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M. Boot A, Ariceta G, Beck-Nielsen SS, Brandi ML, Briot K, Collantes CDL, Giannini S, Haffner D, Keen R, Levtchenko E, Mughal MZ, Makitie O, Nilsson O, Schnabel D, Tripto-Shkolnik L, Zillikens MC, Liu J, Tudor A, Emma F. Real-world non-interventional post-authorization safety study of long-term use of burosumab in children and adolescents with X-linked hypophosphatemia: first interim analysis. Ther Adv Chronic Dis 2024; 15:20406223241247643. [PMID: 38764445 PMCID: PMC11102685 DOI: 10.1177/20406223241247643] [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: 06/01/2023] [Accepted: 04/01/2024] [Indexed: 05/21/2024] Open
Abstract
Background X-linked hypophosphatemia (XLH) is a rare, progressive disorder characterized by excess fibroblast growth factor 23 (FGF23), causing renal phosphate-wasting and impaired active vitamin D synthesis. Burosumab is a recombinant human monoclonal antibody that inhibits FGF23, restoring patient serum phosphate levels. Safety data on long-term burosumab treatment are currently limited. Objectives This post-authorization safety study (PASS) aims to monitor long-term safety outcomes in children and adolescents (1-17 years) treated with burosumab for XLH. This first interim analysis reports the initial PASS safety outcomes. Design A 10-year retrospective and prospective cohort study. Methods This PASS utilizes International XLH Registry (NCT03193476) data, which includes standard diagnostic and monitoring practice data at participating European centers. Results At data cut-off (13 May 2021), 647 participants were included in the International XLH Registry; 367 were receiving burosumab, of which 67 provided consent to be included in the PASS. Mean (SD) follow-up time was 2.2 (1.0) years. Mean (SD) age was 7.3 (4.3) years (range 1.0-17.5 years). Mean duration of burosumab exposure was 29.7 (25.0) months. Overall, 25/67 participants (37.3%) experienced ⩾1 adverse event (AE) during follow-up; 83 AEs were reported. There were no deaths, no AEs leading to treatment withdrawal, nor serious AEs related to treatment. The most frequently reported AEs were classified as 'musculoskeletal and connective tissue disorders', with 'pain in extremity' most frequently reported, followed by 'infections and infestations', with 'tooth abscess' the most frequently reported. Conclusion In this first interim analysis of the PASS, covering the initial 2 years of data collection, the safety profile of burosumab is consistent with previously reported safety data. The PASS will provide long-term safety data over its 10-year duration for healthcare providers and participants with XLH that contribute to improvements in the knowledge of burosumab safety. Trial registration European Union electronic Register of Post-Authorisation Studies: EUPAS32190.
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Affiliation(s)
- Annemieke M. Boot
- Department of Pediatric Endocrinology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
| | - Gema Ariceta
- Department of Pediatric Nephrology, University Hospital Vall d’Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Pediatric Department, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Karine Briot
- AP-HP, Department of Rheumatology, Cochin Hospital, Paris, France
| | - Carmen de Lucas Collantes
- Pediatric Nephrology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padova, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - M. Zulf Mughal
- Department of Pediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Outi Makitie
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Center for Molecular Medicine, Department of Women’s and Children’s Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- Department of Pediatrics and School of Medical Sciences, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Liana Tripto-Shkolnik
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel HaShomer, Israel
| | | | | | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
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Elbadry MI, Tawfeek A, Hirano T, El-Mokhtar MA, Kenawey M, Helmy AM, Ogawa S, Mughal MZ, Nannya Y. A rare homozygous variant in TERT gene causing variable bone marrow failure, fragility fractures, rib anomalies and extremely short telomere lengths with high serum IgE. Br J Haematol 2024; 204:1086-1095. [PMID: 37926112 DOI: 10.1111/bjh.19176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
By whole exome sequencing, we identified a homozygous c.2086 C→T (p.R696C) TERT mutation in patients who present with a spectrum of variable bone marrow failure (BMF), raccoon eyes, dystrophic nails, rib anomalies, fragility fractures (FFs), high IgE level, extremely short telomere lengths (TLs), and skewed numbers of cytotoxic T cells with B and NK cytopenia. Haploinsufficiency in the other family members resulted in short TL and osteopenia. These patients also had the lowest bone mineral density Z-score compared to other BMF-patients. Danazol/zoledronic acid improved the outcomes of BMF and FFs. This causative TERT variant has been observed in one family afflicted with dyskeratosis congenita (DC), and thus, we also define a second report and new phenotype related to the variant which should be suspected in severe cases of DC with co-existent BMF, FFs, high IgE level and rib anomalies.
