT04665323) assessing physical, quality of life (QoL), and economic impacts of FOP on patients and family members. METHODS Patient associations in 15 countries invited their members to participate; individuals with FOP and their family members were eligible. The survey was available online, in 11 languages, from January 18-April 30, 2021. Participants responded to assessments measuring joint function, QoL, healthcare service and living adaptation utilization, out-of-pocket costs, employment, and travel. RESULTS The survey received 463 responses (patients, n=219; family members, n=244). For patients, decreased joint function was associated with reduced QoL and greater reliance on living adaptations. Nearly half of primary caregivers experienced a mild to moderate impact on their health/psychological wellbeing. Most primary caregivers and patients (≥18 years) reported that FOP impacted their career decisions. CONCLUSIONS Data from this survey will improve understanding of the impact of FOP on patients and family members, which is important for identifying unmet needs, optimizing care, and improving support for the FOP community.
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Affiliation(s)
- Mona Al Mukaddam
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine S Toder
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amanda Cali
- The Radiant Hope Foundation, Mountain Lakes, NJ, USA.,The Ian Cali FOP Research Fund, PENN Medicine, The Center for Research in FOP and Related Disorders, Philadelphia, PA, USA.,Tin Soldiers: Global Patient Identification Program, Johannesburg, South Africa
| | - Moira Liljesthröm
- Fundación FOP, Buenos Aires, Argentina.,Argentine Representative to the International President's Council of the International FOP Association, Buenos Aires, Argentina
| | | | | | | | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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9
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Kaplan FS, Groppe JC, Xu M, Towler OW, Grunvald E, Kalunian K, Kallish S, Al Mukaddam M, Pignolo RJ, Shore EM. An ACVR1 R375P pathogenic variant in two families with mild fibrodysplasia ossificans progressiva. Am J Med Genet A 2021; 188:806-817. [PMID: 34854557 DOI: 10.1002/ajmg.a.62585] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 11/11/2022]
Abstract
Genetic variants are vital in informing clinical phenotypes, aiding physical diagnosis, guiding genetic counseling, understanding the molecular basis of disease, and potentially stimulating drug development. Here we describe two families with an ultrarare ACVR1 gain-of-function pathogenic variant (codon 375, Arginine > Proline; ACVR1R375P ) responsible for a mild nonclassic fibrodysplasia ossificans progressiva (FOP) phenotype. Both families include people with the ultrarare ACVR1R375P variant who exhibit features of FOP while other individuals currently do not express any clinical signs of FOP. Thus, the mild ACVR1R375P variant greatly expands the scope and understanding of this rare disorder.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay C Groppe
- Department of Biomedical Sciences, Texas A&M University College of Dentistry, Dallas, Texas, USA
| | - Meiqi Xu
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - O Will Towler
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo Grunvald
- Division of General Internal Medicine, The Department of Medicine, The University of California San Diego, San Diego, California, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, The Department of Medicine, UC San Diego School of Medicine, La Jolla, California, USA
| | - Staci Kallish
- The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Translational Medicine and Human Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert J Pignolo
- The Department of Medicine, The Mayo Clinic, Rochester, Minnesota, USA
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,The Center for Research in FOP & Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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10
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Scott C, Kaplan FS, Friedman C, Delai P, Al Mukaddam M, Cali A, Harries V, Ezra N, Schwegler O. P068 Abstract tin soldiers Global FOP patient search. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab722.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
While looking for one, you may find another: Tin Soldiers and the search for undiagnosed individuals with Fibrodysplasia Ossificans Progressiva (FOP)
Background
FOP is an ultra-rare condition where heterozygous, gain-of-function missense mutations in the ACVR1 gene result in progressive heterotopic bone formation in ligaments, tendons and muscles and result in severe disability.1 FOP has an estimated incidence of 0.6–1.3 per million individuals 2,3 suggesting that currently there are ∼8000 patients living with FOP worldwide, however only about 900 patients are currently diagnosed worldwide The diagnosis is made clinically by identification of typical malformations of the great toes as well as inflammatory swellings (flare-ups) that result in progressive and episodic ossification of soft connective tissues, often triggered by trauma.4 Muscle biopsies, though contraindicated, are frequently performed mistakenly during the course of diagnosis, as FOP is not a well-known condition. There is an urgent need to identify individuals with FOP across the globe in order to avoid harmful biopsies and to provide a pathway to care for patients with FOP.
Tin Soldiers is a global FOP patient search program utilizing multimedia campaigns aimed at educating and bringing attention to FOP, to find individuals across the globe and to connect them to pathways of care. The mission is to identify every person with FOP who is currently undiagnosed, as well as to deliver education and support to those living with a diagnosis, but not connected to support networks. Once found, all people living with FOP are connected to pathways to care. The aim is to describe the Tin Soldiers global FOP patient search program approach and report early results of the program.
Methods
Tin Soldiers creates multimedia campaigns to create awareness and to educate medical professionals, healthcare workers, general public and local communities on FOP. At the heart of the communication program is story-telling of people living with FOP, from a feature-length documentary to public service announcements, animated short films and an 8-part Global Master Series—all designed to bring attention to FOP in order to find patients and provide a pathway to diagnosis and care. Importantly diagnosis is not the end of the journey, it’s just the beginning.
Results
Since official operations commenced in March 2020, Tin Soldiers has trained 535 medical professionals; established an African Clinicians Council of 10 doctors with the intention of mentoring others across the continent; increased the number of African patients with a diagnosis from 25 patients in December 2020–32 in April 2021. Connected previously diagnosed (but not connected) patients to a robust support network and held the first African FOP Family Gathering with clinicians from both South Africa and Nigeria.
On the journey, patients with other conditions have been discovered including Juvenile Idiopathic Arthritis (JIA), Progressive Osseus Heteroplasia (POH) and Multiple Osteochondromas (MO). These patients have been diagnosed and connected to both medical care and patient support. Another important outcome is the continued education of doctors globally with the uptake of the CME Master Series in Russia and planned rollouts in Algeria, Nigeria, Kenya, Namibia, Sweden (in partnership with the national patient organization) and Brazil (under the First Lady’s patronage).
Conclusion
Tin Soldiers offers an innovative model of patient identification, diagnosis, support and education at all levels of care, using the power of story-telling and multi-media marketing. Such a model could be considered for raising the profile of other musculoskeletal or rare conditions and connecting patients to a functioning pathway to care.
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Affiliation(s)
- Christiaan Scott
- Paediatric Rheumatology, Red Cross Children's Hospital, University of Cape Town
| | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania
| | - Clive Friedman
- Schulich School of Medicine and Dentistry Pediatric Oral Health and Dentistry
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa
| | - Mona Al Mukaddam
- Departments of Orthopaedic Surgery & Medicine and The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania
| | - Amanda Cali
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Vanda Harries
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Nicola Ezra
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
| | - Odette Schwegler
- Co-founder and Advisory Board member, Tin Soldier Global Patient Search, Communications Strategist, Tin Soldiers Global FOP Patient Search, Operations Director, Tin Soldiers Global FOP Patient Search, Executive Director, Tin Soldiers Global FOP Patient Search and Founder of Blink Pictures
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11
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Kaplan FS, Teachey DT, Andolina JR, Siegel DM, Mancilla EE, Hsiao EC, Al Mukaddam M, Rocke DM, Pignolo RJ. Off-on-off-on use of imatinib in three children with fibrodysplasia ossificans progressiva. Bone 2021; 150:116016. [PMID: 34022457 DOI: 10.1016/j.bone.2021.116016] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/05/2021] [Accepted: 05/15/2021] [Indexed: 11/21/2022]
Abstract
The compassionate use of available medications with unproven efficacy is often in conflict with their clinical evaluation in placebo-controlled clinical trials. For ultra-rare diseases where no approved treatments exist, such as fibrodysplasia ossificans progressiva (FOP), routine clinical trial enrollment for available medications may be difficult to achieve. Therefore adaptive methods of evaluation are often desirable. Off-on-off-on (O4) approaches offer an opportunity to rapidly assess the potential symptomatic efficacy and tolerability of a medication with a limited number of patients and may aid in the design of more focused clinical trials that are amenable to enrollment. Here we report three children with classic FOP who had recalcitrant flare-ups of the back and who had been treated with an O4 regimen of imatinib. In all three children, fewer flare-ups, decreased swelling and improved function with activities of daily living were reported by the parents and treating physician when the children were "on" imatinib than when they were "off" imatinib. The median time to improvement on imatinib was 2-3 weeks. The anecdotal O4 experience with imatinib reported here in three children with FOP who had recalcitrant flare-ups of the back supports the design of a brief placebo controlled trial to assess the potential efficacy of imatinib in reducing the symptoms in children with refractory flare-ups of FOP. A tool to prospectively measure and quantitate flare-up symptoms is presently being developed and validated and will be used for such a study.
