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Agarwal AR, Kinnard MJ, Murdock C, Zhao AY, Ahiarakwe U, Cohen JS, Moseley KF, Golladay GJ, Thakkar SC. The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis. Osteoporos Int 2024:10.1007/s00198-024-07085-6. [PMID: 38619605 DOI: 10.1007/s00198-024-07085-6] [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: 07/26/2023] [Accepted: 04/03/2024] [Indexed: 04/16/2024]
Abstract
Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF. INTRODUCTION Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs. METHODS Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates. RESULTS Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500. CONCLUSION The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.
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Affiliation(s)
- Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Matthew J Kinnard
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Christopher Murdock
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Amy Y Zhao
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA.
| | - Uzoma Ahiarakwe
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jordan S Cohen
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PD, USA
| | - Kendall F Moseley
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Gay CL, Bosch RJ, McKhann A, Cha R, Morse GD, Wimbish CL, Campbell DM, Moseley KF, Hendrickx S, Messer M, Benson CA, Overton ET, Paccaly A, Jankovic V, Miller E, Tressler R, Li JZ, Kuritzkes DR, Macatangay BJC, Eron JJ, Hardy WD. Safety and Immune Responses Following Anti-PD-1 Monoclonal Antibody Infusions in Healthy Persons With Human Immunodeficiency Virus on Antiretroviral Therapy. Open Forum Infect Dis 2024; 11:ofad694. [PMID: 38449916 PMCID: PMC10917183 DOI: 10.1093/ofid/ofad694] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Background T cells in people with human immunodeficiency virus (HIV) demonstrate an exhausted phenotype, and HIV-specific CD4+ T cells expressing programmed cell death 1 (PD-1) are enriched for latent HIV, making antibody to PD-1 a potential strategy to target the latent reservoir. Methods This was a phase 1/2, randomized (4:1), double-blind, placebo-controlled study in adults with suppressed HIV on antiretroviral therapy with CD4+ counts ≥350 cells/μL who received 2 infusions of cemiplimab versus placebo. The primary outcome was safety, defined as any grade 3 or higher adverse event (AE) or any immune-related AE (irAE). Changes in HIV-1-specific polyfunctional CD4+ and CD8+ T-cell responses were evaluated. Results Five men were enrolled (median CD4+ count, 911 cells/μL; median age, 51 years); 2 received 1 dose of cemiplimab, 2 received 2 doses, and 1 received placebo. One participant had a probable irAE (thyroiditis, grade 2); another had a possible irAE (hepatitis, grade 3), both after a single low-dose (0.3 mg/kg) infusion. The Safety Monitoring Committee recommended no further enrollment or infusions. All 4 cemiplimab recipients were followed for 48 weeks. No other cemiplimab-related serious AEs, irAEs, or grade 3 or higher AEs occurred. One 2-dose recipient of cemiplimab had a 6.2-fold increase in polyfunctional, Gag-specific CD8+ T-cell frequency with supportive increases in plasma HIV RNA and decreases in total HIV DNA. Conclusions One of 4 participants exhibited increased HIV-1-specific T-cell responses and transiently increased HIV-1 expression following 2 cemiplimab infusions. The occurrence of irAEs after a single, low dose may limit translating the promising therapeutic results of cemiplimab for cancer to immunotherapeutic and latency reversal strategies for HIV. Clinical Trials Registration. NCT03787095.
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Affiliation(s)
- Cynthia L Gay
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald J Bosch
- Department of Biostatistics, Center for Biostatistics and AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ashley McKhann
- Department of Biostatistics, Center for Biostatistics and AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Raymond Cha
- Center for Integrated Global Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Gene D Morse
- Center for Integrated Global Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Chanelle L Wimbish
- Department of Clinical Research, Social and Scientific Systems, Inc, a DLH Company, Silver Spring, Maryland, USA
| | - Danielle M Campbell
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Kendall F Moseley
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Steven Hendrickx
- Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Michael Messer
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Constance A Benson
- Department of Medicine, University of California, San Diego, San Diego, California, USA
| | - Edgar T Overton
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- North America Medical Affairs, ViiV Healthcare, Durham, North Carolina, USA
| | - Anne Paccaly
- Departments of Clinical Sciences, Translational Medicine and Precision Medicine, Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Vladimir Jankovic
- Departments of Clinical Sciences, Translational Medicine and Precision Medicine, Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Elizabeth Miller
- Departments of Clinical Sciences, Translational Medicine and Precision Medicine, Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Randall Tressler
- HIV Research Branch, Division of AIDS, National Institute of AIDS, National Institutes of Health, Rockville, Maryland, USA
| | - Jonathan Z Li
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard J C Macatangay
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph J Eron
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - W David Hardy
- Division of Infectious Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Agarwal AR, Tarawneh O, Cohen JS, Gu A, Moseley KF, DeBritz JN, Golladay GJ, Thakkar SC. The incremental risk of fragility fractures in aging men. Osteoporos Int 2024; 35:495-503. [PMID: 37938405 DOI: 10.1007/s00198-023-06956-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION While the United States Preventative Services Task Force recommends osteoporosis screening for women 65 years and older, there is no definitive recommendation for routine osteoporosis screening in men. The purpose of this study was to determine the age at which the odds of fragility fractures (FFx) increase in men to help guide future policy discussions evaluating an optimal screening strategy in this population. METHODS Men older than 49 years were identified in the PearlDiver Patient Records Database. Patients were excluded if they had a prior fragility fracture, if they were at high risk for osteoporosis due to comorbidities, or if they carried a diagnosis of and/or were on treatment for osteoporosis. The prevalence of FFx was trended for each age group. A stratum-specific likelihood ratio (SSLR) analysis was conducted to identify data-driven strata that maximize the incremental FFx risk by age for men. Logistic regression analyses controlling for potential confounders were conducted to test these identified strata. RESULTS The incidence of FFx started to increase after the age of 64 years for men. Further, the identified data-driven age strata associated with a significant and incremental difference in fragility fractures were the following: 50-64, 65-69, 70-72, 73-75, 76-78, 79-80, and 81+. When compared to the youngest age stratum (50-64 years), multivariable regression showed the risk of fragility fracture incrementally increased starting in those aged 70-72 (RR, 1.31; 95% CI. 1.21-1.46; p < 0.001) with the highest risk in those aged 81+ (RR, 5.35; 95% CI, 5.10-5.62; p < 0.001). CONCLUSION In men without a pre-existing history of osteoporosis, the risk of fragility fractures starts to increase after the age of 70. Further work building upon these data may help to identify a specific age at which routine bone health screening in males can help to minimize fractures and their associated morbidity and mortality.
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Affiliation(s)
- A R Agarwal
- Department of Orthopaedic Surgery, George Washington University School of Medicine and, Health Sciences, Washington, DC, USA.
