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Grover M, Ashraf AP, Bowden SA, Calabria A, Diaz-Thomas A, Krishnan S, Miller JL, Robinson ME, DiMeglio LA. Invited Mini Review Metabolic Bone Disease of Prematurity: Overview and Practice Recommendations. Horm Res Paediatr 2024:000536228. [PMID: 38211570 DOI: 10.1159/000536228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024] Open
Abstract
Metabolic bone disease of prematurity (MBDP) is defined by undermineralization of the preterm infant skeleton arising from inadequate prenatal and postnatal calcium (Ca) and phosphate (PO4) accretion. Severe MBDP can be associated with rickets and fractures. Despite advances in neonatal nutrition, MBDP remains prevalent in premature infants due to inadequate mineral accretion ex-utero. There also remain significant knowledge gaps regarding best practices for monitoring and treatment of MBDP among neonatologists and pediatric endocrinologists. Preventing and treating MBDP can prevent serious consequences including rickets or pathologic fractures. Postnatal monitoring to facilitate early recognition of MBDP is best done by first-tier laboratory screening by measuring serum calcium, phosphorus, and alkaline phosphatase to identify infants at risk. If these labs are abnormal, further studies including assessing parathyroid hormone and/or tubular resorption of phosphate can help differentiate between Ca and PO4 deficiency as primary etiologies to guide appropriate treatment with mineral supplements. Additional research into optimal mineral supplementation for the prevention and treatment of MBDP is needed to improve long-term bone health outcomes and provide a fuller evidence base for future treatment guidelines.
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Bowden SA. Current Screening Strategies for the Diagnosis of Adrenal Insufficiency in Children. Pediatric Health Med Ther 2023; 14:117-130. [PMID: 37051221 PMCID: PMC10084833 DOI: 10.2147/phmt.s334576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of hypothalamic-pituitary-adrenal axis due to exogenous glucocorticoids. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often subtle and nonspecific. Clinician awareness and recognition is crucial for timely diagnosis to avoid adrenal crisis. Current screening strategies for the diagnosis of adrenal insufficiency in children in various clinical situations are discussed in this review.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children’s Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
- Correspondence: Sasigarn A Bowden, Nationwide Children’s Hospital, Division of Endocrinology, 700 Children’s Drive, Columbus, OH, 43205, USA, Tel +1 614-722-4118, Fax +1 614-722-4440, Email
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3
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McCutcheon E, Bowden SA, Wasserman H, Diaz-Thomas A, Bijelić V, Bachrach LK, Robinson ME. Treatment Practices and Confidence in the Management of Pediatric Metabolic Bone Disorders. Horm Res Paediatr 2022; 95:354-362. [PMID: 35569443 DOI: 10.1159/000524994] [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: 12/09/2021] [Accepted: 05/05/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pediatric metabolic bone and mineral disorders encompass a wide variety of disorders that can be challenging to diagnose and treat because of inadequate physician training about optimal management. METHODS As practice variation and confidence levels may impact clinical outcome, we sought to assess physician confidence in managing pediatric metabolic bone and mineral disorders and the spectrum of treatment practices among members of the Pediatric Endocrine Society (PES) and the Canadian Pediatric Endocrine Group (CPEG). Questionnaires were distributed via e-mail to all members of the PES and CPEG and 244 were completed. Responses were summarized using descriptive statistics, and proportions were compared using χ2 or Fisher's exact tests, as appropriate. RESULTS Variations were observed among the respondents' confidence in the management of bone disorders and in the criteria used to initiate/discontinue intravenous bisphosphonates or prescribe burosumab therapy. Respondents felt confident with the management of 4 out of 20 pediatric bone conditions (confidence was defined as >90% of respondents reporting feeling "somewhat confident" or "very confident"). Physicians working in a bone clinic were more confident in prescribing burosumab for the treatment of X-linked hypophosphatemic rickets compared to those not working in a bone clinic (65% vs. 47%, p = 0.03). Most respondents (52%) reported having received inadequate training in pediatric metabolic bone and mineral disorders. DISCUSSION/CONCLUSION Dedicated training, knowledge acquisition, and education resources are needed to increase confidence and standardize the use of bone-targeted therapies.
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Affiliation(s)
- Emma McCutcheon
- Division of Endocrinology, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Halley Wasserman
- Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alicia Diaz-Thomas
- Department of Pediatrics-Endocrinology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vid Bijelić
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Laura K Bachrach
- Department of Pediatrics, Stanford University School of Medicine, San Francisco, California, USA
| | - Marie-Eve Robinson
- Division of Endocrinology, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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4
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Bowden JJ, Bowden SA, Ruess L, Adler BH, Hu H, Krishnamurthy R, Krishnamurthy R. Validation of automated bone age analysis from hand radiographs in a North American pediatric population. Pediatr Radiol 2022; 52:1347-1355. [PMID: 35325266 DOI: 10.1007/s00247-022-05310-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 02/19/2021] [Revised: 12/21/2021] [Accepted: 02/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Radiographic bone age assessment by automated software is precise and instantaneous. OBJECTIVE The aim of this study was to evaluate the accuracy of an automated tool for bone age assessment. MATERIALS AND METHODS We compared a total of 586 bone age radiographs from 451 patients, which had been assessed by three radiologists from 2013 to 2018, with bone age analysis by BoneXpert, using the Greulich and Pyle method. We made bone age comparisons in different patient groups based on gender, diagnosis and race, and in a subset with repeated bone age studies. We calculated Spearman correlation (r) and accuracy (root mean square error, or R2). RESULTS Bone age analyses by automated and manual assessments showed a strong correlation (r=0.98; R2=0.96; P<0.0001), with the mean bone age difference of 0.12±0.76 years. Bone age comparisons by the two methods remained strongly correlated (P<0.0001) when stratified by gender, common endocrine conditions including growth disorders and early/precocious puberty, and race. In the longitudinal analysis, we also found a strong correlation between the automated software and manual bone age over time (r=0.7852; R2=0.63; P<0.01). CONCLUSION Automated bone age assessment was found to be reliable and accurate in a large cohort of pediatric patients in a clinical practice setting in North America.