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Affiliation(s)
- Frederick S Kaplan
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America.
| | - David T Teachey
- The Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States of America.
| | - Jeffrey R Andolina
- The Department of Pediatrics, Division of Hematology-Oncology, University of Rochester School of Medicine, Rochester, NY 14642, United States of America.
| | - David M Siegel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY 14642, United States of America.
| | - Edna E Mancilla
- The Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America.
| | - Edward C Hsiao
- The Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Institute for Human Genetics, University of California- San Francisco, San Francisco, CA, United States of America.
| | - Mona Al Mukaddam
- The Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States of America.
| | - David M Rocke
- The Division of Biostatistics, Department of Biomedical Engineering, University of California - Davis, Davis, CA, United States of America.
| | - Robert J Pignolo
- The Department of Medicine, The Mayo Clinic, Rochester, MN 55905, United States of America.
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12
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Turin CG, Joeng KS, Kallish S, Raper A, Asher S, Campeau PM, Khan AN, Al Mukaddam M. Heterozygous variant in WNT1 gene in two brothers with early onset osteoporosis. Bone Rep 2021; 15:101118. [PMID: 34458510 PMCID: PMC8379666 DOI: 10.1016/j.bonr.2021.101118] [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: 06/18/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 11/12/2022] Open
Abstract
Osteoporosis is a multifactorial disorder characterized by low bone mass and strength, leading to increased risk of fracture. The WNT pathway plays a critical role in bone remodeling by enhancing osteoblastic differentiation, which promotes bone formation, and inhibiting osteoclastic differentiation, decreasing bone resorption. Therefore, genetic alterations of this pathway will lead to impaired bone homeostasis and could contribute to varying response to treatment. We present the case of two brothers with early osteoporosis who were found to have a heterozygous variant of unknown significance in the WNT1 gene, c.1060_1061delCAinsG (p.H354Afs*39). This finding demonstrates that frameshift variants in WNT1 may also act in a dominant fashion leading to decreased bone mass.
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Affiliation(s)
- Christie G Turin
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., 4th floor, Philadelphia, PA 19104, USA
| | - Kyu Sang Joeng
- Mckay Orthopaedic Research Laboratory and Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 3450 Hamilton Walk, Philadelphia, PA 19104, USA
| | - Staci Kallish
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5100 Silverstein, Philadelphia, PA 19104, USA
| | - Anna Raper
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5100 Silverstein, Philadelphia, PA 19104, USA
| | - Stephanie Asher
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5100 Silverstein, Philadelphia, PA 19104, USA
| | | | - Amna N Khan
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd., 4th floor, Philadelphia, PA 19104, USA.,Section of Endocrinology, The Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Ave, Philadelphia, PA 19104, USA
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania. 3737 Market St., 3rd floor, Philadelphia, PA 19104, USA
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13
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Ho M, Park BY, Rosenblum NG, Al Mukaddam M, Kaplan FS, Kucherov V, Hubosky SG, Kane G, Desai V, Kramer MR, Ku BS, Schwenk ES, Baratta JL, Harshavardhana D, Grunwald Z. Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva. Am J Case Rep 2021; 22:e931614. [PMID: 34108438 PMCID: PMC8207543 DOI: 10.12659/ajcr.931614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Female, 27-year-old Final Diagnosis: Fibrodysplasia ossificans progressiva Symptoms: Fever Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic • Obstetrics and Gynecology
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Affiliation(s)
- Michelle Ho
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.,Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Beau Y Park
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Norman G Rosenblum
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopedic Surgery, Center for Research in FOP and Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Departments of Medicine and Orthopedic Surgery, Center for Research in FOP and Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Kucherov
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott G Hubosky
- Department of Urology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Kane
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vishal Desai
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael R Kramer
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bon S Ku
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Deepti Harshavardhana
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Zvi Grunwald
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Dahir KM, Mcginniss J, Mellis S, Sanchez RJ, Rocco MD, Keen R, Orcel P, Funck-Brentano T, Roux C, Kolta S, Madeo A, Bubbear JS, Tabarkiewicz J, Szczepanek M, Bachiller-Corral J, Cheung AM, Botman E, Mukaddam MA, Tile L, Portal-Celhay C, Sarkar N, Hou P, Forleo-Neto E, Rankin AJ, Economides AN, Trotter DG, Eekhoff EMW, Kaplan FS, Pignolo RJ. Garetosmab Reduces Flare-ups in Patients With Fibrodysplasia Ossificans Progressiva. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare, autosomal dominant disorder driven by mutations in ACVR1 that render it responsive to Activin A. FOP is characterized by progressive heterotopic ossification (HO) and distressing inflammatory events called “flare-ups.” Flare-ups can precede new HO; however, limited prospective data exists on this phenomenon. Garetosmab (GAR), an investigational human monoclonal antibody against Activin A, blocks formation of new HO in FOP. Methods: This is a post-hoc analysis of LUMINA-1 (NCT03188666) a phase 2, randomized, double-blind, placebo-controlled study, which evaluated the safety and efficacy of GAR (10 mg/kg/week IV) versus placebo (PBO) in adult patients with FOP over 28 weeks. Patient-reported flare-ups were collected via a patient diary and severity level was reported as mild, moderate or severe. Clinician-reported flare-ups were collected as adverse events in the trial. HO lesions were imaged by 18F-NaF positron emission tomography (PET) and whole-body low-dose X-ray computed tomography (CT). Results: There was a two-fold higher proportion of patients who reported one or more flare-ups on PBO 17/24 (71%) compared with GAR 7/20 (35%). Clinicians reported a four-fold higher proportion of patients experiencing one or more flare-ups on PBO 10/24 (42%) compared with GAR 2/20 (10%). Overall rates of flare-up events were two-fold higher on PBO vs. GAR (1.4 vs. 0.65 events/patient/28 weeks) for patient-reported events and eight-fold higher on PBO vs. GAR by clinician report (0.83 vs. 0.10 events/patient/28 weeks). Most flare-ups occurred on the extremities and back; pain was the most commonly reported symptom. Patient-reported flare-ups on PBO were more frequently reported as severe (29.4%) compared with GAR (7.7%). Among subjects with at least 12 weeks of follow-up from start of patient-reported flare-up, development of new HO near the site was 5/27 (18.5%) on PBO and (0%) on GAR. Of all new HO lesions, 41% on PBO and 0% on GAR occurred with spatial and temporal relation to flare-up. Conclusions: Approximately two-thirds of patients on PBO reported flare-ups over 28 weeks. GAR was associated with reductions in frequency and severity of flare-ups. Fewer than 20% of patient-reported flare-ups were associated with new HO, indicating frequent discordance of these phenomena, and compatible with previous reports. GAR’s ability to reduce patient- and clinician-reported flare-ups, as well as new HO lesions may provide an important therapeutic option.