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Affiliation(s)
- Mahmoud I Elbadry
- Division of Haematology, Department of Internal Medicine, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Ahmed Tawfeek
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Tomonori Hirano
- Department of Pathology and Tumor Biology, Kyoto University, Kyoto, Japan
| | - Mohamed A El-Mokhtar
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Asyut, Egypt
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Mohamed Kenawey
- Orthopedic Surgery Department, Faculty of Medicine, Sohag University, Sohag, Egypt
- Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ahmed M Helmy
- Department of Internal Medicine, Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Kyoto University, Kyoto, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, Japan
- Department of Medicine, Centre for Hematology and Regenerative Medicine, Karolinska Institute, Stockholm, Sweden
| | - M Zulf Mughal
- Pediatric Bone Disorders, Al Jalila Children's Speciality Hospital, Dubai, UAE
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Kyoto University, Kyoto, Japan
- Division of Hematopoietic Disease Control, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Boardman-Pretty F, Clift AK, Mahon H, Sawoky N, Mughal MZ. The diagnostic odyssey in children and adolescents with X-linked hypophosphataemia: population-based, case-control study. J Clin Endocrinol Metab 2024:dgae069. [PMID: 38335127 DOI: 10.1210/clinem/dgae069] [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: 09/19/2023] [Revised: 01/09/2024] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
CONTEXT X-linked hypophosphataemia (XLH) is a rare genetic disorder causing renal phosphate wasting, which predicates musculoskeletal manifestations such as rickets. Diagnosis is often delayed. OBJECTIVE To explore the recording of clinical features, and the diagnostic odyssey of children and adolescents with XLH in primary care electronic healthcare records (EHR) in the United Kingdom. METHODS Using the Optimum Patient Care Research Database, individuals aged 20 years or younger after 1st Jan 2000 at date of recorded XLH diagnosis were identified using SNOMED/Read codes, and age-matched to 100 controls. Recording of XLH-related clinical features was summarised, then compared between cases and controls using Chi-squared or Fisher's exact tests. RESULTS 261 XLH cases were identified; 99 met inclusion criteria. Of these, 84/99 had at least 1 XLH-related clinical feature recorded in their primary care EHR. Clinical codes for rickets, genu varum and low phosphate were recorded prior to XLH diagnosis in under 20% of cases (median of 1, 1, and 3 years prior, respectively). Rickets, genu varum, low phosphate, nephrocalcinosis and growth delay were significantly more likely to be recorded in cases. CONCLUSION This characterisation of the EHR phenotypes of children and adolescents with XLH may inform future case-finding approaches to expedite diagnosis in primary care.
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Affiliation(s)
| | | | - Hadley Mahon
- Mendelian, The Trampery, Old Street, London, United Kingdom
| | | | - M Zulf Mughal
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, United Kingdom
- The Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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Huda AU, Mughal MZ. Adding intrathecal midazolam to local anesthetics improves sensory and motor block and reduces pain score without increasing side effects in lower limb surgeries: A meta-analysis and systematic review. Rev Esp Anestesiol Reanim (Engl Ed) 2023:S2341-1929(23)00203-2. [PMID: 38145787 DOI: 10.1016/j.redare.2023.12.006] [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] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/31/2023] [Indexed: 12/27/2023]
Abstract
This meta-analysis was done to investigate the role of intrathecal midazolam in lower limb surgeries regarding prolongation of spinal block, postoperative pain control and associated side effects. The included studies reported onset and duration of sensory and motor block, time to first request analgesia, 24h opioid consumption, postoperative pain control, and associated side effects following use of intrathecal midazolam for lower limb surgeries. This review was performed following the PRISMA guidelines and using the online databases, Medline, Science Direct, Google scholar and Cochrane library. We registered this review with the PROSPERO database (ID-CRD42022346361) in August 2022. A total of 10 randomised controlled trials were included in this meta-analysis. Our results showed patients receiving 1mg intrathecal midazolam showed significantly faster onset of sensory block [P=.001 (CI: -0.98, -0.31)]. Duration of sensory and motor block were also significantly prolonged in intrathecal midazolam group [P<.00001 (CI: 18.08, 39.12), P=.002 (CI: 0.45, 2). Intrathecal midazolam also increased the time to first request analgesia [P=.0003, (CI: 1.22, 4.14)]. Pain scores at 4 and 12h postoperatively were significantly lower in patients receiving intrathecal midazolam [P=.00001 (CI: -1.20, -0.47) and P=.05 (CI: -0.52, -0.01) respectively]. In conclusion, the addition of intrathecal midazolam to local anesthetics in lower limb surgeries results in early onset of sensory and motor block. It also increases the duration of sensory and motor block. The time to first request analgesia is increased. VAS pain scores at 4 and 12h postoperatively were also lower without any increased side effects.
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Affiliation(s)
- A U Huda
- Hamad Medical Corporation, Doha, Qatar.
| | - M Z Mughal
- Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia
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Ariceta G, Beck-Nielsen SS, Boot AM, Brandi ML, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Mughal MZ, Nilsson O, Schnabel D, Tripto-Shkolnik L, Liu J, Williams A, Wood S, Zillikens MC. The International X-Linked Hypophosphatemia (XLH) Registry: first interim analysis of baseline demographic, genetic and clinical data. Orphanet J Rare Dis 2023; 18:304. [PMID: 37752558 PMCID: PMC10523658 DOI: 10.1186/s13023-023-02882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive, renal phosphate-wasting disorder characterized by a pathological increase in FGF23 concentration and activity. Due to its rarity, diagnosis may be delayed, which can adversely affect outcomes. As a chronic disease resulting in progressive accumulation of musculoskeletal manifestations, it is important to understand the natural history of XLH over the patient's lifetime and the impact of drug treatments and other interventions. This multicentre, international patient registry (International XLH Registry) was established to address the paucity of these data. Here we present the findings of the first interim analysis of the registry. RESULTS The International XLH Registry was initiated in August 2017 and includes participants of all ages diagnosed with XLH, regardless of their treatment and management. At the database lock for this first interim analysis (29 March 2021), 579 participants had entered the registry before 30 November 2020 and are included in the analysis (360 children [62.2%], 217 adults [37.5%] and 2 whose ages were not recorded [0.3%]; 64.2% were female). Family history data were available for 319/345 (92.5%) children and 145/187 (77.5%) adults; 62.1% had biological parents affected by XLH. Genetic testing data were available for 341 (94.7%) children and 203 (93.5%) adults; 370/546 (67.8%) had genetic test results; 331/370 (89.5%) had a confirmed PHEX mutation. A notably longer time to diagnosis was observed in adults ≥ 50 years of age (mean [median] duration 9.4 [2.0] years) versus all adults (3.7 [0.1] years) and children (1.0 [0.2] years). Participants presented with normal weight, shorter length or height and elevated body mass index (approximately - 2 and + 2 Z-scores, respectively) versus the general population. Clinical histories were collected for 349 participants (239 children and 110 adults). General data trends for prevalence of bone, dental, renal and joint conditions in all participants were aligned with expectations for a typical population of people with XLH. CONCLUSION The data collected within the International XLH Registry, the largest XLH registry to date, provide substantial information to address the paucity of natural history data, starting with demographic, family history, genetic testing, diagnosis, auxology and baseline data on clinical presentation.