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Affiliation(s)
| | - Sasigarn A Bowden
- Department of Pediatric Endocrinology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Lynne Ruess
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Brent H Adler
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Houchun Hu
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Ramkumar Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
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5
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Zhou D, Rudnicki M, Chua GT, Lawrance SK, Zhou B, Drew JL, Barbar-Smiley F, Armstrong TK, Hilt ME, Birmingham DJ, Passler W, Auletta JJ, Bowden SA, Hoffman RP, Wu YL, Jarjour WN, Mok CC, Ardoin SP, Lau YL, Yu CY. Human Complement C4B Allotypes and Deficiencies in Selected Cases With Autoimmune Diseases. Front Immunol 2021; 12:739430. [PMID: 34764957 PMCID: PMC8577214 DOI: 10.3389/fimmu.2021.739430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/10/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
Human complement C4 is one of the most diverse but heritable effectors for humoral immunity. To help understand the roles of C4 in the defense and pathogenesis of autoimmune and inflammatory diseases, we determined the bases of polymorphisms including the frequent genetic deficiency of C4A and/or C4B isotypes. We demonstrated the diversities of C4A and C4B proteins and their gene copy number variations (CNVs) in healthy subjects and patients with autoimmune disease, such as type 1 diabetes, systemic lupus erythematosus (SLE) and encephalitis. We identified subjects with (a) the fastest migrating C4B allotype, B7, or (b) a deficiency of C4B protein caused by genetic mutation in addition to gene copy-number variation. Those variants and mutants were characterized, sequenced and specific techniques for detection developed. Novel findings were made in four case series. First, the amino acid sequence determinant for C4B7 was likely the R729Q variation at the anaphylatoxin-like region. Second, in healthy White subject MS630, a C-nucleotide deletion at codon-755 led to frameshift mutations in his single C4B gene, which was a private mutation. Third, in European family E94 with multiplex lupus-related mortality and low serum C4 levels, the culprit was a recurrent haplotype with HLA-A30, B18 and DR7 that segregated with two defective C4B genes and identical mutations at the donor splice site of intron-28. Fourth, in East-Asian subject E133P with anti-NMDA receptor encephalitis, the C4B gene had a mutation that changed tryptophan-660 to a stop-codon (W660x), which was present in a haplotype with HLA-DRB1*04:06 and B*15:27. The W660x mutation is recurrent among East-Asians with a frequency of 1.5% but not detectable among patients with SLE. A meticulous annotation of C4 sequences revealed clusters of variations proximal to sites for protein processing, activation and inactivation, and binding of interacting molecules.
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Affiliation(s)
- Danlei Zhou
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael Rudnicki
- Department of Internal Medicine IV - Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Gilbert T Chua
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, SAR China
| | - Simon K Lawrance
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Biology & Earth Science, Otterbein University, Westerville, OH, United States
| | - Bi Zhou
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Joanne L Drew
- Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Fatima Barbar-Smiley
- Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University, Columbus, OH, United States
| | - Taylor K Armstrong
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, United States
| | - Miranda E Hilt
- Department of Biology & Earth Science, Otterbein University, Westerville, OH, United States
| | - Daniel J Birmingham
- Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Werner Passler
- Division of Nephrology and Dialysis, City Hospital, Bolzano, Italy
| | - Jeffrey J Auletta
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States.,Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Sasigarn A Bowden
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States.,Division of Endocrinology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Robert P Hoffman
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States.,Division of Endocrinology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Yee Ling Wu
- Department of Microbiology and Immunology, Loyola University Chicago, Maywood, IL, United States
| | - Wael N Jarjour
- Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong, SAR China
| | - Stacy P Ardoin
- Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University, Columbus, OH, United States.,Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Yu Lung Lau
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, SAR China
| | - Chack Yung Yu
- Center for Microbial Pathogenesis, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, United States.,Division of Rheumatology, Nationwide Children's Hospital, Columbus, OH, United States.,Department of Pediatrics, The Ohio State University, Columbus, OH, United States
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6
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Clayton D, Chavez MB, Tan MH, Kolli TN, Giovani PA, Hammersmith KJ, Bowden SA, Foster BL. Mineralization Defects in the Primary Dentition Associated With X-Linked Hypophosphatemic Rickets. JBMR Plus 2021; 5:e10463. [PMID: 33869987 PMCID: PMC8046057 DOI: 10.1002/jbm4.10463] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/22/2020] [Accepted: 01/10/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Delaney Clayton
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Michael B Chavez
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Michelle H Tan
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Tamara N Kolli
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
| | - Priscila A Giovani
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA.,Department of Pediatric Dentistry, Piracicaba Dental School University of Campinas Campinas Brazil
| | - Kimberly J Hammersmith
- Division of Pediatric Dentistry, College of Dentistry The Ohio State University Columbus OH USA.,Department of Dentistry Nationwide Children's Hospital Columbus OH USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Division of Endocrinology Nationwide Children's Hospital Columbus OH USA.,College of Medicine The Ohio State University Columbus OH USA
| | - Brian L Foster
- Biosciences Division, College of Dentistry The Ohio State University Columbus OH USA
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7
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Bowden SA, Connolly AM, Kinnett K, Zeitler PS. Management of Adrenal Insufficiency Risk After Long-term Systemic Glucocorticoid Therapy in Duchenne Muscular Dystrophy: Clinical Practice Recommendations. J Neuromuscul Dis 2020; 6:31-41. [PMID: 30614808 PMCID: PMC6398538 DOI: 10.3233/jnd-180346] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/16/2022]
Abstract
Long-term glucocorticoid therapy has improved outcomes in patients with Duchenne muscular dystrophy. However, the recommended glucocorticoid dosage suppresses the hypothalamic-pituitary-adrenal axis, leading to adrenal insufficiency that may develop during severe illness, trauma or surgery, and after discontinuation of glucocorticoid therapy. The purpose of this review is to highlight the risk of adrenal insufficiency in this patient population, and provide practical recommendations for management of adrenal insufficiency, glucocorticoid withdrawal, and adrenal function testing. Strategies to increase awareness among patients, families, and health care providers are also discussed.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anne M Connolly
- Department of Neurology, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, New Jersey, USA
| | - Philip S Zeitler
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
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8
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Abstract
Hypophosphatasia (HPP) is an inherited disorder that affects bone and tooth mineralization characterized by low serum alkaline phosphatase. HPP is caused by loss-of-function mutations in the ALPL gene encoding the protein, tissue-nonspecific alkaline phosphatase (TNSALP). TNSALP is expressed by mineralizing cells of the skeleton and dentition and is associated with the mineralization process. Generalized reduction of activity of the TNSALP leads to accumulation of its substrates, including inorganic pyrophosphate (PPi) that inhibits physiological mineralization. This leads to defective skeletal mineralization, with manifestations including rickets, osteomalacia, fractures, and bone pain, all of which can result in multi-systemic complications with significant morbidity, as well as mortality in severe cases. Dental manifestations are nearly universal among affected individuals and feature most prominently premature loss of deciduous teeth. Management of HPP has been limited to supportive care until the introduction of a TNSALP enzyme replacement therapy (ERT), asfotase alfa (AA). AA ERT has proven to be transformative, improving survival in severely affected infants and increasing overall quality of life in children and adults with HPP. This chapter provides an overview of TNSALP expression and functions, summarizes HPP clinical types and pathologies, discusses early attempts at therapies for HPP, summarizes development of HPP mouse models, reviews design and validation of AA ERT, and provides up-to-date accounts of AA ERT efficacy in clinical trials and case reports, including therapeutic response, adverse effects, limitations, and potential future directions in therapy.