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - O Tarawneh
- Department of Orthopaedic Surgery, New York Medical College, Valhalla, NY, USA
| | - J S Cohen
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelpha, PA, USA
| | - A Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and, Health Sciences, Washington, DC, USA
| | - K F Moseley
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - J N DeBritz
- Department of Orthopaedic Surgery, George Washington University School of Medicine and, Health Sciences, Washington, DC, USA
| | - G J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health Center, Richmond, VA, USA
| | - S C Thakkar
- Department of Orthopaedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
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Pishdad R, Moseley KF. Maladie osseuse de Paget. CMAJ 2023; 195:E1138. [PMID: 37640400 PMCID: PMC10462407 DOI: 10.1503/cmaj.230164-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Reza Pishdad
- Division de l'endocrinologie, du diabète et du métabolisme, Faculté de médecine de l'Université Johns Hopkins, Baltimore, Md.
| | - Kendall F Moseley
- Division de l'endocrinologie, du diabète et du métabolisme, Faculté de médecine de l'Université Johns Hopkins, Baltimore, Md
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Pishdad R, Moseley KF. Paget disease of bone. CMAJ 2023; 195:E814. [PMID: 37308214 DOI: 10.1503/cmaj.230164] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Affiliation(s)
- Reza Pishdad
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kendall F Moseley
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
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Lekkala S, Sacher SE, Taylor EA, Williams RM, Moseley KF, Donnelly E. Increased Advanced Glycation Endproducts, Stiffness, and Hardness in Iliac Crest Bone From Postmenopausal Women With Type 2 Diabetes Mellitus on Insulin. J Bone Miner Res 2023; 38:261-277. [PMID: 36478472 PMCID: PMC9898222 DOI: 10.1002/jbmr.4757] [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: 03/17/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
Individuals with type 2 diabetes mellitus (T2DM) have a greater risk of bone fracture compared with those with normal glucose tolerance (NGT). In contrast, individuals with impaired glucose tolerance (IGT) have a lower or similar risk of fracture. Our objective was to understand how progressive glycemic derangement affects advanced glycation endproduct (AGE) content, composition, and mechanical properties of iliac bone from postmenopausal women with NGT (n = 35, age = 65 ± 7 years, HbA1c = 5.8% ± 0.3%), IGT (n = 26, age = 64 ± 5 years, HbA1c = 6.0% ± 0.4%), and T2DM on insulin (n = 25, age = 64 ± 6 years, HbA1c = 9.1% ± 2.2%). AGEs were assessed in all samples using high-performance liquid chromatography to measure pentosidine and in NGT/T2DM samples using multiphoton microscopy to spatially resolve the density of fluorescent AGEs (fAGEs). A subset of samples (n = 14 NGT, n = 14 T2DM) was analyzed with nanoindentation and Raman microscopy. Bone tissue from the T2DM group had greater concentrations of (i) pentosidine versus IGT (cortical +24%, p = 0.087; trabecular +35%, p = 0.007) and versus NGT (cortical +40%, p = 0.003; trabecular +35%, p = 0.004) and (ii) fAGE cross-link density versus NGT (cortical +71%, p < 0.001; trabecular +44%, p < 0.001). Bone pentosidine content in the IGT group was lower than in the T2DM group and did not differ from the NGT group, indicating that the greater AGE content observed in T2DM occurs with progressive diabetes. Individuals with T2DM on metformin had lower cortical bone pentosidine compared with individuals not on metformin (-35%, p = 0.017). Cortical bone from the T2DM group was stiffer (+9%, p = 0.021) and harder (+8%, p = 0.039) versus the NGT group. Bone tissue AGEs, which embrittle bone, increased with worsening glycemic control assessed by HbA1c (Pen: R2 = 0.28, p < 0.001; fAGE density: R2 = 0.30, p < 0.001). These relationships suggest a potential mechanism by which bone fragility may increase despite greater tissue stiffness and hardness in individuals with T2DM; our results suggest that it occurs in the transition from IGT to overt T2DM. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Sashank Lekkala
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY
| | - Sara E. Sacher
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY
| | - Erik A. Taylor
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY
| | | | - Kendall F. Moseley
- Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY
- Research Division, Hospital for Special Surgery, New York, NY
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Dias JP, Piggott DA, Sun J, Wehbeh L, Garza J, Abraham A, Astemborski J, Moseley KF, Basaria S, Varadhan R, Brown TT. SHBG, Bone Mineral Density, and Physical Function Among Injection Drug Users With and Without HIV and HCV. J Clin Endocrinol Metab 2022; 107:e2971-e2981. [PMID: 35293996 PMCID: PMC9202730 DOI: 10.1210/clinem/dgac144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Sex hormone-binding globulin (SHBG) is a glycoprotein that regulates the bioavailability of sex hormones and is higher in people with HIV (PWH) and hepatitis C virus (HCV). SHBG is associated with aging-related diseases, including osteoporosis and frailty in the general population. However, the relationship between SHBG concentration and bone mineral density (BMD) and physical function among PWH and HCV is unclear. OBJECTIVE This study aimed to evaluate the association between chronic infection with HIV and HCV and SHBG, and to assess the relationship of circulating SHBG concentrations with low BMD, physical function impairment, and frailty. METHODS A cross-sectional study was conducted of 278 HCV-exposed (HCV antibody positive) adults enrolled with and without HIV and HCV from the AIDS Linked to the IntraVenous Experience cohort study into 4 groups: HCV-/HIV-, HCV-/HIV+, HCV+/HIV-, and HCV+/HIV+. We evaluated the association between SHBG concentrations and grip strength, gait speed, Short Physical Performance Battery score, frailty (Fried Frailty Phenotype), and BMD (lumbar spine, total hip, and femoral neck T-score) by using adjusted multivariable regression stratified by sex. RESULTS SHBG concentrations were higher in women, in those with HIV RNA greater than 400 copies/mL (P = .02) and HCV RNA greater than 15 IU/mL (P < .001). In adjusted models, higher SHBG concentrations among women were statistically significantly associated with lower grip strength (-0.43 [95% CI, -0.77 to -0.081] kg/10 nmol/L, P < .05), higher odds of frailty (odds ratio, 1.49 [95% CI, 1.07 to 2.08], P < .05), and lower T-scores at the lumbar spine (-0.070 [95% CI, -0.15 to -0.001] SD/10 nmol/L T-score BMD, P < .05). Similar associations were not observed among men. CONCLUSION Higher SHBG concentrations are associated with the presence of HIV and HCV viremia. Among women, but not men, higher SHBG concentrations were associated with lower grip strength, higher odds of frailty, and lower lumbar spine BMD. The underlying mechanisms of these associations require further investigation.