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Affiliation(s)
- Gema Ariceta
- Department of Pediatric Nephrology, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, Barcelona, Spain.
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Aarhus University Hospital, Åarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Åarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatrics, Division of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Karine Briot
- Hôpital Cochin, Service de Rhumatologie, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate Filière OSCAR, AP-HP, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padova, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Ola Nilsson
- Division of Pediatric Endocrinology and Center for Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité, University Medicine Berlin, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Division of Endocrinology, Diabetes and Metabolism, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Sue Wood
- Kyowa Kirin International, Marlow, UK
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Chinoy A, Nicholson J, Skae M, Hannan FM, Thakker RV, Mughal MZ, Padidela R. Neurodevelopmental Abnormalities in Patients with Familial Hypocalciuric Hypercalcemia Type 3. J Pediatr 2023:S0022-3476(23)00126-9. [PMID: 36868303 DOI: 10.1016/j.jpeds.2023.02.013] [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: 09/21/2022] [Revised: 12/26/2022] [Accepted: 02/24/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To evaluate the prevalence and degree of any neurodevelopmental abnormalities in children with familial hypocalciuric hypercalcemia type 3 (FHH3). STUDY DESIGN A formal neurodevelopmental assessment was performed in children diagnosed with FHH3. The Vineland Adaptive Behavior Scales, which is a standardized parent report assessment tool for adaptive behavior, was used to assess communication, social skills, and motor function and to generate a composite score. RESULTS Six patients were diagnosed with hypercalcemia between 0.1 and 8 years of age. All had neurodevelopmental abnormalities in childhood consisting of either global developmental delay, motor delay, expressive speech disturbances, learning difficulties, hyperactivity, or autism spectrum disorder. Four out of the 6 probands had a composite Vineland Adaptive Behavior Scales SDS of < -2.0, indicating adaptive malfunctioning. Significant deficits were observed in the domains of communication (mean SDS: -2.0, P < .01), social skills (mean SDS: -1.3, P < .05), and motor skills (mean SDS: 2.6, P < .05). Individuals were equally affected across domains, with no clear genotype-phenotype correlation. All family members affected with FHH3 also described evidence of neurodevelopmental dysfunction, including mild-to-moderate learning difficulties, dyslexia, and hyperactivity. CONCLUSION Neurodevelopmental abnormalities appear to be a highly penetrant and common feature of FHH3, and early detection is warranted to provide appropriate educational support. This case series also supports consideration of serum calcium measurement as part of the diagnostic work-up in any child presenting with unexplained neurodevelopmental abnormalities.
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Affiliation(s)
- Amish Chinoy
- Paediatric Endocrine Department, Royal Manchester Children's Hospital, Manchester, United Kingdom; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom.
| | - Jacqueline Nicholson
- Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Mars Skae
- Paediatric Endocrine Department, Royal Manchester Children's Hospital, Manchester, United Kingdom; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Fadil M Hannan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - M Zulf Mughal
- Paediatric Endocrine Department, Royal Manchester Children's Hospital, Manchester, United Kingdom; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Raja Padidela
- Paediatric Endocrine Department, Royal Manchester Children's Hospital, Manchester, United Kingdom; Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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Saif SA, Maghoula M, Babiker A, Abanmi M, Nichol F, Al Enazi M, Guevarra E, Sehlie F, Al Shaalan H, Mughal MZ. A Multidisciplinary and a Comprehensive Approach to Reducing Fragility Fractures in Preterm Infants. Curr Pediatr Rev 2022; 19:CPR-EPUB-128363. [PMID: 36545738 DOI: 10.2174/1573396319666221221122013] [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: 05/30/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
With advances in neonatal care, bone fractures prior to discharge from the hospital in preterm infants receiving contemporary neonatal care, are rare. Nevertheless, such fractures do occur in very low birth weight and extremely low birth weight infants who go on to develop metabolic bone disease of prematurity (MBDP), with or without secondary hyperparathyroidism. MBDP is a multifactorial disorder arising from the disruption of bone mass accrual due to premature birth, postnatal immobilisation, and loss of placental oestrogen resulting in bone loss, inadequate provision of bone minerals from enteral and parenteral nutrition, and medications that leach out bone minerals from the skeleton. All of these factors lead to skeletal demineralisation and a decrease in bone strength and an increased risk of fractures of the long bones and ribs. Secondary hyperparathyroidism resulting from phosphate supplements, or enteral/parenteral feeds with a calcium-to-phosphate ratio of < 1.3:1.0 leads to subperiosteal bone resorption, cortical thinning, and further skeletal weakening. Such fractures may occur from routine handling and procedures such as cannulation. Most fractures are asymptomatic and often come to light incidentally on radiographs performed for other indications. In 2015, we instituted a comprehensive and multidisciplinary Neonatal Bone Health Programme (NBHP), the purpose of which was to reduce fragility fractures in high-risk neonates, by optimising enteral and parenteral nutrition, including maintaining calcium-to-phosphate ratio ≥1.3:1, milligram to milligram, biochemical monitoring of MBDP, safe-handling of at-risk neonates, without compromising passive physiotherapy and skin-to-skin contact with parents. The at-risk infants in the programme had radiographs of the torso and limbs at 4 weeks and after 8 weeks from enrolment into the program or before discharge. Following the introduction of the NBHP, the bone fracture incidence reduced from 12.5% to zero over an 18-month period.