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Affiliation(s)
- S A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA.
| | - B L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
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9
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Sarkissian A, Sivaraman V, Bout-Tabaku S, Ardoin SP, Moore-Clingenpeel M, Mruk V, Steigelman H, Morris K, Bowden SA. Bone turnover markers in relation to vitamin D status and disease activity in adults with systemic lupus erythematosus. Lupus 2018; 28:156-162. [PMID: 30509154 DOI: 10.1177/0961203318815593] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 12/13/2022]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus (SLE) have altered bone metabolism and are at risk of osteoporosis. The aim of this study was to examine bone turnover markers in relation to vitamin D, disease activity, and clinical risk factors in patients with established SLE. METHODS Clinical registry and biorepository data of 42 SLE patients were assessed. Serum samples were analyzed for osteocalcin as a marker of bone formation, C-terminal telopeptide of type 1 collagen (CTX) as a marker for bone resorption, and 25-hydroxy vitamin D. RESULTS Patients with a Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI) score of 3 or greater had a lower median osteocalcin level ( P = 0.02) and lower 25-hydroxy vitamin D levels ( P = 0.03) than those with a score of less than 3. No significant differences in bone turnover markers were observed between patients dichotomized into subgroups using a 25-hydroxy vitamin D cut-off of 30 ng/mL or by a daily prednisone dose greater than or 5 mg or less. Osteocalcin levels were negatively correlated with SLEDAI scores ( P = 0.034), and were positively correlated with the CTX index (a ratio of measured CTX value to the upper limit of the normal value for age and gender) ( P < 0.01). No association between the CTX index and SLEDAI scores was found. CONCLUSION SLE disease activity may have direct effects on bone formation, but no effects on bone resorption in this cohort of established SLE patients, probably related to the inflammation-suppressing effects of glucocorticoids, thereby inhibiting cytokine-induced osteoclast activity. A fine balance exists between disease control and the use of glucocorticoids with regard to bone health.
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Affiliation(s)
- A Sarkissian
- 1 Pediatric Rheumatology, Nationwide Children's Hospital and The Ohio State University Medical Center, Columbus, USA
| | - V Sivaraman
- 1 Pediatric Rheumatology, Nationwide Children's Hospital and The Ohio State University Medical Center, Columbus, USA
| | - S Bout-Tabaku
- 2 Pediatric Rheumatology, Sidra Medicine, Doha, Qatar
| | - S P Ardoin
- 1 Pediatric Rheumatology, Nationwide Children's Hospital and The Ohio State University Medical Center, Columbus, USA
| | | | - V Mruk
- 1 Pediatric Rheumatology, Nationwide Children's Hospital and The Ohio State University Medical Center, Columbus, USA
| | - H Steigelman
- 4 Rheumatology and Immunology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - K Morris
- 4 Rheumatology and Immunology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - S A Bowden
- 5 Pediatric Endocrinology, Nationwide Children's Hospital and The Ohio State University Medical Center, Columbus, USA
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10
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Abstract
Adrenal insufficiency may result from a wide variety of congenital or acquired disorders of hypothalamus, pituitary, or adrenal cortex. Destruction or dysfunction of the adrenal cortex is the cause of primary adrenal insufficiency, while secondary adrenal insufficiency is a result of pituitary or hypothalamic disease. Timely diagnosis and clinical management of adrenal insufficiency are critical to prevent morbidity and mortality. This review summarizes the etiologies, presentation, and diagnosis of adrenal insufficiency utilizing different dynamic hormone testing and describes current treatment recommendations and new therapies.