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Affiliation(s)
- Jenny Pena Dias
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Damani A Piggott
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jing Sun
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leen Wehbeh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joshua Garza
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alison Abraham
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health; Department of Epidemiology, School of Public Health and Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kendall F Moseley
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shehzad Basaria
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ravi Varadhan
- Department of Oncology; Biostatistics and Bioinformatics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd T Brown
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Gay CL, Bosch RJ, McKhann A, Moseley KF, Wimbish CL, Hendrickx SM, Messer M, Furlong M, Campbell DM, Jennings C, Benson C, Overton ET, Macatangay BJC, Kuritzkes DR, Miller E, Tressler R, Eron JJ, Hardy WD. Suspected Immune-Related Adverse Events With an Anti-PD-1 Inhibitor in Otherwise Healthy People With HIV. J Acquir Immune Defic Syndr 2021; 87:e234-e236. [PMID: 33929394 PMCID: PMC8263135 DOI: 10.1097/qai.0000000000002716] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Cynthia L. Gay
- Division of Infectious Diseases, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ronald J. Bosch
- Department of Biostatistics, Center for Biostatistics and AIDS Research,Harvard T. H. Chan School of Public Health, Boston, MA
| | - Ashley McKhann
- Department of Biostatistics, Center for Biostatistics and AIDS Research,Harvard T. H. Chan School of Public Health, Boston, MA
| | - Kendall F. Moseley
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chanelle L. Wimbish
- Department of Clinical Research, Social and Scientific Systems, Inc, a DLH Company, Silver Spring, MD
| | | | - Michael Messer
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Maureen Furlong
- Division of Infectious Diseases, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Danielle M. Campbell
- Semel Institute for Neuroscience and Human Behavior, Center for AIDS Research and Education (CARE), University of California, Los Angeles, CA
| | - Cheryl Jennings
- Division of Infectious Diseases, Northwestern University, Chicago, IL
| | - Constance Benson
- Division of Infectious Diseases, University of California, San Diego, CA
| | - Edgar T. Overton
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | | | - Daniel R. Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth Miller
- Clinical Sciences, Global Development, Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | - Randall Tressler
- HIV Research Branch, Division of AIDS, National Institute of AIDS, National Institutes of Health, Rockville, MD
| | - Joseph J. Eron
- Division of Infectious Diseases, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William David Hardy
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
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Moseley KF, Du Z, Sacher SE, Ferguson VL, Donnelly E. Advanced glycation endproducts and bone quality: practical implications for people with type 2 diabetes. Curr Opin Endocrinol Diabetes Obes 2021; 28:360-370. [PMID: 34183538 DOI: 10.1097/med.0000000000000641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Individuals with type 2 diabetes (T2D) are at increased risk of fracture, often despite normal bone density. This observation suggests deficits in bone quality in the setting of abnormal glucose homeostasis. The goal of this article is to review recent developments in our understanding of how advanced glycation end products (AGEs) are incorporated into the skeleton with resultant deleterious effects on bone health and structural integrity in patients with T2D. RECENT FINDINGS The adverse effects of skeletal AGE accumulation on bone remodeling and the ability of the bone to deform and absorb energy prior to fracture have been demonstrated both at the bench as well as in small human studies; however, questions remain as to how these findings might be better explored in large, population-based investigations. SUMMARY Hyperglycemia drives systemic, circulating AGE formation with subsequent accumulation in the bone tissue. In those with T2D, studies suggest that AGEs diminish fracture resistance, though larger clinical studies are needed to better define the direct role of longstanding AGE accumulation on bone strength in humans as well as to motivate potential interventions to reverse or disrupt skeletal AGE deposition with the goal of fracture prevention.
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Affiliation(s)
- Kendall F Moseley
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University, Baltimore, Maryland
| | - Zexu Du
- Department of Materials Science and Engineering, Cornell University, Ithaca
| | - Sara E Sacher
- Department of Materials Science and Engineering, Cornell University, Ithaca
| | - Virginia L Ferguson
- Department of Mechanical Engineering, UCB 427
- Biomedical Engineering Program, UCB 422, University of Colorado, Boulder, Colorado, USA
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca
- Research Division, Hospital for Special Surgery, New York, New York
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Okwuosa TM, Morgans A, Rhee JW, Reding KW, Maliski S, Plana JC, Volgman AS, Moseley KF, Porter CB, Ismail-Khan R. Impact of Hormonal Therapies for Treatment of Hormone-Dependent Cancers (Breast and Prostate) on the Cardiovascular System: Effects and Modifications: A Scientific Statement From the American Heart Association. Circ Genom Precis Med 2021; 14:e000082. [PMID: 33896190 DOI: 10.1161/hcg.0000000000000082] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cardiovascular disease and cancer are the leading causes of death in the United States, and hormone-dependent cancers (breast and prostate cancer) are the most common noncutaneous malignancies in women and men, respectively. The hormonal (endocrine-related) therapies that serve as a backbone for treatment of both cancers improve survival but also increase cardiovascular morbidity and mortality among survivors. This consensus statement describes the risks associated with specific hormonal therapies used to treat breast and prostate cancer and provides an evidence-based approach to prevent and detect adverse cardiovascular outcomes. Areas of uncertainty are highlighted, including the cardiovascular effects of different durations of hormonal therapy, the cardiovascular risks associated with combinations of newer generations of more intensive hormonal treatments, and the specific cardiovascular risks that affect individuals of various races/ethnicities. Finally, there is an emphasis on the use of a multidisciplinary approach to the implementation of lifestyle and pharmacological strategies for management and risk reduction both during and after active treatment.