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Affiliation(s)
| | | | | | | | | | - Richard Keen
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | - Philippe Orcel
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Thomas Funck-Brentano
- AP-HP.Nord - Université de Paris and INSERM U1132 Bioscar, Paris, France, Paris, France
| | - Christian Roux
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sami Kolta
- Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Judith S Bubbear
- Centre for Metabolic Bone Disease Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom
| | | | | | | | | | - Esmée Botman
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, Netherlands
| | - Mona Al Mukaddam
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | | | - E Marelise W Eekhoff
- Amsterdam UMC, Vrije Universiteit, Amsterdam Bone Center, Amsterdam, Netherlands
| | - Frederick S Kaplan
- Departments of Orthopaedics, Medicine and the Center for Research in FOP & Related Disorders, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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15
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Mukaddam MA, Hvisdas C, Sulaj A, Patel K, Tran R. Experience With Anti-Sclerostin Antibody for Osteoporosis Patient With End-Stage Renal Disease on Hemodialysis. J Endocr Soc 2021. [PMCID: PMC8089248 DOI: 10.1210/jendso/bvab048.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Romosozumab is a sclerostin inhibitor indicated for treatment of postmenopausal osteoporosis. Sclerostin inhibits Wnt/Beta-catenin signaling pathway. When sclerostin is inhibited, stimulation of this pathway leads to increased bone formation and production of osteoprotegerin, which also decreases bone resorption. Patients with chronic kidney disease (CKD) demonstrate increased levels of sclerostin that negatively correlates with the rate of bone formation; however, data is lacking for use of romosozumab in this patient population. The report herein details the experience of use of romosozumab in a patient with end-stage renal disease (ESRD) on hemodialysis (HD). Clinical Case: A 37-year-old old African American male was referred after multiple rib fractures and severe non-traumatic T8 compression fracture with nerve compression. His past medical history includes lupus nephritis and cerebritis, ESRD on HD since age 22 status post (s/p) failed renal transplant, and tertiary hyperparathyroidism complicated with fracture in iliac brown tumor and mediastinal parathyromatosis s/p three parathyroid surgeries. Bone mineral density by DXA (g/cm2, Z-score) were as follows: lumbar spine (0.700, -4.0) femoral neck (0.676, -3.8), total hip (0.628,-4.0), 1/3 radius(0.443,-6.2). No prior exposure to antiresorptive or osteoanabolic agents. Pertinent labs included serum calcium 8.5 mg/dL (nl 8.9–10.3 mg/dl), albumin 4.2 g/dL, alkaline phosphatase 319 U/L (nl 38–126), Phosphorus 3.1 mg/dL (2.4–4.7), Creatinine 5.62 mg/dl, 25-OH Vitamin D 31 ng/mL (nl 25 - 80), intact parathyroid hormone 17.9 pmol/L (nl 1.6–6.9). Patient was in excruciating pain and not a surgical candidate due to poor bone quality. Osteoanabolic therapy was recommended given the severity of osteoporosis; however, teriparatide and abaloparaitde were contraindicated given comorbidities. The patient was offered off-label use of Romosozumab with clear understanding that the drug is not approved for this indication and safety/efficacy data in ESRD is not known. The boxed warning regarding increased risk of stroke, myocardial infarction and death were discussed and patient was willing to proceed. Repeat DXA after eleven monthly doses of Romosozumab resulted in a remarkable improvement in bone mineral density at all sites: lumbar spine (+47%), femoral neck (+41%), total hip (+28%), 1/3 radius (+20%). Patient tolerated medication with no side effects or fractures. Serum calcium was monitored prior to initiation and before every dose. No doses were held due to abnormal laboratory values or side effects. Conclusion: This case report summarizes successful experience with the use of Romosozumab in one patient with ESRD on HD with favorable outcomes.
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Affiliation(s)
- Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher Hvisdas
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Anisa Sulaj
- Philadelphia College of Pharmacy, Philadelphia, PA, USA
| | - Kruti Patel
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Richie Tran
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
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16
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Rajapakse CS, Johncola AJ, Batzdorf AS, Jones BC, Al Mukaddam M, Sexton K, Shults J, Leonard MB, Snyder PJ, Wehrli FW. Effect of Low-Intensity Vibration on Bone Strength, Microstructure, and Adiposity in Pre-Osteoporotic Postmenopausal Women: A Randomized Placebo-Controlled Trial. J Bone Miner Res 2021; 36:673-684. [PMID: 33314313 DOI: 10.1002/jbmr.4229] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 08/16/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/31/2022]
Abstract
There has been evidence that cyclical mechanical stimulation may be osteogenic, thus providing opportunities for nonpharmacological treatment of degenerative bone disease. Here, we applied this technology to a cohort of postmenopausal women with varying bone mineral density (BMD) T-scores at the total hip (-0.524 ± 0.843) and spine (-0.795 ± 1.03) to examine the response to intervention after 1 year of daily treatment with 10 minutes of vibration therapy in a randomized double-blinded trial. The device operates either in an active mode (30 Hz and 0.3 g) or placebo. Primary endpoints were changes in bone stiffness at the distal tibia and marrow adiposity of the vertebrae, based on 3 Tesla high-resolution MRI and spectroscopic imaging, respectively. Secondary outcome variables included distal tibial trabecular microstructural parameters and vertebral deformity determined by MRI, volumetric and areal bone densities derived using peripheral quantitative computed tomography (pQCT) of the tibia, and dual-energy X-ray absorptiometry (DXA)-based BMD of the hip and spine. Device adherence was 83% in the active group (n = 42) and 86% in the placebo group (n = 38) and did not differ between groups (p = .7). The mean 12-month changes in tibial stiffness in the treatment group and placebo group were +1.31 ± 6.05% and -2.55 ± 3.90%, respectively (group difference 3.86%, p = .0096). In the active group, marrow fat fraction significantly decreased after 12 months of intervention (p = .0003), whereas no significant change was observed in the placebo group (p = .7; group difference -1.59%, p = .029). Mean differences of the changes in trabecular bone volume fraction (p = .048) and erosion index (p = .044) were also significant, as was pQCT-derived trabecular volumetric BMD (vBMD; p = .016) at the tibia. The data are commensurate with the hypothesis that vibration therapy is protective against loss in mechanical strength and, further, that the intervention minimizes the shift from the osteoblastic to the adipocytic lineage of mesenchymal stem cells. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Chamith S Rajapakse
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Alyssa J Johncola
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brandon C Jones
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly Sexton
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter J Snyder
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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17
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Turin CG, Wilson RJ, Mangone C, Rosenspire K, Berman J, Walker M, Amaravadi R, Al Mukaddam M. A Case of Tumor-Induced Osteomalacia: Finding the Culprit Acetabular Tumor and Successful Resection with a Novel Hip Joint-Preserving Surgery. J Orthop Case Rep 2021; 11:37-41. [PMID: 34239825 PMCID: PMC8241250 DOI: 10.13107/jocr.2021.v11.i03.2078] [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] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection of the tumor can be curative. However, these tumors are typically difficult to find anatomically due to small size and location. CASE REPORT We present the case of a patient who presented for evaluation of recurrent fractures and hypophosphatemia in the setting of elevated FGF23 suggestive of TIO. 68Gallium-DOTATATE revealed multiple somatostatin avid lesions in several ribs, left acetabulum, sacrum, right tibia, and feet, some of which appeared with fracture on computed tomography scan, initially concerning for metastatic disease. However, the lesion in acetabulum was considered the culprit tumor given its remarkably higher maximum standard uptake values. Complete surgical removal of the FGF23-secreting tumor led to cure of this disease. CONCLUSION This case report highlights the challenges with functional imaging differentiating fractures from the culprit lesion and reports on a novel surgical technique that allowed for surgical cure while preserving the hip joint.
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Affiliation(s)
- Christie G. Turin
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Robert J. Wilson
- Department of Orthopaedic, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ciera Mangone
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Karen Rosenspire
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Berman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Michelle Walker
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
| | - Ravi Amaravadi
- Department of Hematology and Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Mona Al Mukaddam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Pennsylvania, Philadelphia, PA, United States
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18
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Kaplan FS, Al Mukaddam M, Stanley A, Towler OW, Shore EM. Fibrodysplasia ossificans progressiva (FOP): A disorder of osteochondrogenesis. Bone 2020; 140:115539. [PMID: 32730934 PMCID: PMC7502483 DOI: 10.1016/j.bone.2020.115539] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/01/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder of extraskeletal bone formation, but could appropriately be viewed as a seminal disorder of osteochondrogenesis. Many, if not most, of the musculoskeletal features of FOP are related to dysregulated chondrogenesis including abnormal articular cartilage formation, abnormal diarthrodial joint specification, growth plate dysplasia, osteochondroma formation, heterotopic endochondral ossification (HEO), and precocious arthropathy. In FOP, causative activating mutations of Activin receptor A type I (ACVR1), a bone morphogenetic protein (BMP) type I receptor, are responsible for the osteochondrodysplasia that impacts developmental phenotypes as well as postnatal features of this illustrative disorder. Here, we highlight the myriad developmental and postnatal effects on osteochondrogenesis that emanate directly from mutant ACVR1 and dysregulated bone morphogenetic protein (BMP) signaling in FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Mona Al Mukaddam
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Alexandra Stanley
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - O Will Towler
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Eileen M Shore
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Genetics, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, USA.