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Affiliation(s)
- Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Rohan Henry
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
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11
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Abstract
Hypophosphatasia (HPP) is a multi-systemic metabolic disorder caused by loss-of-function mutations in the ALPL gene that encodes the mineralization-associated enzyme, tissue-nonspecific alkaline phosphatase (TNSALP). HPP is characterized by defective bone and dental mineralization, leading to skeletal abnormalities with complications resulting in significant morbidity and mortality. Management of HPP has been limited to supportive care until the introduction of a recently approved enzyme replacement therapy employing bone-targeted recombinant human TNSALP, asfotase alfa (AA). This new therapy has been transformative as it improves survival in severely affected infants, and overall quality of life in children and adults with HPP. This review provides an overview of HPP, focusing on important steps in the development of AA enzyme replacement therapy, including the drug design, preclinical studies in the HPP mouse model, and outcomes from clinical trials and case report publications to date, with special attention given to response to therapy of skeletal manifestations, biochemical features, and other clinical manifestations. The limitations, adverse effects, and outcomes of AA are outlined and the place in therapy for individuals with HPP is discussed.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH 43205, USA,
| | - Brian L Foster
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH 43205, USA
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12
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Bowden SA, Adler BH. Reappearance of hypomineralized bone after discontinuation of asfotase alfa treatment for severe childhood hypophosphatasia. Osteoporos Int 2018; 29:2155-2156. [PMID: 29967930 DOI: 10.1007/s00198-018-4613-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/18/2018] [Indexed: 11/26/2022]
Affiliation(s)
- S A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - B H Adler
- Department of Radiology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, 43205, USA
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13
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Abstract
We describe the clinical outcome of asfotase alfa therapy in a 16-year-old boy with severe childhood hypophosphatasia (HPP), who began therapy at age 15 years. The patient was diagnosed with HPP at age 2 years when he presented with genu varum and premature loss of primary teeth. He had a history of multiple fractures requiring 16 orthopedic surgeries with rod and pin placement in his lower extremities. He had chronic skeletal pain and used cane to ambulate with great difficulty. His height Z score at age 15 years was - 5. He had severe scoliosis and deformity of both legs. Bone radiograph showed hypomineralization and characteristic "tongues" of radiolucency in the distal radius and ulna. His serum alkaline phosphatase level was stable, with elevated serum pyridoxal 5'-phosphate and urine phosphoethanolamine, consistent with HPP. He was started on asfotase alfa 2 mg/kg given subcutaneously thrice weekly. He had marked clinical improvement in mobility with no report of pain after 3 months of treatment. At 6 month, he walked without cane and participated in outdoor activities with peers. Bone radiograph at 6 months showed striking improvement in previous radiolucent areas. At 9 months, his annualized growth velocity was 9.5 cm/year, while growth velocity of arm span was 12 cm/year. However, at 12 months, he was noted to have worsening scoliosis from 60 degrees before therapy to 110 degrees, with a slight decrease in height, necessitating a spinal fusion surgery. In conclusion, treatment with asfotase alfa significantly improved physical function, pain, overall quality of life, and skeletal radiographic findings in this patient. Close monitoring for progression of scoliosis in adolescents with HPP treated with asfotase alfa is recommended.
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Affiliation(s)
- S A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - B H Adler
- Department of Radiology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, 43205, USA
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14
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Abstract
Zoledronic acid (ZA), a highly potent intravenous bisphosphonate (BP), has been increasingly used in children with primary and secondary osteoporosis due to its convenience of shorter infusion time and less frequent dosing compared to pamidronate. Many studies have also demonstrated beneficial effects of ZA in other conditions such as hypercalcemia of malignancy, fibrous dysplasia (FD), chemotherapy-related osteonecrosis (ON) and metastatic bone disease. This review summarizes pharmacologic properties, mechanism of action, dosing regimen, and therapeutic outcomes of ZA in a variety of metabolic bone disorders in children. Several potential novel uses of ZA are also discussed. Safety concerns and adverse effects are also highlighted.
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Affiliation(s)
- Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children’s Hospital/the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - John D. Mahan
- Division of Nephrology, Department of Pediatrics, Nationwide Children’s Hospital/the Ohio State University College of Medicine, Columbus, Ohio, USA
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15
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Henry RK, Chaudhari M, Bowden SA. Short Stature and Macrodactyly in a 13-Year-Old Female. Clin Pediatr (Phila) 2016; 55:1071-4. [PMID: 27566682 DOI: 10.1177/0009922816665088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rohan K Henry
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Monika Chaudhari
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sasigarn A Bowden
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
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Bowden SA, Akusoba CI, Hayes JR, Mahan JD. Biochemical markers of bone turnover in children with clinical bone fragility. J Pediatr Endocrinol Metab 2016; 29:715-22. [PMID: 27049615 DOI: 10.1515/jpem-2014-0525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 02/09/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of biochemical bone turnover markers (BTMs) in assessing low bone mass and monitoring bisphosphonate treatment in pediatric patients with clinical bone fragility is not well established. The aim of the study was to examine the correlations of BTMs and the bone mineral density (BMD), and evaluate the effects of bisphosphonates therapy on BTMs in children with clinical bone fragility. METHODS Clinical data of 115 patients with clinical bone fragility (mean age 9.7±5.8 years), 102 of whom received bisphosphonates, were studied. Serum alkaline phosphatase (ALP), osteocalcin (OC), urine pyridinoline (PD) and deoxypyridinoline (DPD), BMD at baseline and subsequent years were analyzed. RESULTS There was a significant negative correlation between urine PD and lumbar BMD (slope=-0.29, p<0.001). There were no correlations between BTMs and lumbar BMD Z-score. There was a significant positive correlation between serum OC and serum ALP, urine PD and DPD (p<0.001). Serum OC, urine PD and DPD index, as expressed as measured value/upper limit of normal value for age, decreased during the first 3 years of bisphosphonate therapy. CONCLUSIONS In children with clinical bone fragility, BTMs correlated with each other, but not with lumbar BMD Z-score. While they were not reliable predictors of degree of low BMD, the bone markers showed suppression during bisphosphonate therapy and may be helpful in monitoring the response to therapy.