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Hunt HB, Miller NA, Hemmerling KJ, Koga M, Lopez KA, Taylor EA, Sellmeyer DE, Moseley KF, Donnelly E. Bone Tissue Composition in Postmenopausal Women Varies With Glycemic Control From Normal Glucose Tolerance to Type 2 Diabetes Mellitus. J Bone Miner Res 2021; 36:334-346. [PMID: 32970898 DOI: 10.1002/jbmr.4186] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 03/17/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
The risk of fragility fracture increases for people with type 2 diabetes mellitus (T2DM), even after controlling for bone mineral density, body mass index, visual impairment, and falls. We hypothesize that progressive glycemic derangement alters microscale bone tissue composition. We used Fourier-transform infrared (FTIR) imaging to analyze the composition of iliac crest biopsies from cohorts of postmenopausal women characterized by oral glucose tolerance testing: normal glucose tolerance (NGT; n = 35, age = 65 ± 7 years, HbA1c = 5.8 ± 0.3%), impaired glucose tolerance (IGT; n = 26, age = 64 ± 5 years, HbA1c = 6.0 ± 0.4%), and overt T2DM on insulin (n = 25, age = 64 ± 6 years, HbA1c = 9.13 ± 0.6). The distributions of cortical bone mineral content had greater mean values (+7%) and were narrower (-10%) in T2DM versus NGT groups (p < 0.05). The distributions of acid phosphate, an indicator of new mineral, were narrower in cortical T2DM versus NGT and IGT groups (-14% and -14%, respectively) and in trabecular NGT and IGT versus T2DM groups (-11% and -10%, respectively) (all p < 0.05). The distributions of crystallinity were wider in cortical NGT versus T2DM groups (+16%) and in trabecular NGT versus T2DM groups (+14%) (all p < 0.05). Additionally, bone turnover was lower in T2DM versus NGT groups (P1NP: -25%, CTx: -30%, ucOC: -24%). Serum pentosidine was similar across groups. The FTIR compositional and biochemical marker values of the IGT group typically fell between the NGT and T2DM group values, although the differences were not always statistically significant. In summary, worsening glycemic control was associated with greater mineral content and narrower distributions of acid phosphate, an indicator of new mineral, which together are consistent with observations of lower turnover; however, wider distributions of mineral crystallinity were also observed. A more mineralized, less heterogeneous tissue may affect tissue-level mechanical properties and in turn degrade macroscale skeletal integrity. In conclusion, these data are the first evidence of progressive alteration of bone tissue composition with worsening glycemic control in humans. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Heather B Hunt
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Nicholas A Miller
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Kimberly J Hemmerling
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Maho Koga
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Kelsie A Lopez
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA
| | - Erik A Taylor
- Sibley School of Mechanical Engineering, Cornell University, Ithaca, NY, USA
| | - Deborah E Sellmeyer
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kendall F Moseley
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eve Donnelly
- Department of Materials Science and Engineering, Cornell University, Ithaca, NY, USA.,Research Division, Hospital for Special Surgery, New York, NY, USA
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12
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Ehresman J, Schilling A, Yang X, Pennington Z, Ahmed AK, Cottrill E, Lubelski D, Khan M, Moseley KF, Sciubba DM. Vertebral bone quality score predicts fragility fractures independently of bone mineral density. Spine J 2021; 21:20-27. [PMID: 32474223 DOI: 10.1016/j.spinee.2020.05.540] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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: 02/03/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Current evidence suggests that dual-energy x-ray absorptiometry (DXA) scans, the conventional method defining osteoporosis, is underutilized and, when used, may underestimate patient risk for skeletal fragility. It has recently been suggested that other imaging modalities may better estimate bone quality, such as the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score which also may assess vertebral compression fracture risk in patients with spine metastases. PURPOSE To evaluate whether VBQ score is predictive of fragility fractures in a population with pre-existing low bone density and at high-risk for fracture. STUDY DESIGN/SETTING Retrospective single-center cohort. PATIENT SAMPLE Patients followed at a metabolic bone clinic for osteopenia and/or osteoporosis. OUTCOME MEASURES Radiographically-documented new-onset fragility fracture. METHODS Patients with a DXA and MRI scans at the time of consultation and ≥2-year follow-up were included. Details were gathered about patient demographics, health history, current medication use, and serological studies of kidney function and bone turnover. For each patient, VBQ score was calculated using T1-weighted lumbar MRI images. Univariable and multivariable analyses were used to identify the independent predictors of a new fragility fracture. To support the construct validity of VBQ, patient VBQ scores were compared to those in a cohort of 45 healthy adults. RESULTS Seventy-two (39.1%) study participants suffered fragility fractures, the occurrence of which was associated with higher VBQ score (3.50 vs. 3.01; p<.001), chronic glucocorticoid use (30.6% vs. 15.2%; p=.014), and a history of prior fragility fracture (36.1% vs. 21.4%; p=.030). Mean VBQ score across all patients in the study cohort was significantly higher than the mean VBQ score in the healthy controls (p<.001). In multivariable analysis, new-onset fracture was independently associated with history of prior fracture (OR=6.94; 95% confidence interval [2.48-19.40]; p<.001), higher VBQ score (OR=2.40 per point; [1.30-4.44]; p=.003), higher body mass index (OR=1.09 per kg/m²; [1.01-1.17]; p=.03), and chronic glucocorticoid use (OR=2.89; [1.03-8.17]; p=0.043). Notably, DXA bone mineral density (BMD) was not found to be significantly predictive of new-onset fractures in the multivariable analysis (p=.081). CONCLUSIONS Here we demonstrate the novel, MRI-derived VBQ score is both an independent predictor of fragility fracture in at-risk patients and a superior predictor of fracture risk than DXA-measured BMD. Given the frequency with which MRIs are obtained by patients undergoing spine surgery consultation, we believe the VBQ score could be a valuable tool for estimating bone quality in order to optimize the management of these patients.
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Affiliation(s)
- Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Andrew Schilling
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Xinghai Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA; Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ali Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA
| | - Majid Khan
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kendall F Moseley
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 5-185A, Baltimore, MD 21287, USA.
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13
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Abstract
PURPOSE OF REVIEW Type 2 diabetes mellitus (T2DM) has been shown to negatively impact bone quality and increase fracture risk. While the pathophysiology of bone fragility in T2DM is not clear and likely multifactorial, medications used to treat T2DM are increasingly scrutinized for their potential role in aberrant bone metabolism. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are gaining popularity in patients with T2DM. In addition to lowering blood glucose, there is evidence that these drugs offer cardiac and renal benefit to individuals with T2DM, leading to FDA-approved indications for use in at-risk individuals. At the same time, there remain concerns that SGLT2 inhibitors, specifically canagliflozin, have adverse effects on bone metabolism and increase fracture risk in T2DM. This review seeks to further clarify the impact of these agents on the skeleton. RECENT FINDINGS SGLT2 inhibitors may indirectly disrupt calcium and phosphate homeostasis, contribute to weight loss, and cause hypotension, resulting in bone mineral density (BMD) losses and increased falls. The true long-term impact of SGLT2 inhibitors on the diabetic skeleton is still unclear; this review summarizes the results in studies investigating the impact of SGLT2 inhibitors on fracture risk in T2DM. Whereas studies performed with dapagliflozin and empagliflozin have not shown an increased risk of bone fractures compared with placebo, some studies have shown increased markers of bone turnover and reduced bone mineral density with canagliflozin treatment. While an increased fracture risk was observed with canagliflozin in the CANVAS trial (HR 1.26; 95% CI 1.04, 1.52), an increased risk was not seen in the CANVAS-R (HR 0.86) or CREDENCE (HR 0.98) trials. There is substantial evidence of the cardiac and renal protective benefits of SGLT2 inhibitors. There does not appear to be an increased fracture risk with the use of dapagliflozin or empagliflozin. Given the possible association between canagliflozin and adverse bone outcomes described in CANVAS, canagliflozin use should be pursued in individuals with T2DM only after careful consideration of the individual's skeletal risk.
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Affiliation(s)
- Kristen Jackson
- School of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University, 5501 Hopkins Bayview Circle, 2A62, Baltimore, MD, 21224, USA
| | - Kendall F Moseley
- School of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University, 5501 Hopkins Bayview Circle, 2A62, Baltimore, MD, 21224, USA.