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19
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Strahs A, Marino R, Kaplan FS. A natural history study of fibrodysplasia ossificans progressiva (FOP): 12-month outcome results. Bone Rep 2020. [DOI: 10.1016/j.bonr.2020.100607] [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: 11/25/2022] Open
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20
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Strahs A, Grogan DR, Marino R, Kaplan FS. Measuring outcomes in ultra-rare bone diseases: Methodology of the palovarotene fibrodysplasia ossificans progressiva clinical development programme. Bone Rep 2020. [DOI: 10.1016/j.bonr.2020.100609] [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: 11/15/2022] Open
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21
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Kou S, De Cunto C, Baujat G, Wentworth KL, Grogan DR, Brown MA, Di Rocco M, Keen R, Al Mukaddam M, le Quan Sang KH, Masharani U, Kaplan FS, Pignolo RJ, Hsiao EC. Patients with ACVR1 R206H mutations have an increased prevalence of cardiac conduction abnormalities on electrocardiogram in a natural history study of Fibrodysplasia Ossificans Progressiva. Orphanet J Rare Dis 2020; 15:193. [PMID: 32727600 PMCID: PMC7389682 DOI: 10.1186/s13023-020-01465-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/31/2020] [Accepted: 07/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Genetic contributors to cardiac arrhythmias are often found in cardiovascular conduction pathways and ion channel proteins. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare disease of massive heterotopic ossification caused by a highly recurrent R206H mutation in ACVR1/ALK2. This mutation causes abnormal activation of the bone morphogenetic protein (BMP) pathway in response to Activin A. Prior studies suggested increased risks of cardiopulmonary complications in FOP. We examined participants in a Natural History Study (NHS) of FOP (ClinicalTrials.gov #NCT02322255) to better understand their cardiovascular status. Methods The NHS is an ongoing 3 year international multi-center longitudinal study of 114 patients (ages 4–56 years) with genetically confirmed ACVR1/ALK2R206H FOP. Patients were clinically assessed at baseline and 12 months. Electrocardiograms (ECGs) were reviewed in a central ECG laboratory. Conduction abnormalities were compared against clinical data collected in the NHS, and echocardiograms collected from NHS and non-NHS patients. Results Conduction abnormalities were present in 45.3% of baseline ECGs, with the majority of abnormalities classified as nonspecific intraventricular conduction delay (37.7%). More specifically, 22.2% of patients > 18 years old had conduction abnormalities, which was significantly higher than a prior published study of a healthy population (5.9%; n = 3978) (p < 0.00001). Patients with FOP < 18 years old also had a high prevalence of conduction abnormalities (62.3%). The 12-month follow up data was similar to baseline results. Conduction abnormalities did not correlate with chest wall deformities, scoliosis, pulmonary function test results, or increased Cumulative Analog Joint Involvement Scale scores. Echocardiograms from 22 patients with FOP revealed 8 with structural cardiac abnormalities, only 1 of which correlated with a conduction abnormality. Conclusions We found that patients with FOP may have subclinical conduction abnormalities manifesting on ECG, independent of heterotopic ossification. Although clinically significant heart disease is not typically associated with FOP, and the clinical implications for cardiovascular risk remain unclear, knowledge about ECG and echocardiogram changes is important for clinical care and research trials in patients with FOP. Further studies on how ACVR1/ALK2R206H affects cardiac health will help elucidate the underlying mechanism.
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Affiliation(s)
- Samuel Kou
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Geneviève Baujat
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Kelly L Wentworth
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA.,Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Donna R Grogan
- Clementia Pharmaceuticals, an Ipsen Company, Montreal, Canada
| | - Matthew A Brown
- Guy's & St. Thomas' NHS Foundation Trust and King's College London NIHR Biomedical Research Centre, London, England
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh le Quan Sang
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Frederick S Kaplan
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA. .,The Institute for Human Genetics and the Program in Craniofacial Biology, University of California, San Francisco, CA, USA.
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22
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Berman J, Turin CG, Walker M, Wilson R, Rosenspire K, Mangone C, Amaravadi R, Mukaddam MA. SAT-337 Ga-DOTATATE and Tumor Induced Osteomalacia: Finding the Culprit Lesion. J Endocr Soc 2020. [PMCID: PMC7209290 DOI: 10.1210/jendso/bvaa046.735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Introduction
Tumor-induced osteomalacia (TIO) is a very rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection can be curative; however, these tumors are typically difficult to identify due to size and location.
Clinical case
A 43-year-old man was referred to Endocrinology for evaluation of recurrent fractures and hypophosphatemia. First stress fracture was diagnosed at age 41, followed by musculoskeletal pain in several locations. Lower extremity MRI showed chronic left fibular stress fracture, new stress fracture in fifth metatarsal and right tibia. Tc99m-MDP bone scan revealed multiple foci of increased tracer uptake in bilateral ribs, hips, and lower extremities. Laboratory evaluation showed normal calcium (9.3 mg/dL, normal range [NR]: 8.7-10.2), low phosphorus (1.5 mg/dL, NR: 2.5-4.7), low 1,25-dihydroxyvitamin D (13 pg/mL, NR: 19.9-79.3), low 24-hour urine calcium (78mg), high phosphate excretion fraction in urine (27%, normal <5%), high ALP (163 U/L, NR: 38-126), and high FGF23 (238 RU/mL, NR<180). 25 OH vitamin D (36 ng/mL) and iPTH (5.7 pmol/L, NR: 1.6-6.9) were normal. Patient was started on calcitriol and phosphate supplements. Due to concern for TIO, a PET scan with 68Ga-DOTATATE was performed which showed multiple somatostatin avid lesions concerning for metastatic disease. However, after re-review with radiology, it was felt that other areas of uptake were due to fractures and not tumor given remarkably higher SUV in left acetabular lesion (SUV 20 vs 4-5). The left acetabular lesion was biopsied, followed by surgical resection. Pathology was consistent with phosphaturic mesenchymal tumor with uninvolved margins. FGF23 normalized within 24 hours after surgery (127 RU/mL) and calcitriol and phosphate supplements were discontinued on post-operative day 10.
Clinical lesson
TIO is a rare paraneoplastic syndrome commonly caused by phosphaturic mesenchymal tumors that secrete FGF23. Once the diagnosis of TIO is confirmed, the tumor is localized by anatomical or functional imaging. 68Ga-DOTATATE scan is currently the imaging modality of choice for localization. However, there are other pathologic processes, such as fractures, that could affect the interpretation of PET scans. Osteoblastic activity is increased in fractures, which results in increased uptake in Ga-DOTATATE PET scan since osteoblasts express somatostatin receptor. Our patient was initially thought to have multiple avid lesions concerning for metastatic disease, but culprit lesion was differentiated based on SUVs and confirmed with biopsy. Clinical and biochemical abnormalities resolved after surgery. Early recognition of culprit lesion in TIO is crucial, as successful surgery is curative and would lead to significant improvement in the quality of life of patients.