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Mytinger JR, Bowden SA. Adrenal Function Testing Following Hormone Therapy for Infantile Spasms: Case Series and Review of Literature. Front Neurol 2015; 6:259. [PMID: 26696958 PMCID: PMC4672028 DOI: 10.3389/fneur.2015.00259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 09/02/2015] [Accepted: 11/24/2015] [Indexed: 11/17/2022] Open
Abstract
Prednisolone and adrenocorticotropic hormone (ACTH) are “hormone” therapies for infantile spasms. There is limited data on the occurrence of decreased adrenal reserve or signs of clinical adrenal insufficiency after hormone therapy. This is a retrospective medical record review of patients referred to our Infantile Spasms Program. Our standardized infantile spasms management guideline began in September 2012 and initially included a post-hormone laboratory assessment of adrenal function. Medical records were assessed for hormone treatments, adrenal function testing, and signs of adrenal insufficiency. Forty-two patients who received one or both hormone therapies met inclusion criteria. A post-hormone laboratory assessment of adrenal function was done in 14 patients. Of these 14 patients, 2 had an abnormal laboratory assessment of adrenal function, both by adrenal stimulation testing – one after ACTH and one after prednisolone. One patient received hydrocortisone replacement and the other received stress dose hydrocortisone as needed; neither patient developed signs of adrenal insufficiency. Another patient treated with both types of hormone therapy in tandem, who did not have a post-hormone laboratory assessment, developed signs of mild adrenal insufficiency and required replacement hydrocortisone. Our study suggests that adrenal suppression can occur after modern hormone therapy regimens. We found two patients with abnormal adrenal function testing after hormone therapy and another patient with signs adrenal insufficiency. Given the seriousness of adrenal crisis, caregiver education on the signs of adrenal insufficiency is critical. Greater vigilance may be indicated in patients receiving both types of hormone therapy in tandem. Although a routine post-hormone laboratory assessment of adrenal function may not be feasible in all patients, replacement or stress dose hydrocortisone is necessary for all patients with suspected adrenal insufficiency.
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Affiliation(s)
- John R Mytinger
- Department of Pediatrics, Division of Pediatric Neurology, Nationwide Children's Hospital, The Ohio State University , Columbus, OH , USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Division of Pediatric Endocrinology, Nationwide Children's Hospital, The Ohio State University , Columbus, OH , USA
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Kusumi K, Ayoob R, Bowden SA, Ingraham S, Mahan JD. Beneficial effects of intravenous pamidronate treatment in children with osteogenesis imperfecta under 24 months of age. J Bone Miner Metab 2015; 33:560-8. [PMID: 25319557 DOI: 10.1007/s00774-014-0618-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
Abstract
Osteogenesis imperfecta (OI) is an inherited disorder characterized by bone fragility and low bone mass. Low bone density and fracture is a cause of morbidity. Limited data exists on bisphosphonate treatment in patients under 24 months of age. The objective of the study was to examine the safety and efficacy of pamidronate in children under 24 months with OI. To do so, we carried out a retrospective chart review and analysis of OI patients started on intravenous pamidronate under 24 months of age. Pamidronate was administered in three-day cycles. Growth, the number of fractures, and lumbar bone mineral densities were recorded both prior to and after treatment initiation. A total of 18 patients were reviewed. Five were classified as OI type I, seven were type III, and six were type IV. The mean age at treatment initiation was 12 months (range 11 days to 23 months). The mean lumbar z score at baseline was -3.63, which improved to -1.53 at one year (P < 0.01) and 0.79 (P < 0.01) at the end of the study. The fracture rate improved from 68 fractures in 209 months (0.32 fractures/patient-month) before treatment to 41 fractures in 1,248 months (0.03 fractures/patient-month) post-treatment (P < 0.05). Height standard deviation score (SDS) was conserved from baseline to end of study (-2.12 ± 2.45 vs. -2.45 ± 2.73) (P = 0.05) with an average follow-up of 73 months. The only adverse effect recorded in six infants was fever during the initial pamidronate infusion. Treatment with intravenous pamidronate is safe, significantly improves lumbar bone mineral density (L-BMD), and reduces fracture rates in young infants with OI while preserving linear growth.
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Affiliation(s)
- Kirsten Kusumi
- Division of Nephrology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, 700 Children's Dr., Columbus, OH, 43205, USA,
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Inagaki F, Hinrichs KU, Kubo Y, Bowles MW, Heuer VB, Hong WL, Hoshino T, Ijiri A, Imachi H, Ito M, Kaneko M, Lever MA, Lin YS, Methé BA, Morita S, Morono Y, Tanikawa W, Bihan M, Bowden SA, Elvert M, Glombitza C, Gross D, Harrington GJ, Hori T, Li K, Limmer D, Liu CH, Murayama M, Ohkouchi N, Ono S, Park YS, Phillips SC, Prieto-Mollar X, Purkey M, Riedinger N, Sanada Y, Sauvage J, Snyder G, Susilawati R, Takano Y, Tasumi E, Terada T, Tomaru H, Trembath-Reichert E, Wang DT, Yamada Y. DEEP BIOSPHERE. Exploring deep microbial life in coal-bearing sediment down to ~2.5 km below the ocean floor. Science 2015. [PMID: 26206933 DOI: 10.1126/science.aaa6882] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Microbial life inhabits deeply buried marine sediments, but the extent of this vast ecosystem remains poorly constrained. Here we provide evidence for the existence of microbial communities in ~40° to 60°C sediment associated with lignite coal beds at ~1.5 to 2.5 km below the seafloor in the Pacific Ocean off Japan. Microbial methanogenesis was indicated by the isotopic compositions of methane and carbon dioxide, biomarkers, cultivation data, and gas compositions. Concentrations of indigenous microbial cells below 1.5 km ranged from <10 to ~10(4) cells cm(-3). Peak concentrations occurred in lignite layers, where communities differed markedly from shallower subseafloor communities and instead resembled organotrophic communities in forest soils. This suggests that terrigenous sediments retain indigenous community members tens of millions of years after burial in the seabed.