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14
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Naidoo J, Zhang J, Lipson EJ, Forde PM, Suresh K, Moseley KF, Mehta S, Kwatra SG, Parian AM, Kim AK, Probasco JC, Rouf R, Thorne JE, Shanbhag S, Riemer J, Shah AA, Pardoll DM, Bingham CO, Brahmer JR, Cappelli LC. A Multidisciplinary Toxicity Team for Cancer Immunotherapy-Related Adverse Events. J Natl Compr Canc Netw 2020; 17:712-720. [PMID: 31200355 DOI: 10.6004/jnccn.2018.7268] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/04/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) may cause immune-related adverse events (irAEs). Methods to obtain real-time multidisciplinary input for irAEs that require subspecialist care are unknown. This study aimed to determine whether a virtual multidisciplinary immune-related toxicity (IR-tox) team of oncology and medicine subspecialists would be feasible to implement, be used by oncology providers, and identify patients for whom multidisciplinary input is sought. PATIENTS AND METHODS Patients treated with ICIs and referred to the IR-tox team in August 2017 through March 2018 were identified. Feasibility was defined as receipt of electronic referrals and provision of recommendations within 24 hours of referral. Use was defined as the proportion of referring providers who used the team's recommendations, which was determined through a postpilot survey. Demographics and tumor, treatment, and referral data were collected. Patient features and irAE associations were analyzed. RESULTS The IR-tox team was found to be feasible and used: 117 referrals from 102 patients were received in 8 months, all providers received recommendations within 24 hours, 100% of surveyed providers used the recommendations, and 74% changed patient management based on IR-tox team recommendations. Referrals were for suspected irAEs (n=106; 91%) and suitability to treat with ICIs (n=11; 10%). In referred patients, median age was 64 years, 54% were men, 13% had prior autoimmunity, and 46% received ICI combinations versus monotherapy (54%). The most commonly referred toxicities were pneumonitis (23%), arthritis (16%), and dermatitis (15%); 15% of patients had multisystem toxicities. Multiple referrals were more common in those treated with combination ICIs (odds ratio [OR], 6.0; P=.035) or with multisystem toxicities (OR, 8.1; P=.005). The IR-tox team provided a new multidisciplinary forum to assist providers in diagnosing and managing complex irAEs. This model identifies educational and service needs, and patients with irAEs for whom multidisciplinary care is most sought. CONCLUSIONS A virtual multidisciplinary toxicity team for irAEs was a feasible and used service, and facilitated toxicity identification and management.
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Affiliation(s)
- Jarushka Naidoo
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Jiajia Zhang
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Evan J Lipson
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Patrick M Forde
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Karthik Suresh
- Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Kendall F Moseley
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism
| | - Seema Mehta
- Department of Medicine, Division of Infectious Diseases
| | | | | | - Amy K Kim
- Department of Medicine, Division of Gastroenterology
| | | | | | - Jennifer E Thorne
- Department of Medicine, Division of Ophthalmology.,Department of Epidemiology, and
| | - Satish Shanbhag
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Joanne Riemer
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Ami A Shah
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Drew M Pardoll
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Clifton O Bingham
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julie R Brahmer
- Bloomberg-Kimmel Institute for Cancer Immunotherapy, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Laura C Cappelli
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Abstract
Abstract
Introduction: The diagnosis and management of hypercalcemia in hospitalized patients can be challenging. Hypercalcemia is often associated with significant morbidity and end-organ damage which may delay a patient’s recovery. Case report: A 63-years-old female presented for evaluation of left hip pain and was found to have an infection of the prosthetic joint. Past medical history was significant for type 2 diabetes and atrial fibrillation. No known history of malignancy or excess calcium, vitamins A or D intake. Past surgical history was significant for multiple left hip fixation surgeries and a left hip arthroplasty 4 months prior. Patient’s serum calcium on admission was 8.4 mg/dL (corrected 9.5 mg/dL, range 9.5-10.5 mg/dL), serum creatinine 1.2 mg/dL (range, 0.5 - 1.2 mg/dL). Three days later, she underwent surgical irrigation and debridement of the left hip with placement of 30 cc STIMULAN® antibiotic beads with vancomycin. On postoperative day (POD) 5, patient was found to be confused. Laboratory workup revealed serum calcium 13 mg/dL, ionized calcium 1.91 mmol/L (range, 1.12-1.32 mmol/L), serum creatinine 1.6 mg/dL, intact PTH 10 (range, 15- 65 pg/mL), PTH-rp 15 pg/mL (range, 14-27 pg/mL), 25-OH-vitamin D 18 ng/mL (range, 30-60 ng/mL), 1,25-OH2-vitamin D <8 ng/mL (range, 18-72 ng/mL). Clinical challenge: The differential diagnosis of non-PTH mediated hypercalcemia includes malignancy, granulomatosis and/or excess calcium intake. The patient’s history and laboratory data were not consistent with these etiologies. The temporal nature of the hypercalcemia in relation to implantation of antibiotic beads suggest causality of exogenous calcium sulfate and development of the patient’s hypercalcemia. Mild renal insufficiency, as well as immobilization in the setting of surgery, were likely also contributory. Treatment and outcome: This patient was first treated with aggressive intravenous saline and calcitonin. Serum calcium rose to 13.7 mg/dL and pamidronate 30 mg was administered. Hypercalcemia resolved on POD 11 with improvement in patient functional status. Discussion: Hypercalcemia due to implanted calcium sulfate antibiotic beads is not well described outside of case reports. Kallala found hypercalcemia in less than 0.01% of patients who underwent bead implantation, with all the affected patients presenting with preoperative renal failure. Conclusion: Hypercalcemia in the setting of calcium sulfate antibiotic beads implantation may contribute to a patient’s confusion and increase length-of-stay. We recommend serum calcium and creatinine to be closely monitored during the perioperative period in patients who receive calcium sulfate antibiotic beads. Risk factors for the development of hypercalcemia require additional study, though patients with pre-existing renal insufficiency may not be good candidates for the mechanism of antibiotic administration.