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Affiliation(s)
- Saif Al Saif
- Neonatal Department, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammad Maghoula
- Neonatal Department, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Amir Babiker
- King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Division of Pediatric Endocrinology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mashael Abanmi
- Department of Physiotherapy, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Fiona Nichol
- Department of Occupational Therapy, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Modhi Al Enazi
- Neonatal Department, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Elenor Guevarra
- Department of Dieticians, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faisal Sehlie
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hesham Al Shaalan
- Department of Pediatric Radiology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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Suntharesan J, Agarwal U, Lim J, Collingwood C, Avula S, Mughal MZ, Nitschke Y, Botschen U, Rutsch F, Ramakrishnan R. An Unusual Case of Transient Cardiac Calcification Identified on Antenatal Echocardiography: A Generalized Arterial Calcification of Infancy (GACI) Like Presentation. Calcif Tissue Int 2022; 111:646-652. [PMID: 36220940 DOI: 10.1007/s00223-022-01026-3] [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: 04/28/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022]
Abstract
Generalised arterial calcification of infancy (GACI) is an ultra-rare life-threatening genetic disorder. Arterial calcification is identified during foetal ultrasound scan (USS) as increased cardiac and/or vascular echogenicity. Inorganic pyrophosphate (PPi) is the main inhibitor of arterial calcification. Pathogenic variants in ENPP1, ABCC6 and NT5E causing low PPi lead to ectopic calcifications. Rheumatoid arthritis (RA) is an acquired condition that can also lead to arterial calcification in adults. We present an extremely rare case of a transient GACI-like condition identified during foetal echocardiogram of an infant born to a mother diagnosed with RA, which spontaneously resolved postnatally. This case highlights that foetal ultrasound scans of pregnant women with RA should be carefully evaluated for cardiovascular calcifications.
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Affiliation(s)
- Jananie Suntharesan
- Department of Endocrinology, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK
| | - Umber Agarwal
- Deparment of Fetal Medicine, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - Joyce Lim
- Department of Cardiology, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK
| | - Catherine Collingwood
- Department of Biochemistry, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK
| | - Shivaram Avula
- Department of Radiology, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK
| | - M Zulf Mughal
- Department of Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Yvonne Nitschke
- Department of General Paediatrics, Münster University Children's Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Ulrike Botschen
- Department of General Paediatrics, Münster University Children's Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Frank Rutsch
- Department of General Paediatrics, Münster University Children's Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Renuka Ramakrishnan
- Department of Endocrinology, Alder Hey Children's Hospital, Eaton Road, Liverpool, L12 2AP, UK.
- Consultant Paediatric Endocrinologist, Lead for Metabolic Bone Service, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
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Brandi ML, Ariceta G, Beck-Nielsen SS, Boot AM, Briot K, de Lucas Collantes C, Emma F, Giannini S, Haffner D, Keen R, Levtchenko E, Mӓkitie O, Nilsson O, Schnabel D, Tripto-Shkolnik L, Zillikens MC, Liu J, Tudor A, Mughal MZ. Post-authorisation safety study of burosumab use in paediatric, adolescent and adult patients with X-linked hypophosphataemia: rationale and description. Ther Adv Chronic Dis 2022; 13:20406223221117471. [PMID: 36082134 PMCID: PMC9445456 DOI: 10.1177/20406223221117471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background: X-linked hypophosphataemia (XLH) is a rare, inherited, phosphate-wasting disorder that elevates fibroblast growth factor 23 (FGF23), causing renal phosphate-wasting and impaired active vitamin D (1,25(OH)2D) synthesis. Disease characteristics include rickets, osteomalacia, odontomalacia, and short stature. Historically, treatment has been oral phosphate and 1,25(OH)2D supplements. However, these treatments do not correct the primary pathogenic mechanism or treat all symptoms and can be associated with adverse effects. Burosumab is a recombinant human immunoglobulin G1 monoclonal antibody against FGF23, approved for treating XLH in several geographical regions, including Europe and Israel. Burosumab restores normal serum phosphate levels, minimising the clinical consequences of XLH. Safety data on long-term treatment with burosumab are lacking owing to the rarity of XLH. This post-authorisation safety study (PASS) aims to evaluate the safety outcomes in patients aged >1 year. Methods: The PASS is a 10-year retrospective and prospective cohort study utilising data from the International XLH Registry (NCT03193476), which includes standard diagnostic and monitoring practice data at participating centres. The PASS aims to evaluate frequency and severity of safety outcomes, frequency and outcomes of pregnancies in female patients, and safety outcomes in patients with mild to moderate kidney disease at baseline, in children, adolescents and adults treated with burosumab for XLH. It is expected that there will be at least 400 patients who will be administered burosumab. Results: Data collection started on 24 April 2019. The expected date of the final study report is 31 December 2028, with two interim reports. Conclusion: This PASS will provide data on the long-term safety of burosumab treatment for XLH patients and describe safety outcomes for patients receiving burosumab contrasted with those patients receiving other XLH treatments, to help inform the future management of XLH patients. The PASS will be the largest real-world safety study of burosumab. Registry identification: The International XLH Registry is registered with clinicaltrials.gov as NCT03193476 (https://clinicaltrials.gov/ct2/show/NCT03193476), and the PASS is registered with the European Union electronic Register of Post-Authorisation Studies as EUPAS32190 (http://www.encepp.eu/encepp/viewResource.htm?id=32191).