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Affiliation(s)
- F Inagaki
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - K-U Hinrichs
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - Y Kubo
- Center for Deep-Earth Exploration, JAMSTEC, Yokohama 236-0061, Japan. Research and Development Center for Ocean Drilling Science, JAMSTEC, Yokohama 236-0001, Japan
| | - M W Bowles
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - V B Heuer
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - W-L Hong
- College of Earth, Ocean, and Atmospheric Sciences, Oregon State University, Corvallis, OR 97331, USA
| | - T Hoshino
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - A Ijiri
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - H Imachi
- Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan. Department of Subsurface Geobiological Analysis and Research, JAMSTEC, Yokosuka 237-0061, Japan
| | - M Ito
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - M Kaneko
- Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan. Department of Biogeochemistry, JAMSTEC, Yokosuka 237-0061, Japan
| | - M A Lever
- Center for Geomicrobiology, Department of Bioscience, Aarhus University, DK-8000 Aarhus C, Denmark
| | - Y-S Lin
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - B A Methé
- Department of Environmental Genomics, J. Craig Venter Institute, Rockville, MD 20850, USA
| | - S Morita
- Geological Survey of Japan, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Ibaraki 305-8567, Japan
| | - Y Morono
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - W Tanikawa
- Kochi Institute for Core Sample Research, Japan Agency for Marine-Earth Science and Technology (JAMSTEC), Nankoku, Kochi 783-8502, Japan. Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan
| | - M Bihan
- Department of Environmental Genomics, J. Craig Venter Institute, Rockville, MD 20850, USA
| | - S A Bowden
- Department of Geology and Petroleum Geology, School of Geosciences, University of Aberdeen, Aberdeen AB2A 3UE, UK
| | - M Elvert
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - C Glombitza
- Center for Geomicrobiology, Department of Bioscience, Aarhus University, DK-8000 Aarhus C, Denmark
| | - D Gross
- Department of Applied Geosciences and Geophysics, Montanuniversität, 8700 Leoben, Austria
| | - G J Harrington
- School of Geography, Earth and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - T Hori
- Environmental Management Research Institute, AIST, Tsukuba, Ibaraki 305-8569, Japan
| | - K Li
- Department of Environmental Genomics, J. Craig Venter Institute, Rockville, MD 20850, USA
| | - D Limmer
- Department of Geology and Petroleum Geology, School of Geosciences, University of Aberdeen, Aberdeen AB2A 3UE, UK
| | - C-H Liu
- The State Key Laboratory of Pharmaceutical Biotechnology, School of Life Science, Nanjing University, Nanjing, Jiangsu 210093, China
| | - M Murayama
- Center for Advanced Marine Core Research, Kochi University, Nankoku, Kochi 783-8502, Japan
| | - N Ohkouchi
- Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan. Department of Biogeochemistry, JAMSTEC, Yokosuka 237-0061, Japan
| | - S Ono
- Department of Earth, Atmospheric and Planetary Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Y-S Park
- Petroleum and Marine Resources Research Division, Korea Institute of Geoscience and Mineral Resources, Yuseong-gu, Daejeon 305-350, Korea
| | - S C Phillips
- Department of Earth Sciences, University of New Hampshire, Durham, NH 03824, USA
| | - X Prieto-Mollar
- MARUM Center for Marine Environmental Sciences, University of Bremen, D-28359 Bremen, Germany
| | - M Purkey
- Department of Earth and Atmospheric Sciences, University of Nebraska-Lincoln, Lincoln, NE 68588, USA
| | - N Riedinger
- Department of Earth Sciences, University of California Riverside, Riverside, CA 92521, USA
| | - Y Sanada
- Center for Deep-Earth Exploration, JAMSTEC, Yokohama 236-0061, Japan. Research and Development Center for Ocean Drilling Science, JAMSTEC, Yokohama 236-0001, Japan
| | - J Sauvage
- Graduate School of Oceanography, University of Rhode Island, Narragansett, RI 02882, USA
| | - G Snyder
- Department of Earth Science, Rice University, Houston, TX 77005, USA
| | - R Susilawati
- School of Earth Science, University of Queensland, Brisbane Queensland 4072, Australia
| | - Y Takano
- Research and Development Center for Marine Resources, JAMSTEC, Yokosuka 237-0061, Japan. Department of Biogeochemistry, JAMSTEC, Yokosuka 237-0061, Japan
| | - E Tasumi
- Department of Subsurface Geobiological Analysis and Research, JAMSTEC, Yokosuka 237-0061, Japan
| | - T Terada
- Marine Works Japan, Yokosuka 237-0063, Japan
| | - H Tomaru
- Department of Earth Sciences, Graduate School of Science, Chiba University, Chiba 263-8522, Japan
| | - E Trembath-Reichert
- Geological and Planetary Sciences, California Institute of Technology, Pasadena, CA 91125, USA
| | - D T Wang
- Department of Earth, Atmospheric and Planetary Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Y Yamada
- Research and Development Center for Ocean Drilling Science, JAMSTEC, Yokohama 236-0001, Japan. Department of Urban Management, Graduate School of Engineering, Kyoto University, Kyoto 615-8540, Japan
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Affiliation(s)
- Brian K Bowden
- Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
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Thompson MD, Kalmar E, Bowden SA. Severe hyponatraemia with absence of hyperkalaemia in rapidly progressive Addison's disease. BMJ Case Rep 2015; 2015:bcr-2015-209903. [PMID: 26021383 DOI: 10.1136/bcr-2015-209903] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of rapidly progressing Addison's disease in adrenal crisis with severe hyponatraemia and absence of hyperkalaemia in a 10-year-old girl. She presented with 2 weeks of vomiting, fatigue and weight loss. Her serum electrolytes obtained 1 week prior to presentation were normal, except for mild hyponatraemia at 131 mmol/L, which dropped to 112 mmol/L on admission. She had normal serum potassium, low-serum osmolality, with elevated urine sodium and osmolality, indistinguishable from syndrome of inappropriate antidiuretic hormone (SIADH). Subsequently, Addison's disease was diagnosed on the basis of gingival hyperpigmentation and undetectable cortisol on adrenocorticotropic hormone stimulation test. She rapidly responded to stress dose hydrocortisone, followed by hydrocortisone and fludrocortisone replacement therapy. The absence of hyperkalaemia in the presence of severe hyponatraemia cannot rule out Addison's disease in children. The mechanism of hypo-osmolar hyponatraemia in primary adrenal insufficiency and clinical clues to differentiate it from SIADH are discussed.