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Affiliation(s)
- Mahsa Motevalli
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Kendall F Moseley
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Smita Jha
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Bethesda, MD, USA
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16
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Abusamaan MS, Marzinke MA, Ashok A, Carroll K, Lane K, Jeun R, Moseley KF, Carson KA, Mathioudakis NN. Hypoglycemic risk exposures in relation to low serum glucose values in ambulatory patients. Medicine (Baltimore) 2020; 99:e18679. [PMID: 31914062 PMCID: PMC6959883 DOI: 10.1097/md.0000000000018679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study aimed to correlate hypoglycemic risk exposures (HREs) with low blood glucose value (BGV) in ambulatory patients to inform selection of a glucose critical action value (CAV).This was a retrospective study of ambulatory patients with at least 1 serum glucose ≤70 mg/dL obtained at 2 laboratories within the Johns Hopkins Health System over 3.8 years. Multivariable logistic regression was used to evaluate association of BGV cut-offs of <60, <54, <50, and <45 mg/dL with HREs. HREs were classified as "high hypoglycemic risk" (HHR), "moderate hypoglycemic risk" (MHR), "low hypoglycemic risk" (LHR), and "no hypoglycemic risk" (NHR).A total of 5404 patient samples of BG ≤70 mg/dL were analyzed, of which 30.3%, 23.2%, 28.5%, 18.0% occurred in NHR, LHR, MHR, and HHR groups, respectively. An inverse relationship was noted between BGV cut-offs and HHR, but no association was observed for LHR or MHR. After adjusting for age, sex, and race, there was an inverse association between BG thresholds and the odds of HHR. For classification of HHR, BGV cut-offs of <60, <54, <50, and <45 mg/dL correctly classified 71.2%, 69.8%, 68.8%, and 67.2% of BG samples, achieved false-positive rates of 13.6%, 4.7%, 1.7%, and 0.5% and positive likelihood ratios of 3.3, 6.0, 11.2, and 23.4, respectively.Nearly 70% of low BGVs occurred in patients with at least 1 HRE, but only ∼20% occurred in HHR patients. Given their high positive likelihood ratios, BGVs <54 or <50 mg/dL are reasonable candidates for CAVs that would allow sufficient clinician response time while minimizing false-positive alerts.
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Affiliation(s)
| | - Mark A. Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine
| | - Aditya Ashok
- Division of Endocrinology, Diabetes, & Metabolism
| | - Karen Carroll
- Department of Pathology, Johns Hopkins University School of Medicine
| | - Kyrstin Lane
- Division of Endocrinology, Diabetes, & Metabolism
| | - Rebecca Jeun
- Division of Endocrinology, Diabetes, & Metabolism
| | | | - Kathryn A. Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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17
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Moseley KF, Naidoo J, Bingham CO, Carducci MA, Forde PM, Gibney GT, Lipson EJ, Shah AA, Sharfman WH, Cappelli LC. Immune-related adverse events with immune checkpoint inhibitors affecting the skeleton: a seminal case series. J Immunother Cancer 2018; 6:104. [PMID: 30305172 PMCID: PMC6180387 DOI: 10.1186/s40425-018-0417-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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: 06/18/2018] [Accepted: 09/21/2018] [Indexed: 02/03/2023] Open
Abstract
Background The use of immune checkpoint inhibitors is increasing in cancer therapy today. It is critical that treatment teams become familiar with the organ systems potentially impacted by immune-related adverse events associated with these drugs. Here, we report adverse skeletal effects of immunotherapy, a phenomenon not previously described. Case presentations In this retrospective case series, clinical, laboratory and imaging data were obtained in patients referred to endocrinology or rheumatology with new fractures (n = 3) or resorptive bone lesions (n = 3) that developed while on agents targeting PD-1, CTLA-4 or both. The average age of patients was 59.3 (SD 8.6), and five were male. Cancer types included melanoma, renal cell carcinoma and non-small cell lung cancer. All fracture patients had vertebral compression, and two of the three had multiple fracture sites involved. Sites of resorptive lesions included the shoulder, hand and clavicle. Biochemically, elevated or high-normal markers of bone resorption were seen in five of the six patients. Erythrocyte sedimentation rate was elevated in three of the four patients where checked. Conclusions This case series represents the first description of potential skeletal adverse effects related to immune checkpoint inhibitors. These findings are important for providers caring for patients who experience musculoskeletal symptoms and may merit additional evaluation.
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Affiliation(s)
- Kendall F Moseley
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jarushka Naidoo
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifton O Bingham
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A Carducci
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patrick M Forde
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geoffrey T Gibney
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington D.C., USA
| | - Evan J Lipson
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ami A Shah
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William H Sharfman
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laura C Cappelli
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Abstract
BACKGROUND Paradoxically, elderly persons with type 2 diabetes mellitus (T2DM) fracture despite having higher bone density than nondiabetics. Systemic factors associated with aging and T2DM may have detrimental, local effects on the skeleton. One such factor could be by altering the microenvironment of the mesenchymal stem cells (MSCs), multipotent progenitors capable of differentiating into adipocytes or osteoblasts. METHODS Sera were obtained from four participant groups (n = 40 total, 10 per group): (1) young women with normal glucose tolerance (NGTY), (2) postmenopausal women with NGT), (3) postmenopausal women with impaired glucose tolerance (IGT), and (4) postmenopausal women with T2DM. Sera were incubated with human MSCs for 14 days. Cell proliferation and apoptosis were measured using EdU and TUNEL labeling assays, respectively. MSC differentiation for each group was determined using osteogenic and adipogenic gene expression markers quantified by qRT-PCR, as well as Alizarin Red and Oil Red O staining. RESULTS Expression of adipogenic genes was greater than twofold higher (P < 0.05) in MSCs cultured with T2DM sera compared to those incubated with NGTY, NGT, or IGT sera. The increase in adipogenic gene expression corresponded with increased Oil Red O staining. Despite the increased adipogenic differentiation of MSCs exposed to T2DM sera, cell proliferation and apoptosis rates as well as osteoblastic activity were not significantly different among the four conditions. CONCLUSIONS Systemic, circulating factors in the serum of older women with T2DM may promote MSC differentiation into adipocytes versus osteoblasts. Increased differentiation of MSCs into adipocytes is one possible mechanism by which T2DM increases fracture risk.
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Affiliation(s)
- Kendall F. Moseley
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Center Tower, Suite 4300, Baltimore, MD 21224
| | - Máire E. Doyle
- Diabetes Section, LCI, NIA/NIH; 251 Bayview Boulevard, BRC, Baltimore, MD 21224
| | - Suzanne M. Jan de Beur
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Center Tower, Suite 4300, Baltimore, MD 21224
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19
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Abraham AG, Shafi T, Tighiouart H, Moseley KF, Post WS, Inker LA, Coresh J, Shlipak MG, Levey AS. Effects of Body Size and Composition on Sex Differences in Measured GFR in a US Community-Based Older Cohort (MESA-Kidney). Am J Kidney Dis 2018; 72:767-770. [PMID: 30041875 DOI: 10.1053/j.ajkd.2018.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/12/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Alison G Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tariq Shafi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Kendall F Moseley
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wendy S Post
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA.