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Kou S, DeCunto C, Baujat G, Wentworth KL, Grogan D, Brown MA, Rocco MD, Keen R, Mukaddam MA, Kaplan FS, Pignolo RJ, Hsiao EC. SUN-344 Patients with Fibrodysplasia Ossificans Progressiva Have an Increased Prevalence of Cardiac Conduction Abnormalities. J Endocr Soc 2020. [PMCID: PMC7209090 DOI: 10.1210/jendso/bvaa046.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Genetic contributors to cardiac arrhythmias often found in cardiovascular conduction pathway and channel proteins. However, genes outside of these categories can contribute to cardiovascular conduction abnormalities. Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease characterized by large volumes heterotopic ossification caused by a highly recurrent R206H mutation in the ACVR1/Alk2 gene. This mutation produces an abnormal activation of the bone morphogenetic pathway (BMP) pathway in response to Activin A. Prior studies suggested an increased risk of cardiopulmonary complications in FOP1. We examined patients in a Natural History Study (NHS) of FOP (NCT02322255) to better understand their cardiovascular risk. Methods The NHS is an ongoing 3 year international multi-center cross-sectional study of 114 patients with FOP (ages 4–56 years) genetically verified to have the AVCR1 R206H mutation. Patients at baseline and 12 months were assessed by electrocardiogram (ECG). Abnormal lead placements were excluded. ECG readings were assessed in a central ECG laboratory. Results At baseline, 45.3% (48/106) of ECGs showed conduction abnormalities. The majority of these abnormalities were classified as nonspecific intraventricular conduction delay (37.7% of all ECGs). For patients > 18 years old, 22.7% (10/44) had conduction abnormalities, which was significantly higher than previously reported in the healthy population (5.9%; n=3978)2 (proportional t-test; p<0.00001). FOP patients < 18 years of age also had an extremely high prevalence of conduction abnormalities (60.3%, 38/61). The NHS 12-month follow up data showed similar prevalence. The high frequency of conduction abnormalities did not correlate with the presence of chest wall deformities or scoliosis, abnormal pulmonary function test results, increased cumulative analog joint involvement scale (CAJIS) scores, or abnormal echocardiograms. Conclusions Our results show that some patients with FOP may have subclinical conduction abnormalities. These ECG changes appear to be independent of chest wall deformities or scoliosis, although ectopic bone may make ECG measurement in FOP patients challenging. Though there is no reported association of FOP with clinically significant heart block to date and clinical implications for cardiovascular risk remain unclear, knowledge about these ECG changes may be important for planning clinical care and clinical trials of investigational agents in patients with FOP. Further studies of how the AVCR1 R206H activating mutation and BMP signaling changes cardiac conduction are needed to better understand the mechanistic link. References (1)Hingorani et al. Indian J Med Res. 2012; 135:322–330 (2)Kussmaul et al. Clinical Orthopaedic Related Research. 1998; 346:104–109
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Affiliation(s)
- Samuel Kou
- University of California, San Francisco, San Francisco, CA, USA
| | - Carmen DeCunto
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Geneviève Baujat
- Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | | | | | - Matthew A Brown
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London NIHR Biomedical Research Centre, London, United Kingdom
| | | | - Richard Keen
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom
| | | | | | | | - Edward Chiaming Hsiao
- University of California (San Francisco) Endocrine Fellowship Program, San Francisco, CA, USA
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Mukaddam MA, Pignolo RJ, Baujat G, Brown MA, De Cunto C, Rocco MD, Hsiao EC, Keen RW, Sang KHLQ, Strahs A, Marino R, Kaplan FS. OR29-05 A Natural History Study of Fibrodysplasia Ossificans Progressiva (FOP): 12-Month Outcomes. J Endocr Soc 2020. [PMCID: PMC7208621 DOI: 10.1210/jendso/bvaa046.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: FOP is an ultra-rare, severely disabling genetic disorder characterized by episodic flare-ups and heterotopic ossification (HO) leading to restricted movement, physical disability, and early death. FOP may initially be misdiagnosed in ~90% of individuals leading to unnecessary and often harmful interventions. Patients with FOP are diagnosed and managed by multiple specialties, including endocrinologists. Data from an ongoing, prospective, longitudinal, global, natural history study (NCT02322255) were used to investigate the progression of FOP, HO formation, and impact on physical functioning over time. We present results from the first 12 months of the 3-year study. Methods: Males and females with FOP and a documented ACVR1 R206H mutation participated. HO volume was assessed by low-dose whole body computed tomography (WBCT) scan, excluding the head. All imaging was interpreted at a blinded, central laboratory using pre-specified procedures. Functional outcomes were evaluated using the Cumulative Analogue Joint Involvement Scale (CAJIS; for each joint: score=0 represents <10% involvement, score=1 represents 10–90% involvement, and score=2 represents >90% ankylosed across 15 major joints; total score range 0 to 30 [higher scores indicate more severe mobility limitations]) and the FOP Physical Function Questionnaire (FOP-PFQ; percent total score). Changes from Baseline at Month 12 were evaluated for new HO volume, CAJIS, and FOP-PFQ. Results: Of 114 participants (pts) with Baseline data, 99 (4 to 56 years at enrollment; mean 17 years of age; 56% male) also had a Month 12 assessment. A total of 93 pts had evaluable WBCT scans at Baseline and Month 12 and were included in the HO analysis. In total, 40% (37/93) of pts had new HO over 12 months; the mean volume of new HO in these pts was 57,706 mm3 (SD=100,079 mm3; median=20,753 mm3; range: 522 to 438,826 mm3). Of the pts with new HO, 65% (24/37) reported at least one flare-up (mean rate of 2.3 flare-ups/year). Over 12 months, 60% (56/93) of pts did not have new HO; 43% (24/56) of them reported at least one flare-up (mean rate of 1.8 flare-ups/year). Mean changes from Baseline in CAJIS and FOP-PFQ were minimal: CAJIS: 0.6 (SD=2.4; median=1.0; n=99) and FOP-PFQ: 4.4% (SD=11.2; median=3.7%; n=90); and were similar across pts with or without new HO. Conclusions: In participants with FOP, although deterioration of physical function is expected over a patient’s lifetime, CAJIS and FOP-PFQ scores did not worsen significantly in the relative short-term of this study. However, HO volume, quantified by WBCT, increased over the course of 12 months. These results show that measuring HO may be a viable way to monitor changes in FOP over short periods of time.
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Affiliation(s)
- Mona Al Mukaddam
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Geneviève Baujat
- Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London NIHR Biomedical Research Centre, London, United Kingdom
| | | | - Maja Di Rocco
- Department of Pediatrics, Giannina Gaslini Institute, Genova, Italy
| | - Edward C Hsiao
- UCSF Metabolic Bone Clinic, the Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Richard W Keen
- Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | | | | | - Rose Marino
- Clementia Pharmaceuticals Inc., Newton, MA, USA
| | - Frederick S Kaplan
- The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Pignolo RJ, Cheung K, Kile S, Fitzpatrick MA, De Cunto C, Al Mukaddam M, Hsiao EC, Baujat G, Delai P, Eekhoff EMW, Di Rocco M, Grunwald Z, Haga N, Keen R, Levi B, Morhart R, Scott C, Sherman A, Zhang K, Kaplan FS. Self-reported baseline phenotypes from the International Fibrodysplasia Ossificans Progressiva (FOP) Association Global Registry. Bone 2020; 134:115274. [PMID: 32062004 DOI: 10.1016/j.bone.2020.115274] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/21/2022]
Abstract
A global, patient-reported registry has been established to characterize the course of disease and track clinical outcomes in patients with fibrodysplasia ossificans progressiva (FOP), an ultra-rare genetic condition of progressive heterotopic ossification (HO) that results in ankylosis of joints and renders most affected individuals immobile by the second decade of life. Here, we present baseline phenotypes on 299 patients (median age 21 years; range 0.1 to 78 years) from 54 countries based on aggregate data from the International FOP Association (IFOPA) Global Registry (the "FOP Registry"). The mean current age of the patients is 23.7 years (range, 0.1 to 78 years). Baseline characteristics are presented for FOP diagnosis, HO, flare-ups and precedent events, system-based prevalent symptomatology, encounters with medical and dental care providers, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale scores, physical function, as well as the use of aids, assistive devices, and adaptations. Correlations of PROMIS Global Health scores with HO burden and physical function are calculated. Associations of joint mobility with PROMIS Global Health scores, physical function, and use of aids, assistive devices, and adaptations are summarized. Overall, the FOP Registry database contains a broad sample of the global FOP patient population, providing a useful tool for expanding knowledge of FOP, designing clinical trials and facilitating evidence-based decisions about the optimal monitoring and management of affected individuals.
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Affiliation(s)
- Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Kin Cheung
- BioSAS Consulting, Inc., Wellesley, MA, United States
| | - Sammi Kile
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Mary Anne Fitzpatrick
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, The UCSF Metabolic Bone Clinic, The Institute of Human Genetics, the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, CA, United States.
| | - Genevieve Baujat
- Departement de Genetique, Institut IMAGINE, Hôpital Necker-Enfants Malades, Paris, France.
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil.
| | - Elisabeth M W Eekhoff
- VU Medical Center Amsterdam, Department of Internal Medicine/Section Endocrinology, Amsterdam, the Netherlands.
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy.
| | - Zvi Grunwald
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom.
| | - Benjamin Levi
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States.
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany.
| | - Christiaan Scott
- Department of Paediatric Rheumatology, Red Cross Children's Hospital, Cape Town, South Africa.
| | - Adam Sherman
- International FOP Association, 1520 Clay St, Suite H2, North Kansas City, MO, United States.
| | - Keqin Zhang
- Tongji Hospital, Shanghai Tongji University, Shanghai, PR China
| | - Fredrick S Kaplan
- Departments of Orthopaedic Surgery and Medicine, The Center for Research in FOP & Related Disorders, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, United States.