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Affiliation(s)
- Michael D Thompson
- Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | - Eileen Kalmar
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sasigarn A Bowden
- Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
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Affiliation(s)
- Rohan K Henry
- Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sasigarn A Bowden
- Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
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Buckner JL, Bowden SA, Mahan JD. Optimizing Bone Health in Duchenne Muscular Dystrophy. Int J Endocrinol 2015; 2015:928385. [PMID: 26124831 PMCID: PMC4466394 DOI: 10.1155/2015/928385] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 01/30/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterized by progressive muscle weakness, with eventual loss of ambulation and premature death. The approved therapy with corticosteroids improves muscle strength, prolongs ambulation, and maintains pulmonary function. However, the osteoporotic impact of chronic corticosteroid use further impairs the underlying reduced bone mass seen in DMD, leading to increased fragility fractures of long bones and vertebrae. These serious sequelae adversely affect quality of life and can impact survival. The current clinical issues relating to bone health and bone health screening methods in DMD are presented in this review. Diagnostic studies, including biochemical markers of bone turnover and bone mineral density by dual energy X-ray absorptiometry (DXA), as well as spinal imaging using densitometric lateral spinal imaging, and treatment to optimize bone health in patients with DMD are discussed. Treatment with bisphosphonates offers a method to increase bone mass in these children; oral and intravenous bisphosphonates have been used successfully although treatment is typically reserved for children with fractures and/or bone pain with low bone mass by DXA.
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Affiliation(s)
- Jason L. Buckner
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
- *Jason L. Buckner:
| | - Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
| | - John D. Mahan
- Division of Nephrology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
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Coshway LK, Indyk JA, Bowden SA. Repeating ACTH Stimulation Test Is Necessary to Diagnose ACTH Deficiency in Neonatal Hypopituitarism With Initial False Negative Result. Glob Pediatr Health 2014; 1:2333794X14563385. [PMID: 27335928 PMCID: PMC4804690 DOI: 10.1177/2333794x14563385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Loyal K Coshway
- Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
| | - Justin A Indyk
- Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sasigarn A Bowden
- Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
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Bowden SA, Patel HP, Beebe A, McBride KL. Successful Medical Therapy for Hypophosphatemic Rickets due to Mitochondrial Complex I Deficiency Induced de Toni-Debré-Fanconi Syndrome. Case Rep Pediatr 2013; 2013:354314. [PMID: 24386581 PMCID: PMC3872385 DOI: 10.1155/2013/354314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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] [Received: 09/19/2013] [Accepted: 11/14/2013] [Indexed: 11/17/2022] Open
Abstract
Primary de Toni-Debré-Fanconi syndrome is a non-FGF23-mediated hypophosphatemic disorder due to a primary defect in renal proximal tubule cell function resulting in hyperphosphaturia, renal tubular acidosis, glycosuria, and generalized aminoaciduria. The orthopaedic sequela and response to treatment of this rare disorder are limited in the literature. Herein we report a long term followup of a 10-year-old female presenting at 1 year of age with rickets initially misdiagnosed as vitamin D deficiency rickets. She was referred to the metabolic bone and genetics clinics at 5 years of age with severe genu valgum deformities of 24 degrees and worsening rickets. She had polyuria, polydipsia, enuresis, and bone pain. Diagnosis of hypophosphatemic rickets due to de Toni-Debré-Fanconi syndrome was subsequently made. Respiratory chain enzyme analysis identified a complex I mitochondrial deficiency as the underlying cause. She was treated with phosphate (50-70 mg/kg/day), calcitriol (30 ng/kg/day), and sodium citrate with resolution of bone pain and normal growth. By 10 years of age, her genu valgus deformities were 4 degrees with healing of rickets. Her excellent orthopaedic outcome despite late proper medical therapy is likely due to the intrinsic renal tubular defect that is more responsive to combined alkali, phosphate, and calcitriol therapy.
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Affiliation(s)
- Sasigarn A. Bowden
- Division of Endocrinology, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Hiren P. Patel
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
| | - Allan Beebe
- Division of Orthopedics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
| | - Kim L. McBride
- Center for Cardiovascular and Pulmonary Research, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
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Bowden SA. Diabetic ketoacidosis at the onset of type 1 diabetes. BMJ 2011; 343:d3278. [PMID: 21737468 DOI: 10.1136/bmj.d3278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Bowden SA, Robinson RF, Carr R, Mahan JD. Prevalence of vitamin D deficiency and insufficiency in children with osteopenia or osteoporosis referred to a pediatric metabolic bone clinic. Pediatrics 2008; 121:e1585-90. [PMID: 18519464 DOI: 10.1542/peds.2007-2111] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [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: 11/24/2022] Open
Abstract
OBJECTIVES The purpose of this work was to determine the prevalence of vitamin D deficiency and insufficiency in children with osteopenia or osteoporosis and to evaluate the relationship between serum 25-hydroxyvitamin D levels and bone parameters, including bone mineral density. MATERIALS AND METHODS Serum 25-hydroxyvitamin D, 1,25 dihydroxyvitamin D, parathyroid hormone, and other bone markers, as well as bone mineral density, were obtained for 85 pediatric patients with primary osteoporosis (caused by osteogenesis imperfecta or juvenile idiopathic osteoporosis) and secondary osteopenia or osteoporosis caused by various underlying chronic illnesses. Pearson's correlation was used to assess the relationship between vitamin D levels and different bone parameters. RESULTS Vitamin D insufficiency (defined as serum 25-hydroxyvitamin D <30 ng/mL) was observed in 80.0% of patients. Overt vitamin D deficiency (defined as serum 25-hydroxyvitamin D <10 ng/mL) was present in 3.5% of patients. Using a more recent definition for vitamin D deficiency in adults (defined as serum 25-hydroxyvitamin D <20 ng/mL), 21.1% of the patients had vitamin D deficiency. There was a significant inverse correlation between 25-hydroxyvitamin D and parathyroid hormone levels. There was a positive correlation between 1,25 dihydroxyvitamin D and parathyroid hormone, alkaline phosphatase, and urine markers for bone turnover. CONCLUSIONS Vitamin D insufficiency was remarkably common in pediatric patients with primary and secondary osteopenia or osteoporosis. The inverse relationship between 25-hydroxyvitamin D and parathyroid hormone levels suggests a physiologic impact of insufficient vitamin D levels that may contribute to low bone mass or worsen the primary bone disease. We suggest that monitoring and supplementation of vitamin D should be a priority in the management of pediatric patients with osteopenia or osteoporosis.