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20
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Brehler M, Cao Q, Moseley KF, Osgood G, Morris C, Demehri S, Yorkston J, Siewerdsen JH, Zbijewski W. Robust Quantitative Assessment of Trabecular Microarchitecture in Extremity Cone-Beam CT Using Optimized Segmentation Algorithms. Proc SPIE Int Soc Opt Eng 2018; 10578. [PMID: 31337926 DOI: 10.1117/12.2293346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Purpose In-vivo evaluation of bone microarchitecture remains challenging because of limited resolution of conventional orthopaedic imaging modalities. We investigate the performance of flat-panel detector extremity Cone-Beam CT (CBCT) in quantitative analysis of trabecular bone. To enable accurate morphometry of fine trabecular bone architecture, advanced CBCT pre-processing and segmentation algorithms are developed. Methods The study involved 35 transilliac bone biopsy samples imaged on extremity CBCT (voxel size 75 μm, imaging dose ~13 mGy) and gold standard μCT (voxel size 7.67 μm). CBCT image segmentation was performed using (i) global Otsu's thresholding, (ii) Bernsen's local thresholding, (iii) Bernsen's local thresholding with additional histogram-based global pre-thresholding, and (iv) the same as (iii) but combined with contrast enhancement using a Laplacian Pyramid. Correlations between extremity CBCT with the different segmentation algorithms and gold standard μCT were investigated for measurements of Bone Volume over Total Volume (BV/TV), Trabecular Thickness (Tb.Th), Trabecular Spacing (Tb.Sp), and Trabecular Number (Tb.N). Results The combination of local thresholding with global pre-thresholding and Laplacian contrast enhancement outperformed other CBCT segmentation methods. Using this optimal segmentation scheme, strong correlation between extremity CBCT and μCT was achieved, with Pearson coefficients of 0.93 for BV/TV, 0.89 for Tb.Th, 0.91 for Tb.Sp, and 0.88 for Tb.N (all results statistically significant). Compared to a simple global CBCT segmentation using Otsu's algorithm, the advanced segmentation method achieved ~20% improvement in the correlation coefficient for Tb.Th and ~50% improvement for Tb.Sp. Conclusions Extremity CBCT combined with advanced image pre-processing and segmentation achieves high correlation with gold standard μCT in measurements of trabecular microstructure. This motivates ongoing development of clinical applications of extremity CBCT in in-vivo evaluation of bone health e.g. in early osteoarthritis and osteoporosis.
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Affiliation(s)
- M Brehler
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
| | - Q Cao
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
| | - K F Moseley
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, Baltimore, MD USA
| | - G Osgood
- Department of Orthopedics, Johns Hopkins University, Baltimore, MD USA
| | - C Morris
- Department of Orthopedics, Johns Hopkins University, Baltimore, MD USA
| | - S Demehri
- Department of Radiology, Johns Hopkins University, Baltimore, MD USA
| | | | - J H Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA.,Department of Radiology, Johns Hopkins University, Baltimore, MD USA
| | - W Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD USA
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Moseley KF, Chia CW, Simonsick EM, Egan JM, Ferrucci L, Sellmeyer DE. Sex-specific differences in progressive glucose intolerance and hip geometry: the Baltimore Longitudinal Study of Aging. Osteoporos Int 2015; 26:1555-62. [PMID: 25619633 PMCID: PMC4753799 DOI: 10.1007/s00198-015-3027-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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: 11/11/2014] [Accepted: 01/04/2015] [Indexed: 01/06/2023]
Abstract
UNLABELLED Fracture risk is increased in type 2 diabetes mellitus (T2DM). The effect of pre-diabetes and T2DM on bone macroarchitecture and strength has not been well investigated. In this study, we show that in women only, both pre-diabetes and T2DM are associated with decreased hip bending strength and mineralization which might lead to skeletal weakness. INTRODUCTION Older men and women with T2DM are at increased risk for fracture despite normal bone mineral density (BMD). The discordance between bone quantity and skeletal fragility has driven investigation into additional determinants of fracture resistance in T2DM. Additionally, the effect of pre-diabetes on bone strength has not been well described. The aim of this study was to determine differences in bone macroarchitecture and strength, measured by hip geometry, in persons with normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and T2DM. METHODS We performed cross-sectional analyses of older (age >55 years) men (n = 472) and women (n = 473) participating in the Baltimore Longitudinal Study of Aging (BLSA) classified as NGT, IGT, or T2DM based on oral glucose tolerance testing. Bone strength measures included the hip geometry parameters of section modulus (Z), cross-sectional area (CSA), and buckling ratio (BR). Sex-stratified analyses were conducted using adjusted stepwise regression models. RESULTS In women, IGT and T2DM were negatively associated with hip geometry parameters including mineralization in cross section (CSA, ß -0.076 and -0.073, respectively; both p < 0.05) and hip bending strength (Z, ß -0.097 and -0.09, respectively; both p < 0.05); conversely, IGT and T2DM were associated with improved compressive strength (BR, ß -0.31 and -0.29, respectively; both p < 0.05). There was no significant association between glycemic status and hip geometry in men. CONCLUSIONS In women only, both IGT and T2DM were inversely associated with bone macroarchitecture and measures of bone mineralization and bending strength. The same association between worsening glycemic status and bone strength was not observed in men. These data suggest a differential effect of sex on hip geometry with evolving glucose intolerance.
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Affiliation(s)
- K F Moseley
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD, USA,
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Moseley KF, Weaver CM, Appel L, Sebastian A, Sellmeyer DE. Potassium citrate supplementation results in sustained improvement in calcium balance in older men and women. J Bone Miner Res 2013; 28:497-504. [PMID: 22991267 PMCID: PMC3578058 DOI: 10.1002/jbmr.1764] [Citation(s) in RCA: 57] [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] [Received: 06/04/2012] [Revised: 08/22/2012] [Accepted: 09/04/2012] [Indexed: 11/09/2022]
Abstract
The dietary acid load created by the typical Western diet may adversely impact the skeleton by disrupting calcium metabolism. Whether neutralizing dietary acid with alkaline potassium salts results in sustained improvements in calcium balance remains controversial. In this randomized, double-blind, placebo-controlled study, 52 men and women (mean age 65.2 ± 6.2 years) were randomly assigned to potassium citrate 60 mmol/d, 90 mmol/d, or placebo daily with measurements of bone turnover markers, net acid excretion, and calcium metabolism, including intestinal fractional calcium absorption and calcium balance, obtained at baseline and at 6 months. At 6 months, net acid excretion was significantly lower in both treatment groups compared to placebo and it was negative, meaning subjects' dietary acid was completely neutralized (-11.3 mmol/d on 60 mmol/d; -29.5 mmol/d on 90 mmol/d, p < 0.001 compared to placebo). At 6 months, 24-hour urine calcium was significantly reduced in persons taking potassium citrate 60 mmol/d (-46 ± 15.9 mg/d) and 90 mmol/d (-59 ± 31.6 mg/d) compared with placebo (p < 0.01). Fractional calcium absorption was not changed by potassium citrate supplementation. Net calcium balance was significantly improved in participants taking potassium citrate 90 mmol/d compared to placebo (142 ± 80 mg/d on 90 mmol/d versus -80 ± 54 mg/d on placebo; p = 0.02). Calcium balance was also improved on potassium citrate 60 mmol/d, but this did not reach statistical significance (p = 0.18). Serum C-telopeptide decreased significantly in both potassium citrate groups compared to placebo (-34.6 ± 39.1 ng/L on 90 mmol/d, p = 0.05; -71.6 ± 40.7 ng/L on 60 mmol/d, p = 0.02) whereas bone-specific alkaline phosphatase did not change. Intact parathyroid hormone was significantly decreased in the 90 mmol/d group (p = 0.01). Readily available, safe, and easily administered in an oral form, potassium citrate has the potential to improve skeletal health. Longer-term trials with definitive outcomes such as bone density and fracture are needed.