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26
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Wilson A, White B, Grogan DR, Kaplan FS. Correction to: Natural history of fibrodysplasia ossificans progressiva: cross-sectional analysis of annotated baseline phenotypes. Orphanet J Rare Dis 2019; 14:113. [PMID: 31122250 PMCID: PMC6532205 DOI: 10.1186/s13023-019-1096-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Geneviève Baujat
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation (IHBI), Translational Research Institute, Princess Alexandra Hospital, Queensland University of Technology (QUT), Queensland, Australia
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, The Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh Le Quan Sang
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Amy Wilson
- Clementia Pharmaceuticals Inc, Newton, MA, USA
| | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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27
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Pignolo RJ, Baujat G, Brown MA, De Cunto C, Di Rocco M, Hsiao EC, Keen R, Al Mukaddam M, Sang KHLQ, Wilson A, White B, Grogan DR, Kaplan FS. Natural history of fibrodysplasia ossificans progressiva: cross-sectional analysis of annotated baseline phenotypes. Orphanet J Rare Dis 2019; 14:98. [PMID: 31053156 PMCID: PMC6499994 DOI: 10.1186/s13023-019-1068-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [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: 11/09/2018] [Accepted: 04/17/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Fibrodysplasia Ossificans Progressiva (FOP; OMIM#135100) is an ultra-rare, severely disabling genetic disease characterized by congenital malformation of the great toes and progressive heterotopic ossification (HO) in muscles, tendons, ligaments, fascia, and aponeuroses often preceded by painful, recurrent soft tissue swelling (flare-ups). The formation of HO leads to progressive disability, severe functional limitations in joint mobility, and to a shortened life-span. In this prospective natural history study, we describe the baseline, cross-sectional disease phenotype of 114 individuals with FOP. METHODS All subjects underwent protocol-specified baseline assessments to determine their disease status. Cross-sectional analyses were performed using linear regression in which functional evaluations (Cumulative Analogue Joint Involvement Scale [CAJIS] and the FOP-Physical Function Questionnaire [FOP-PFQ]) and the burden of HO as measured by low-dose whole body CT (volume of HO and number of body regions with HO) were assessed. RESULTS Findings from 114 subjects (age range 4 to 56 years) were evaluated. While subject age was significantly (p < 0.0001) correlated with increased CAJIS (r = 0.66) and FOP-PFQ scores (r = 0.41), the estimated mean increases per year (based on cross-sectional average changes over time) were small (0.47 units and 1.2%, respectively). There was also a significant (p < 0.0001) correlation between baseline age and HO volume (r = 0.56), with an estimated mean increase of 25,574 mm3/year. There were significant (p < 0.0001) correlations between the objective assessment of HO volume and clinical assessments of CAJIS (r = 0.57) and FOP-PFQ (r = 0.52). CONCLUSIONS Based on the cross-sectional analysis of the baseline data, functional and physical disability as assessed by CAJIS and the FOP-PFQ increased over time. Although longitudinal data are not yet available, the cross-sectional analyses suggest that CAJIS and FOP-PFQ are not sensitive to detect substantial progression over a 1- to 2-year period. Future evaluation of longitudinal data will test this hypothesis. The statistically significant correlations between HO volume and the functional endpoints, and the estimated average annual increase in total HO volume, suggest that the formation of new HO will be measurable over the relative short-term course of a clinical trial, and represents an endpoint that is clinically meaningful to patients. TRIAL REGISTRATION This study ( NCT02322255 ) was first posted on 23 December, 2014.
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Affiliation(s)
| | - Geneviève Baujat
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation (IHBI), Translational Research Institute, Princess Alexandra Hospital, Queensland University of Technology (QUT), Queensland, Australia
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, the Institute of Human Genetics, and the UCSF Program in Craniofacial Biology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Departments of Medicine and Orthopaedic Surgery, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh Le Quan Sang
- Departement de Genetique, Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Amy Wilson
- Clementia Pharmaceuticals Inc, Newton, MA, USA
| | | | | | - Frederick S Kaplan
- Departments of Orthopaedic Surgery & Medicine, The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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28
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Hsiao EC, Di Rocco M, Cali A, Zasloff M, Al Mukaddam M, Pignolo RJ, Grunwald Z, Netelenbos C, Keen R, Baujat G, Brown MA, Cho TJ, De Cunto C, Delai P, Haga N, Morhart R, Scott C, Zhang K, Diecidue RJ, Friedman CS, Kaplan FS, Eekhoff EMW. Special considerations for clinical trials in fibrodysplasia ossificans progressiva (FOP). Br J Clin Pharmacol 2018; 85:1199-1207. [PMID: 30281842 PMCID: PMC6533500 DOI: 10.1111/bcp.13777] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/23/2018] [Accepted: 09/24/2018] [Indexed: 12/23/2022] Open
Abstract
Clinical trials for orphan diseases are critical for developing effective therapies. One such condition, fibrodysplasia ossificans progressiva (FOP; MIM#135100), is characterized by progressive heterotopic ossification (HO) that leads to severe disability. Individuals with FOP are extremely sensitive to even minor traumatic events. There has been substantial recent interest in clinical trials for novel and urgently‐needed treatments for FOP. The International Clinical Council on FOP (ICC) was established in 2016 to provide consolidated and coordinated advice on the best practices for clinical care and clinical research for individuals who suffer from FOP. The Clinical Trials Committee of the ICC developed a focused list of key considerations that encompass the specific and unique needs of the FOP community – considerations that are endorsed by the entire ICC. These considerations complement established protocols for developing and executing robust clinical trials by providing a foundation for helping to ensure the safety of subjects with FOP in clinical research trials.
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Affiliation(s)
- Edward C Hsiao
- Division of Endocrinology and Metabolism, and the Institute for Human Genetics, Department of Medicine, University of California, San Francisco, CA, USA
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Amanda Cali
- Radiant Hope Foundation and the Ian Cali FOP Research Fund, PENN Medicine, Center for Research in FOP & Related Disorders
| | - Michael Zasloff
- Departments of Orthopaedic Surgery and Genetics, The Center for Research in FOP & Related Disorders, University of Pennsylvania School of Medicine; and MedStar Georgetown Transplant Institute Georgetown University School of Medicine, Washington, DC, USA
| | - Mona Al Mukaddam
- Division of Endocrinology, Diabetes and Metabolism, Departments of Medicine and Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Zvi Grunwald
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Coen Netelenbos
- Department of Internal Medicine section Endocrinology, Amsterdam Bone Center, Amsterdam University Medical Centers location VUmc, Amsterdam, the Netherlands
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Genevieve Baujat
- Centre de Référence Maladies Osseuses Constitutionnelles, Departement de Génétique, Hôpital Necker-Enfants Malades, Institut Imagine, Paris, France
| | - Matthew A Brown
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Tae-Joon Cho
- Division of Pediatric Orthopaedics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Patricia Delai
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo-SP, Brazil
| | - Nobuhiko Haga
- Department of Rehabilitation Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Rolf Morhart
- Department of Pediatrics, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany
| | - Christiaan Scott
- Paediatric Rheumatology, Red Cross Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Keqin Zhang
- Department of Endocrinology, Tongji Hospital, Shanghai Tongji University, Shanghai, China
| | - Robert J Diecidue
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Clive S Friedman
- Schulich School of Medicine and Dentistry, Pediatric Oral Health and Dentistry, London, ON, Canada
| | - Fredrick S Kaplan
- Departments of Medicine & Orthopaedic Surgery, Center for Research in FOP & Related Disorders, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elisabeth M W Eekhoff
- Department of Internal Medicine section Endocrinology, Amsterdam Bone Center, Amsterdam University Medical Centers location VUmc, Amsterdam, the Netherlands
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Agarwal R, Kallish S, Al Mukaddam M. Hypoparathyroidism due to 22Q11 Deletion Syndrome Presenting as Acute Cardiomyopathy. AACE Clin Case Rep 2018. [DOI: 10.4158/accr-2018-0117] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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30
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Dhaliwal R, Foster NC, Boyle C, Al Mukaddam M, Weinstock RS, Rickels MR, Shah VN, DiMeglio LA. Determinants of fracture in adults with type 1 diabetes in the USA: Results from the T1D Exchange Clinic Registry. J Diabetes Complications 2018; 32:1006-1011. [PMID: 30220582 DOI: 10.1016/j.jdiacomp.2018.08.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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: 06/26/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
AIMS To examine the prevalence/determinants of fracture in the T1D Exchange Clinic Registry. RESEARCH DESIGN/METHODS Adults (≥18 years) with T1D duration ≥5 years, diagnosed before age 45 years completed a fracture questionnaire. Additional characteristics were collected from registry data. Only fractures reported as occurring after T1D diagnosis were included. Characteristics were compared between those with and without fractures. RESULTS Respondents included 756 adults (mean age 39 ± 16 years, 28% ≥50 years, 63% female, 90% non-Hispanic White, diabetes duration 24 ± 14 years); 48% reported ≥1 fracture since diagnosis. Of the 659 reported fractures, 24% involved metatarsal/toe, 21% metacarpal/fingers, 14% fibula/tibia, 5% hip/pelvis/femur and 3% vertebrae. Those with fracture were more likely to be older (43 ± 16 vs. 36 ± 14 years), have longer T1D duration (28 ± 14 vs. 20 ± 12 years), been diagnosed with T1D before age 20 years (79% vs. 71%) compared to those without fracture (all p-values < 0.01). CONCLUSIONS Data from this national sample suggest fractures in adults with T1D are common at young age and frequently involve peripheral sites. Age, longer diabetes duration, and T1D diagnosis prior to peak bone mass accrual are notable risk factors. Further research is needed to examine the impact of these determinants on fracture risk in T1D.