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Affiliation(s)
- Sasigarn A Bowden
- Columbus Children's Hospital, Division of Endocrinology, 700 Children's Dr, Columbus, OH 43205, USA.
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Bowden SA, Duck MM, Hoffman RP. Young children (<5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes 2008; 9:197-201. [PMID: 18547233 DOI: 10.1111/j.1399-5448.2008.00376.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [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: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether there are different rates of partial remission in preschool, school-age children, and adolescents with type 1 diabetes mellitus (T1DM) and to identify clinical characteristics that are associated with increased rate of partial remission. DESIGN/METHODS A total of 152 consecutive patients with newly diagnosed T1DM in 2004 were studied. Clinical characteristics at diagnosis, hemoglobin A1C (HbA1C), and total daily insulin dose (TDD) at 3-month interval follow-up for 1 yr were analyzed in each age-group (group 1, aged <5 yr; group 2, aged 5-12 yr; and group 3, aged >12 yr). Partial remission was defined as TDD <0.5 units/kg/d with HbA1C <8% assessed at 6 months after diagnosis. RESULTS Young children (group 1, 26.8%) and adolescents (group 3, 29%) had low rates of partial remission compared with school-age children (group 2, 56%, p = 0.002). There were no differences in the rates of diabetic ketoacidosis (DKA), autoantibody frequency, and HbA1C at diagnosis between age-groups. DKA at diagnosis was associated with less likelihood of having partial remission (p < 0.001). There were no associations between gender, autoantibodies, and HbA1C at diagnosis and the rate of partial remission. CONCLUSIONS Young children and adolescent children with T1DM had a low rate of partial remission. Metabolic control was poorest in young children, whereas higher dose insulin in adolescents because of insulin resistance contributes to less likelihood of having partial remission. DKA at diagnosis was associated with low rate of partial remission. It is possible that the low frequency of honeymoon phase in young children reflects more aggressive beta-cell destruction in young children.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Columbus Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Bowden SA, Hoffman RP. Triple diabetes: coexistence of type 1 diabetes mellitus and a novel mutation in the gene responsible for MODY3 in an overweight adolescent. Pediatr Diabetes 2008; 9:162-4. [PMID: 18221440 DOI: 10.1111/j.1399-5448.2007.00335.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [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: 11/28/2022] Open
Abstract
We report an interesting and unique case of an overweight adolescent with a novel mutation of the maturity-onset diabetes of the young (MODY)3 gene [hepatocyte nuclear factor-1 alpha (HNF-1alpha)] and positive islet cell autoantibodies. The patient is a 17-yr-old Caucasian female, who was diagnosed with type 2 diabetes mellitus, treated with metformin and glipizide, with poor control for 18 months prior to being referred to the Endocrinology clinic. Family history was strongly positive for type 2 diabetes (father, paternal aunts, uncles, and grandmother). All were diagnosed at age 40-50 and treated with oral hypoglycemic agents. The patient's body mass index was 36.4 kg/m(2). She had no acanthosis nigricans. Initial hemoglobin A1c was 11.9%, with fasting glucose of 234 mg/dL and fasting insulin 10.7 microU/mL. She was started on insulin therapy (0.6 units/kg/d), resulting in good glycemic control. Oral hypoglycemic agents were discontinued. Immunologic studies showed positive islet cell (29 U/mL, normal <1.0) and glutamic acid decarboxylase-65 (0.9 U/mL, normal <0.5) antibodies. Sequencing for HNF-1alpha gene revealed a nucleotide A to G substitution (ACC to GCC), resulting in a missense mutation, T196A. To our knowledge, T196A has not been previously reported. The coexistence of type 1 diabetes autoimmunity and a mutation in the gene responsible for MODY3 in this overweight patient is intriguing and might explain the early onset of progressive insulinopenia compared with the later age of diabetes onset of the earlier generation in the family.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Columbus Children's Hospital, The Ohio State University, Columbus, OH 43205, USA.
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Abstract
We describe an 8 year-old boy with growth acceleration due to an invasive growth hormone (GH)-secreting pituitary macroadenoma who was successfully treated with the somatostatin analogue octreotide prior to transsphenoidal microsurgery. His tumor was resected completely and the patient remains in remission.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, The Ohio State University/Columbus Children's Hospital, Columbus, OH 43205, USA.
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Bowden SA, Germak JA. Klinefelter syndrome presenting with precocious puberty due to a human chorionic gonadotropin (hCG)-producing mediastinal germinoma. J Pediatr Endocrinol Metab 2006; 19:1371. [PMID: 17220068 DOI: 10.1515/jpem.2006.19.11.1371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bowden SA, Monaghan PB, Wilson R, Parnell J, Cooper JM. The liquid-liquid diffusive extraction of hydrocarbons from a North Sea oil using a microfluidic format. Lab Chip 2006; 6:740-3. [PMID: 16738724 DOI: 10.1039/b518162c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Extraction of a GC-amenable hydrocarbon fraction from oil by liquid-liquid diffusion across a laminar interface can be performed in a microfluidic format. Analysis of figures of merit, determined using standard analytical techniques, show this method to be an effective new tool for rapidly processing small quantities of oil and petroleum for GC analysis. Methods based upon similar microsystems devices could find widespread use in a variety of fields, including those associated with organic geochemistry and oil exploration and production, where the manipulation of petroleum constituents (greater than C14) is necessary for analytical purposes.
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Affiliation(s)
- S A Bowden
- Department of Geology & Petroleum Geology, University of Aberdeen, Aberdeen AB24 3UE, UK.
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