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Affiliation(s)
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Signe Sparre Beck-Nielsen
- Centre for Rare Diseases, Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annemieke M Boot
- Department of Pediatric Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karine Briot
- APHP, Department of Rheumatology, Cochin Hospital, Université de Paris, Paris, France
| | - Carmen de Lucas Collantes
- Department of Nephrology, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sandro Giannini
- Department of Medicine, Clinica Medica 1, University of Padua, Padua, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Richard Keen
- Metabolic Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Elena Levtchenko
- Department of Pediatric Nephrology and Development and Regeneration, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Outi Mӓkitie
- Pediatric Endocrinology, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Department of Medical Sciences and Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
| | - Dirk Schnabel
- Center for Chronic Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Liana Tripto-Shkolnik
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC Bone Center - Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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10
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Wade L, Aindow A, Isherwood L, Mughal MZ, Ramakrishnan R. Successful use of cinacalcet monotherapy in the management of siblings with homozygous calcium-sensing receptor mutation. J Pediatr Endocrinol Metab 2022; 35:549-556. [PMID: 35073615 DOI: 10.1515/jpem-2021-0632] [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: 10/11/2021] [Accepted: 12/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Neonatal severe hyperparathyroidism (NSHPT) due to pathogenic mutations in the calcium-sensing receptor (CASR) is a serious medical condition that can lead to symptomatic hypercalcaemia and has detrimental effects on a child's growth and development. What is new: This report adds to evidence that homozygous CASR mutations can be managed with cinacalcet monotherapy as an alternative to parathyroidectomy. And, early use of cinacalcet in NSHPT can result in improvements in symptoms, growth and developmental milestones. CASE PRESENTATION We present two siblings with NSHPT due to homozygous mutation in the CASR gene with moderate hypercalcaemia. Both were treated with cinacalcet monotherapy and showed significant improvement in growth parameters including head circumference, developmental milestones and hypercalcaemic symptoms, once their calcium and parathyroid hormone levels normalised. CONCLUSIONS This report highlights the role of cinacalcet in managing elevated serum calcium levels in a select group of infants with NSHPT due to homozygous CASR mutations, resulting in improvement in hypercalcaemic symptoms, growth and neurodevelopmental outcomes.
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Affiliation(s)
- Laura Wade
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anita Aindow
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - M Zulf Mughal
- Manchester Foundation NHS Trust, Manchester, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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11
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Chinoy A, Iruloh C, Kerr B, Mughal MZ, Padidela R. Normal Mid-Gestation Fetal Ultrasonography Cannot Reliably Exclude Severe Perinatal Hypophosphatasia. Horm Res Paediatr 2022; 94:307-312. [PMID: 34438404 DOI: 10.1159/000519209] [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: 05/08/2021] [Accepted: 07/22/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hypophosphatasia is a systemic bone disease characterized by inhibition of bone mineralization due to mutations in the ALPL gene that results in a deficiency of tissue nonspecific alkaline phosphatase. The perinatal form is the most severe. In the past, this form was lethal, although human recombinant enzyme replacement therapy has now been developed and licensed, which improves survival. Perinatal hypophosphatasia is usually suggested on antenatal ultrasonography with undermineralization of the long bones, skull, and thoracic cavity. In the UK, antenatal ultrasonography for fetal anomalies is conducted at mid-gestation (i.e., 18-21 weeks gestational age), and if normal, no further routine scans are performed. Usually, this would identify abnormalities in bone mineralization suggestive of perinatal hypophosphatasia. CASES We describe 2 cases of perinatal hypophosphatasia where mid-gestation ultrasonography was normal. In the first case, where a previous pregnancy had been terminated for perinatal hypophosphatasia, third trimester ultrasonography revealed skeletal features of hypophosphatasia. In the second case, the diagnosis of perinatal hypophosphatasia was made only immediately after birth. CONCLUSION We conclude that serial antenatal ultrasonography or antenatal genetic testing should be considered in all pregnancies with a positive family history of hypophosphatasia, as mid-gestation ultrasonography cannot reliably exclude perinatal hypophosphatasia. This is especially important given that effective enzyme replacement therapy is now available.