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Affiliation(s)
- Ruban Dhaliwal
- SUNY Upstate Medical University, Syracuse, NY, United States of America
| | - Nicole C Foster
- Jaeb Center for Health Research, Tampa, FL, United States of America
| | - Claire Boyle
- Jaeb Center for Health Research, Tampa, FL, United States of America.
| | - Mona Al Mukaddam
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Ruth S Weinstock
- SUNY Upstate Medical University, Syracuse, NY, United States of America
| | - Michael R Rickels
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Viral N Shah
- Barbara Davis Center for Diabetes, Aurora, CO, United States of America
| | - Linda A DiMeglio
- Indiana University School of Medicine, Indianapolis, IN, United States of America
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Shah VN, Wu M, Foster N, Dhaliwal R, Al Mukaddam M. Severe hypoglycemia is associated with high risk for falls in adults with type 1 diabetes. Arch Osteoporos 2018; 13:66. [PMID: 29892791 DOI: 10.1007/s11657-018-0475-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 11/03/2017] [Accepted: 05/04/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We evaluated fall frequency and factors affecting falls among middle-aged and older adults with type 1 diabetes (T1D) from T1D Exchange Registry. Twenty-nine percent of T1D participants reported falls within the past 12 months. Severe hypoglycemia, diabetic peripheral neuropathy, and depression were associated with falls in adults with T1D. PURPOSE Fall is an important risk factor for osteoporotic fracture; we evaluated fall frequency and factors affecting falls among middle-aged and older adults with type 1 diabetes (T1D). METHODS Participants aged ≥ 55 years with T1D completed an email-based questionnaire on falls in the prior 12 months. Demographic, clinical, and fall-related information were gathered from the questionnaire; HbA1c was recorded from medical record data extraction. RESULTS Four hundred and thirty five adults with T1D completed the fall questionnaire (mean age 64 ± 7 years, 57% females, and 97% were non-Hispanic whites). The mean diabetes duration was 36 years with mean HbA1c of 7.3%. Among the 435 participants, 126 reported at least one fall in the prior 12 months (29%). The fall frequency values in adults (55-64 years) with T1D and older adults (> 65 years) were 26 and 32%, respectively (p = 0.16). There was no significant difference in frequency of fall between female and male participants (31 vs. 26%, p = 0.33). Of 126 participants who had a fall, 44% had injuries due to fall, 24% required medical attention, and 13 participants reported fracture (10%). Severe hypoglycemia (odds ratio (OR) 3.6), diabetic peripheral neuropathy (OR 2.2), and depression (OR 1.7) were associated with falls in adults with T1D. Forty-one percent of participants were fearful of falls. CONCLUSIONS This is the first study on prevalence and risk factors for falls suggesting that falls are common in T1D and severe hypoglycemia is a unique diabetes-related factor associated with threefold higher risk for falls.
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Affiliation(s)
- Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, Aurora, CO, 80045, USA
| | - Mengdi Wu
- Jaeb Center for Health Research, 15310 Amberly Dr, Suite 350, Tampa, FL, 33647, USA.
| | - Nicole Foster
- Jaeb Center for Health Research, 15310 Amberly Dr, Suite 350, Tampa, FL, 33647, USA
| | - Ruban Dhaliwal
- SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY, 13210, USA
| | - Mona Al Mukaddam
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
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Al Mukaddam M, Rajapakse CS, Pignolo RJ, Kaplan FS, Smith SE. Imaging assessment of fibrodysplasia ossificans progressiva: Qualitative, quantitative and questionable. Bone 2018; 109:147-152. [PMID: 28822792 DOI: 10.1016/j.bone.2017.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 10/19/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare autosomal dominant genetic disorder of heterotopic ossification (HO) characterized by skeletal anomalies and episodic soft tissue swelling (flare-ups) that can transform into heterotopic bone. The progressive development of heterotopic bone and progressive arthropathy leads to significant limitation of mobility. This paper will review various imaging modalities used in evaluating episodic soft tissue swelling (flare-ups), heterotopic bone and skeletal anomalies. Different imaging modalities are required at different stages of the disease. Ultrasound and MRI can be useful for evaluating edema in early stages of a flare-up; MRI being superior to ultrasonography. Plain radiographs and computed tomography (CT) can evaluate heterotopic bone in later stages of HO, but CT scan is better at evaluating presence and the volume of heterotopic bone. Functional imaging demonstrates increased activity at sites of flare-ups, their utility in determining disease progression need to be further evaluated. Cost, radiation exposure, availability of various imaging modalities and the ability of FOP patients to fit in the scanner are all considerations when requesting radiographic tests in a patient with FOP. Future studies are required to determine if early radiographic findings can determine disease progression and response to treatment in this disorder.
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Affiliation(s)
- Mona Al Mukaddam
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Chamith S Rajapakse
- Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Orthopedics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Robert J Pignolo
- Department of Medicine, The Mayo Clinic, Rochester, MN 55905, United States
| | - Frederick S Kaplan
- Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Orthopedics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP and Related Disorders, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Stacy E Smith
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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Abstract
BACKGROUND Flare-ups of the hips are among the most feared and disabling complications of fibrodysplasia ossificans progressiva (FOP) and are poorly understood. In order to better understand the nature of hip flare-ups in FOP, we evaluated 25 consecutive individuals with classic FOP (14 males, 11 females; 3-56years old, median age, 17years old) who presented with acute unilateral hip pain. RESULTS All 25 individuals were suspected of having a flare-up of the hip based on clinical history and a favorable response to a four day course of high-dose oral prednisone. Ten individuals (40%) experienced rebound symptoms of pain and/or stiffness within seven days after discontinuation of prednisone and all ten subsequently developed heterotopic ossification (HO) or decreased mobility of the affected hip. None of the 14 individuals who experienced sustained relief of symptoms following a course of oral prednisone experienced HO or decreased mobility. Incidental radiographic findings at the time of presentation were multifactoral and included osteochondromas of the proximal femur (18/25; 72%), degenerative arthritis (17/25; 68%), developmental hip dysplasia (15/25; 60%), previously existing heterotopic ossification (12/25; 48%), intra-articular synovial osteochondromatosis (8/25; 32%) or traumatic fractures through pre-existing heterotopic bone (1/25; 4%). CONCLUSIONS Developmental joint pathology may confound clinical evaluation of hip pain in FOP. The most useful modality for suspecting an ossification-prone flare-up of the hip was lack of sustained response to a brief course of oral prednisone. Evaluation of soft tissue edema by ultrasound or magnetic resonance imaging showed promise in identifying ossification-prone flare-ups and warrants further analysis in prospective studies.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Clinical Medicine, Division of Endocrinology, Diabetes and Metabolism, Center for Research in FOP & Related Disorders, Penn Medicine University City, 3737 Market Street, 3rd floor, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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Gupta RR, Delai PLR, Glaser DL, Rocke DM, Al Mukaddam M, Pignolo RJ, Kaplan FS. Prevalence and risk factors for kidney stones in fibrodysplasia ossificans progressiva. Bone 2018; 109:120-123. [PMID: 29241827 DOI: 10.1016/j.bone.2017.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 12/06/2017] [Accepted: 12/10/2017] [Indexed: 11/24/2022]
Abstract
The worldwide prevalence and risk factors for kidney stones in patients with fibrodysplasia ossificans progressiva (FOP) are unknown. We conducted a survey of 383 patient-members of the International Fibrodysplasia Ossificans Progressiva Association, comprising the entire global membership of the international FOP community. Two hundred seven patients from 31 nations and 6 continents (54%) responded. Nineteen of 207 respondents had kidney stones, revealing a worldwide prevalence of 9.2%. In a confirmatory follow-up study of subjects participating in a longitudinal FOP natural history study, 9 of 114 individuals reported a history of kidney stones (7.9%). In both study populations patients with kidney stones were found to be more functionally impaired compared to those without nephrolithiasis. The prevalence of kidney stones in the adult FOP population of the Unites States was 15.8% (9/57 individuals) compared to a sex- and age-weighted prevalence of 4.5% (p=4×10-5) in the general population. Although geographical variation exists, patients with FOP have an approximately three-fold greater prevalence of kidney stones than the general population. This unusually high prevalence may be due to high bone turnover from chronic immobilization, or to unknown mechanistic effects of the activating FOP mutation in activin A receptor, type I/activin-like kinase-2 (ACVR1/ALK2), increasing the disease burden and morbidity in this already disabling condition.