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Santa-Maria CA, Cimino-Mathews A, Moseley KF, Wolff AC, Blakeley JO, Connolly RM. Complete radiologic response and long-term survival with use of systemic high-dose methotrexate for breast cancer-associated leptomeningeal disease. Clin Breast Cancer 2012; 12:445-9. [PMID: 23010203 DOI: 10.1016/j.clbc.2012.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 05/12/2012] [Accepted: 07/09/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Cesar A Santa-Maria
- Department of Medical Oncology, The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW To discuss current literature and hypotheses pertaining to the pathophysiology of increased bone fragility and fracture in men and women with type 2 diabetes mellitus. RECENT FINDINGS Despite high bone mineral density, studies have shown that men and women with type 2 diabetes mellitus (T2DM) are at increased risk for fracture. Complications of T2DM including retinopathy and autonomic dysfunction may contribute to bone fracture by increasing fall risk. Nephropathy may lead to renal osteodystrophy. Lean mass and potentially fat mass, may additionally contribute to skeletal health in diabetes. There is increasing acknowledgement that the marrow microenvironment is critical to efficient bone remodeling. Medications including thiazolidinediones and selective serotonin reuptake inhibitors may also impair bone remodeling by acting on mesenchymal stem cell differentiation and osteoblastogenesis. T2DM is associated with significant alterations in systemic inflammation, advanced glycation end-product accumulation and reactive oxygen species generation. These systemic changes may also directly and adversely impact the remodeling cycle and lead to bone fragility in T2DM, though more research is needed. SUMMARY Fracture is a devastating event with dismal health consequences. Identifying the extrinsic and intrinsic biochemical causes of bone fracture in T2DM will speed the discovery of effective strategies for fracture prevention and treatment in this at-risk population.
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Affiliation(s)
- Kendall F Moseley
- Division of Endocrinology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.
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Moseley KF, Dobrosielski DA, Stewart KJ, Sellmeyer DE, Jan De Beur SM. Lean mass predicts hip geometry in men and women with non-insulin-requiring type 2 diabetes mellitus. J Clin Densitom 2011; 14:332-9. [PMID: 21652249 PMCID: PMC3150220 DOI: 10.1016/j.jocd.2011.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [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] [Received: 02/11/2011] [Revised: 04/12/2011] [Accepted: 04/14/2011] [Indexed: 12/25/2022]
Abstract
Persons with type 2 diabetes mellitus (T2DM) are at increased risk for hip fracture despite normal bone mineral density (BMD). The contribution of body composition to hip geometry, a measure of hip strength, has not been studied in T2DM. We hypothesized that lean mass would predict hip geometry. Subjects (n=134) for this cross-sectional analysis were men and women aged 56 ± 6yr with non-insulin-requiring T2DM. Fat and lean mass were measured with dual-energy X-ray absorptiometry (DXA). Abdominal fat was measured with magnetic resonance imaging. Hip geometry parameters including section modulus, cross-sectional area, and buckling ratio were estimated from DXA using validated formulae. Subjects had normal BMD, elevated body mass indices (29-41 kg/m(2)), and controlled T2DM (hemoglobin A1c: 5.1-8.3%). In bivariate analysis, lean mass was positively associated with section modulus and cross-sectional area in both sexes (r=0.36-0.55, p<0.05). In multivariate analyses, lean mass remained a significant predictor of all hip strength estimates in both sexes. In women alone, fat mass predicted parameters of hip strength. These data demonstrate that lean mass is significantly associated with hip strength in subjects with non-insulin-requiring T2DM. Resistance exercises that build lean mass may be an intervention for hip fracture prevention in T2DM, although additional research is needed.
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Affiliation(s)
- Kendall F. Moseley
- Division of Endocrinology & Metabolism, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Kerry J. Stewart
- Division of Cardiology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Deborah E. Sellmeyer
- Division of Endocrinology & Metabolism, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Suzanne M. Jan De Beur
- Division of Endocrinology & Metabolism, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Moseley KF, Dobrosielski DA, Stewart KJ, De Beur SMJ, Sellmeyer DE. Lean mass and fat mass predict bone mineral density in middle-aged individuals with noninsulin-requiring type 2 diabetes mellitus. Clin Endocrinol (Oxf) 2011; 74:565-71. [PMID: 21198741 DOI: 10.1111/j.1365-2265.2010.03965.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Despite high bone mineral density (BMD), persons with type 2 diabetes are at greater risk of fracture. The relationship between body composition and BMD in noninsulin-requiring diabetes is unclear. The aim was to examine how fat and lean mass independently affect the skeleton in this population. RESEARCH DESIGN AND METHODS Subjects for this cross-sectional analysis were men (n = 78) and women (n = 56) aged 40-65 years (56 ± 6 years) with uncomplicated, noninsulin-requiring type 2 diabetes. Total body fat and lean mass, total body, hip and lumbar spine BMD were measured with dual energy X-ray absorptiometry. Magnetic resonance imaging measured total abdominal, visceral and subcutaneous (SQ) fat. RESULTS Subjects had normal all-site BMD and were obese to overweight (body mass index 29-41 kg/m(2)) with controlled diabetes (HbA1c women 6·6 ± 1·2%, men 6·7 ± 1·6%). Lean mass was positively associated with total body, hip, femoral neck and hip BMD in both sexes. Fat mass, abdominal total and SQ fat were associated with total body and hip BMD in women. In multivariate analyses adjusted for sex, lean mass significantly predicted total, hip and femoral neck BMD in men and women. In unadjusted models, lean mass continued to predict BMD at these sites in men; fat mass also predicted total body, femoral and hip BMD in women. CONCLUSIONS In men and women with uncomplicated, noninsulin-requiring diabetes, lean mass significantly predicted BMD at the total body, hip and femoral neck. Further research is needed to determine whether acquisition or maintenance of lean mass in T2DM can prevent hip fracture in this at-risk population.
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Affiliation(s)
- Kendall F Moseley
- Division of Endocrinology and Metabolism, The Johns Hopkins, Baltimore, MD, USA.
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