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Affiliation(s)
- Amish Chinoy
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Chibuike Iruloh
- Fetal Medicine Unit, St. Mary's Hospital, Manchester, United Kingdom
| | - Bronwyn Kerr
- Division of Evolution and Genomic Sciences, School of Biological Sciences, University of Manchester, Manchester, United Kingdom
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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12
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Mughal MZ, Baroncelli GI, de Lucas-Collantes C, Linglart A, Magnolato A, Raimann A, Santos F, Schnabel D, Shaw N, Nilsson O. Burosumab for X-linked hypophosphatemia in children and adolescents: Opinion based on early experience in seven European countries. Front Endocrinol (Lausanne) 2022; 13:1034580. [PMID: 36798486 PMCID: PMC9928183 DOI: 10.3389/fendo.2022.1034580] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/11/2022] [Indexed: 02/03/2023] Open
Abstract
Given the relatively recent introduction of burosumab in the management of X-linked hypophosphatemia (XLH), there is limited real-world data to guide its use in clinical practice. As a group of European physicians experienced with burosumab treatment in clinical practice, we convened with the objective of sharing these practice-based insights on the use of burosumab in children and adolescents with XLH. We attended two virtual meetings, then discussed key questions via Within3, a virtual online platform. Points of discussion related to patient selection criteria, burosumab starting dose, dose titration and treatment monitoring. Our discussions revealed that criteria for selecting children with XLH varied across Europe from all children above 1 year to only children with overt rickets despite conventional treatment being eligible. We initiated burosumab dosing according to guidance in the Summary of Product Characteristics, an international consensus statement from 2019 and local country guidelines. Dose titration was primarily guided by serum phosphate levels, with some centers also using the ratio of tubular maximum reabsorption of phosphate to glomerular filtration rate (TmP/GFR). We monitored response to burosumab treatment clinically (growth, deformities, bone pain and physical functioning), radiologically (rickets and deformities) and biochemically (serum phosphate, alkaline phosphatase, 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, urine calcium-creatinine ratio and TmP/GFR). Key suggestions made by our group were initiation of burosumab treatment in children as early as possible, from the age of 1 year, particularly in those with profound rickets, and a need for clinical studies on continuation of burosumab throughout adolescence and into adulthood.
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Affiliation(s)
- M. Zulf Mughal
- Department of Paediatric Endocrinology and Metabolic Bone Diseases, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- The Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
- *Correspondence: M. Zulf Mughal,
| | - Giampiero I. Baroncelli
- Division of Pediatrics, Endocrine Unit, ERN-BOND Representative, Department of Obstetrics, Gynecology and Pediatrics, University-Hospital, Pisa, Italy
| | - Carmen de Lucas-Collantes
- Servicio Nefrología, Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, Madrid, Spain
| | - Agnès Linglart
- AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, Bicêtre Paris Saclay Hospital, Paris, France
- Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Paris Saclay University, Paris, France
| | - Andrea Magnolato
- Department of Pediatrics, Institute for Maternal and Child Health – IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Adalbert Raimann
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Vienna Bone and Growth Center, Vienna, Austria
| | - Fernando Santos
- Hospital Universitario Central de Asturias (HUCA), University of Oviedo, Oviedo, Spain
| | - Dirk Schnabel
- Center for Chronic Sick Children, Pediatric Endocrinology, Charitè, University Medicine, Berlin, Germany
| | - Nick Shaw
- Department of Endocrinology and Diabetes, Birmingham Women’s and Children’s NHS Foundation Trust, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Ola Nilsson
- Division of Pediatric Endocrinology, Department of Women’s and Children’s Health , Karolinska Institutet and University Hospital, Stockholm, Sweden
- School of Medical Sciences, Department of Pediatrics, Örebro University and University Hospital, Örebro, Sweden
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13
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Ireland A, Riddell A, Prentice A, Eelloo J, Mughal MZ, Ward KA. Development of tibia & fibula bone deficits in children with neurofibromatosis type I - A longitudinal case-control comparison. Bone 2022; 154:116183. [PMID: 34600162 DOI: 10.1016/j.bone.2021.116183] [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: 06/08/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 11/25/2022]
Abstract
Neurofibromatosis type 1 (NF1) is associated with lower bone mass and increased risk of fracture. Children with NF1 display faltering growth from mid-childhood. However, to date tibia bone development in children with NF1 across childhood and the role of body size have not been explored. Therefore, we recruited 24 children with NF1 (12 girls, mean age 8.2 ± 1.1y) and 104 children without NF1 (52 girls, mean age 11 ± 1.7y). Tibia and fibula bone characteristics were assessed at 4% and 38% distal-proximal tibia length in all children at baseline using peripheral quantitative computed tomography (pQCT). Longitudinal scans were obtained in 21 children with NF1 (12 girls) over 3.4 ± 0.3y and 71 children without NF1 (34 girls) over 1.1 ± 0.1y, such that at follow-up mean age of both groups (NF1 10.9 ± 1.3y, controls 11.4 ± 1.4y) were similar. Effects of group (NF1/control) on bone outcomes as well as group-by-age interactions, indicating differences in rate of change in bone outcome bone outcomes were assessed via linear mixed effects models with adjustment for sex, age, pubertal status and in additional models with adjustment for height and weight Z-scores. Group (NF1/control)-by-age interactions indicated a slower rate of tibia and fibula bone mass accrual in children with NF1 at all measured sites. These associations were attenuated by 25-50% by adjustment for height and weight Z-scores. At the 4% site, deficits in bone mass at older ages were related to slower trabecular BMD accrual. At the 38% site, group-by-age interactions suggested that bone mass deficits resulted from poorer accrual of cortical CSA and to a lesser extent cortical BMD. Lower limb bone mass deficits evident in children with NF1 appear to be progressive and emerge in mid-childhood. In part, they are related to development of a similar pattern of deficits in longitudinal growth and body weight in NF1. Interventions promoting muscle development or physical activity may be partially effective in attenuating bone mass accrual deficits in this population.