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Affiliation(s)
- Rishi R Gupta
- Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States; Department of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States
| | - Patricia L R Delai
- Research Institute of Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - David L Glaser
- Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States.
| | - David M Rocke
- Division of Biostatistics, School of Medicine, University of California-Davis, Davis, CA 95616, United States.
| | - Mona Al Mukaddam
- Department of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, United States.
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States; Department of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, United States.
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Kaplan FS, Zeitlin L, Dunn SP, Benor S, Hagin D, Al Mukaddam M, Pignolo RJ. Acute and chronic rapamycin use in patients with Fibrodysplasia Ossificans Progressiva: A report of two cases. Bone 2018; 109:281-284. [PMID: 29241828 DOI: 10.1016/j.bone.2017.12.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 12/06/2017] [Accepted: 12/10/2017] [Indexed: 12/28/2022]
Abstract
Fibrodysplasia Ossificans Progressiva (FOP) is an ultrarare genetic disorder of progressive, disabling heterotopic ossification for which there is presently no definitive treatment. Several recent studies in genetic mouse models of FOP support involvement of the mechanistic target of rapamycin complex 1 (mTORC1) pathway in the pathophysiology of FOP and propose the repurposed use of rapamycin, an inhibitor of mTORC1 signaling in clinical trials for the management of FOP. Here we report two patients with the classic FOP mutation who received rapamycin-one for four months on a compassionate basis for treatment of acute flare-ups of the neck and back that were refractory to corticosteroid therapy-and the other for 18years for chronic immunosuppression following liver transplantation for intercurrent cytomegalovirus infection. In both patients, FOP progressed despite the use of rapamycin. This report highlights the real-world use of rapamycin in two FOP patients and provides insight into the use of rapamycin in clinical trials for the management of FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Leonid Zeitlin
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - Stephen P Dunn
- Department of Surgery, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE 19803, United States.
| | - Shira Benor
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - David Hagin
- Department of Medicine, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, University of Tel Aviv, 6 Weizmann St, 64239 Tel Aviv, Israel.
| | - Mona Al Mukaddam
- Department of Medicine, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States; The Center for Research in FOP & Related Disorders, The Perelman School of Medicine of The University of Pennsylvania, Philadelphia, PA 19104, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, United States.
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Kaplan FS, Al Mukaddam M, Pignolo RJ. Longitudinal patient-reported mobility assessment in fibrodysplasia ossificans progressiva (FOP). Bone 2018; 109:158-161. [PMID: 28600150 DOI: 10.1016/j.bone.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 05/02/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a rare, disabling genetic disorder characterized by episodic soft tissue swelling (flare-ups) that leads to progressive heterotopic ossification and restricted joint mobility. METHODS Here we present the first longitudinal patient-reported mobility assessment (PRMA) in FOP based on a simple evaluation tool. At initial presentation and follow-up (1-11year span; median: 6 year span), 64 patients (36 females; 28 males) with classic FOP completed a questionnaire designed to rapidly assess mobility at 15 sites (three axial; six upper limb, and six lower limb). In order to validate this instrument, twenty-one of 64 patients (33%) underwent a cumulative analogue joint involvement scale (CAJIS) evaluation by two physicians within six months of their second self-assessment. RESULTS We found that: 1) mobility changes were episodic and regional, occurring first in the neck and trunk, followed by the upper limbs and finally the lower limbs; 2) interval improvements in mobility did occur, most notably in the lower limbs (18%), and less so in the upper limbs (12%) and trunk (3%), and 3) patient-reported mobility assessments correlate highly (R2=0.81) with physician-reported CAJIS evaluations. CONCLUSION This is the first longitudinal PRMA in FOP and provides a simple and valid tool that can be used in the design and evaluation of clinical trials in this progressively disabling disease.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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Kaplan FS, Al Mukaddam M, Pignolo RJ. A cumulative analogue joint involvement scale (CAJIS) for fibrodysplasia ossificans progressiva (FOP). Bone 2017; 101:123-128. [PMID: 28465250 DOI: 10.1016/j.bone.2017.04.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 03/01/2017] [Revised: 04/26/2017] [Accepted: 04/26/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a catastrophic genetic disorder of progressive heterotopic ossification (HO). Assessment of functional mobility in FOP will be essential to support clinical trials of investigational agents. RESULTS Of necessity, we developed a simple, rapidly-administered, cumulative analogue joint involvement scale (CAJIS) for FOP based on assessments in 144 individuals worldwide with classic FOP. CONCLUSIONS CAJIS scores correlated with patient age, activities of daily living, and ambulatory function with excellent inter-rater variability. We show here that the CAJIS score provides an accurate and reproducible snapshot of total body and regional mobility burden in FOP.
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Affiliation(s)
- Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
| | - Robert J Pignolo
- Department of Medicine, Mayo Clinic School of Medicine, Mayo Clinic, Rochester, MN, United States.
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Al Mukaddam M, Rajapakse CS, Bhagat YA, Wehrli FW, Guo W, Peachey H, LeBeau SO, Zemel BS, Wang C, Swerdloff RS, Kapoor SC, Snyder PJ. Effects of testosterone and growth hormone on the structural and mechanical properties of bone by micro-MRI in the distal tibia of men with hypopituitarism. J Clin Endocrinol Metab 2014; 99:1236-44. [PMID: 24423356 PMCID: PMC3973782 DOI: 10.1210/jc.2013-3665] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Severe deficiencies of testosterone (T) and GH are associated with low bone mineral density (BMD) and increased fracture risk. Replacement of T in hypogonadal men improves several bone parameters. Replacement of GH in GH-deficient men improves BMD. OBJECTIVE Our objective was to determine whether T and GH treatment together improves the structural and mechanical parameters of bone more than T alone in men with hypopituitarism. DESIGN AND SUBJECTS This randomized, prospective, 2-year study included 32 men with severe deficiencies of T and GH due to panhypopituitarism. INTERVENTION Subjects were randomized to receive T alone (n = 15) or T and GH (n = 17) for 2 years. MAIN OUTCOME MEASURES We evaluated magnetic resonance microimaging-derived structural (bone volume fraction [BVF] and trabecular thickness) and mechanical (axial stiffness [AS], a measure of bone strength) properties of the distal tibia at baseline and after 1 and 2 years of treatment. RESULTS Treatment with T and GH did not affect BVF, thickness, or AS differently from T alone. T treatment in all subjects for 2 years increased trabecular BVF by 9.6% (P < .0001), trabecular thickness by 2.6% (P < .001), and trabecular AS by 9.8% (P < .001). In contrast, testosterone treatment in all subjects significantly increased cortical thickness by 2.4% (P < .01) but decreased cortical BVF by -4.7% (P < .01) and cortical AS by -6.9% (P < .01). CONCLUSION Combined T and GH treatment of men with hypopituitarism for 2 years did not improve the measured structural or mechanical parameters of the distal tibia more than T alone. However, testosterone significantly increased the structural and mechanical properties of trabecular bone but decreased most of these properties of cortical bone, illustrating the potential importance of assessing trabecular and cortical bone separately in future studies of the effect of testosterone on bone.
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Affiliation(s)
- Mona Al Mukaddam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine (M.A.M., H.P., S.O.L., P.J.S.); Laboratory of Structural NMR Imaging, Department of Radiology (C.S.R., Y.A.B., F.W.W.), Department of Biostatistics and Epidemiology (W.G.), and the Clinical and Translational Research Center (S.C.K.), Raymond and Ruth Perelman School of Medicine, University of Pennsylvania; and the Division of Gastroenterology, Hepatology, and Nutrition (B.S.Z.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104; and Division of Endocrinology and Metabolism (C.W., R.S.S.), Harbor-University of California at Los Angeles Medical Center and Los Angeles Biomedical Research Institute, Torrance, California 90509
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