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Affiliation(s)
- Alex Ireland
- Musculoskeletal Science and Sports Medicine Research Centre, Department of Life Sciences, Manchester Metropolitan University, Manchester, UK.
| | - Amy Riddell
- Institute for Infection and Immunity, Paediatric Infectious Diseases Research Group, St. George's University of London, UK; previously at MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - Ann Prentice
- previously at MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK; MRC Nutrition and Bone Health Group, Cambridge, UK
| | - Judith Eelloo
- Nationally Commissioned Complex NF1 Service, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - M Zulf Mughal
- Nationally Commissioned Complex NF1 Service, Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK; School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Kate A Ward
- MRC Lifecourse Epidemiology Unit, Human Development and Health, University of Southampton, Southampton, UK
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14
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Chinoy A, Vassallo GR, Wright EB, Eelloo J, West S, Hupton E, Galloway P, Pilkington A, Padidela R, Mughal MZ. The skeletal muscle phenotype of children with Neurofibromatosis Type 1 - A clinical perspective. J Musculoskelet Neuronal Interact 2022; 22:70-78. [PMID: 35234161 PMCID: PMC8919663] [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] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neurofibromatosis type 1 (NF1) can affect multiple systems in the body. An under recognised phenotype is one of muscle weakness. Clinical studies using dynamometry and jumping mechanography have demonstrated that children with NF1 are more likely to have reduced muscle force and power. Many children with NF1 are unable to undertake physical activities to the same level as their peers, and report leg pains on physical activity and aching hands on writing. Children and adolescents with NF1 reporting symptoms of muscle weakness should have a focused assessment to exclude alternative causes of muscle weakness. Assessments of muscle strength and fine motor skills by physiotherapists and occupational therapists can provide objective evidence of muscle function and deficits, allowing supporting systems in education and at home to be implemented. In the absence of an evidence base for management of NF1-related muscle weakness, we recommend muscle-strengthening exercises and generic strategies for pain and fatigue management. Currently, trials are underway involving whole-body vibration therapy and carnitine supplementation as potential future management options.
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Affiliation(s)
- Amish Chinoy
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK,Corresponding author: Amish Chinoy, Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL, UK E-mail:
| | - Grace R. Vassallo
- NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK,Department of Paediatric Neurology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Emma Burkitt Wright
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK, NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Judith Eelloo
- NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Siobhan West
- NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK,Department of Paediatric Neurology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Eileen Hupton
- NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paula Galloway
- Therapy and Dietetic Department, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Amy Pilkington
- Therapy and Dietetic Department, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - M. Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK,Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK, NHSE Highly Specialised Service for Complex NF1, Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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15
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Ferreira CR, Kintzinger K, Hackbarth ME, Botschen U, Nitschke Y, Mughal MZ, Baujat G, Schnabel D, Yuen E, Gahl WA, Gafni RI, Liu Q, Huertas P, Khursigara G, Rutsch F. Ectopic Calcification and Hypophosphatemic Rickets: Natural History of ENPP1 and ABCC6 Deficiencies. J Bone Miner Res 2021; 36:2193-2202. [PMID: 34355424 PMCID: PMC8595532 DOI: 10.1002/jbmr.4418] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 02/06/2023]
Abstract
Generalized arterial calcification of infancy (GACI) is a rare disorder caused by ENPP1 or ABCC6 variants. GACI is characterized by low pyrophosphate, arterial calcification, and high mortality during the first year of life, but the natural course and possible differences between the causative genes remain unknown. In all, 247 individual records for patients with GACI (from birth to 58.3 years of age) across 19 countries were reviewed. Overall mortality was 54.7% (13.4% in utero or stillborn), with a 50.4% probability of death before the age of 6 months (critical period). Contrary to previous publications, we found that bisphosphonate treatment had no survival benefit based on a start-time matched analysis and inconclusive results when initiated within 2 weeks of birth. Despite a similar prevalence of GACI phenotypes between ENPP1 and ABCC6 deficiencies, including arterial calcification (77.2% and 89.5%, respectively), organ calcification (65.8% and 84.2%, respectively), and cardiovascular complications (58.4% and 78.9%, respectively), mortality was higher for ENPP1 versus ABCC6 variants (40.5% versus 10.5%, respectively; p = 0.0157). Higher prevalence of rickets was reported in 70.8% of surviving affected individuals with ENPP1 compared with that of ABCC6 (11.8%; p = 0.0001). Eleven affected individuals presenting with rickets and without a GACI diagnosis, termed autosomal recessive hypophosphatemic rickets type 2 (ARHR2), all had confirmed ENPP1 variants. Approximately 70% of these patients demonstrated evidence of ectopic calcification or complications similar to those seen in individuals with GACI, which shows that ARHR2 is not a distinct condition from GACI but represents part of the spectrum of ENPP1 deficiency. Overall, this study identified an early mortality risk in GACI patients despite attempts to treat with bisphosphonates, high prevalence of rickets almost exclusive to ENPP1 deficiency, and a spectrum of heterogenous calcification and multiple organ complications with both ENPP1 and ABCC6 variants, which suggests an overlapping pathology. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristina Kintzinger
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - Mary E Hackbarth
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ulrike Botschen
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - Yvonne Nitschke
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Genevieve Baujat
- Centre de Référence Maladies Osseuses Constitutionnelles (CR MOC) et Filière OSCAR, Département de Génétique, Hôpital Necker-Enfants Malades, Paris, France
| | - Dirk Schnabel
- Center for Chronically Sick Children, Pediatric Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Eric Yuen
- Inozyme Pharma, Inc., Boston, MA, USA
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rachel I Gafni
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Qing Liu
- Quantitative & Regulatory Medical Science, LLC, Long Valley, NJ, USA
| | | | | | - Frank Rutsch
- Department of General Pediatrics, Münster University Children's Hospital, Münster, Germany
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16
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Khadora M, Mughal MZ. Burosumab treatment in a child with cutaneous skeletal hypophosphatemia syndrome: A case report. Bone Rep 2021; 15:101138. [PMID: 34660853 PMCID: PMC8502709 DOI: 10.1016/j.bonr.2021.101138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/27/2022] Open
Abstract
Cutaneous skeletal hypophosphatemia syndrome (CSHS) is a rare disorder caused by somatic mosaicism for the gain of function RAS mutations . Affected patients have segmental epidermal nevi, dysplastic cortical bony lesions, and fibroblast growth factor-23 (FGF23)–mediated hypophosphatemic rickets. Herein, we describe a case of an Emirati girl with CSHS, whose hypophosphatemic rickets and osteomalcic pseudofractures and dysplastic bony lesions failed to recover due to poor adherence to treatment with oral phosphate supplements and alfacalcidol (conventional treatment). Treatment with burosumab, a fully human immunoglobulin G1 monoclonal antibody against FGF23 for 12 months, led to normalization of serum inorganic phosphate and alkaline phosphatase levels, radiographic healing of rickets, partial healing of pseudofractures, improvement in 6-minute walk test, and the physical scale of the Pediatric Quality of Life Inventory. We conclude that burosumab is effective in treatment of CSHS, however results of the ongoing phase 2 trial in adults (NCT02304367) are awaited. Cutaneous skeletal hypophosphatemia syndrome (CSHS) is caused by somatic gain-of-function RAS mutations. It is associated with fibroblast growth factor-23 (FGF23) mediated hypophosphatemic rickets. Burosumab, a monoclonal antibody to FGF23 may have a role in the treatment of CSHS.
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Affiliation(s)
- Manal Khadora
- Department of Pediatric Endocrinology, Latifa Hospital, Oud Metha Road, Al Jaddaf, Dubai, United Arab Emirates
| | - M Zulf Mughal
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK.,Faculty of Biology, Medicine & Health, University of Manchester, Manchester M13 9PL, UK
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17
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Uday S, Shaw NJ, Mughal MZ, Randell T, Högler W, Santos R, Padidela R. Monitoring response to conventional treatment in children with XLH: Value of ALP and Rickets Severity Score (RSS) in a real world setting. Bone 2021; 151:116025. [PMID: 34052463 DOI: 10.1016/j.bone.2021.116025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 04/22/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION X-linked hypophosphataemia (XLH) is conventionally managed with oral phosphate and active vitamin D analogues. OBJECTIVES To evaluate long term treatment response by assessing biochemical disease activity [serum alkaline phosphatase (ALP)], radiological rickets severity score (RSS), growth and morbidity in patients with XLH on conventional therapy and assess the correlation between serum ALP and RSS. METHODS XLH patients from 3 UK tertiary centres with ≥3 radiographs one year apart were included. Data was collected retrospectively. The RSS was assessed from routine hand and knee radiographs and ALP z scores were calculated using age-specific reference data. RESULTS Thirty-eight (male = 12) patients met the inclusion criteria. The mean ± SD knee, wrist and total RSS at baseline (median age 1.2 years) were 2.0 ± 1.2, 1.9 ± 1.2 and 3.6 ± 1.3 respectively; and at the most recent clinic visit (median age 9.0 years, range 3.3-18.9) were 1.6 ± 1.0, 1.0 ± 1.0 and 2.5 ± 1.5 respectively. The mean ± SD serum ALP z scores at baseline and the most recent visit were 4.2 ± 2.3 and 4.0 ± 3.3. Median height SDS at baseline and most recent visit were -1.2 and -2.1 (p = 0.05). Dental abscess, craniosynostosis, limb deformity requiring orthopaedic intervention and nephrocalcinosis were present in 31.5%, 7.9%, 31.6% and 42.1% of the cohort respectively. There was no statistically significant (p > 0.05) correlation between ALP z scores and knee (r = 0.07) or total (r = 0.12) RSS. CONCLUSIONS Conventional therapy was not effective in significantly improving biochemical and radiological features of disease. The lack of association between serum ALP and rickets severity on radiographs limits the value of ALP as the sole indicator of rickets activity in patients receiving conventional therapy.
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Affiliation(s)
- S Uday
- IMSR, University of Birmingham, Birmingham, UK; Birmingham Women's and Children's Hospital, Birmingham, UK.
| | - N J Shaw
- IMSR, University of Birmingham, Birmingham, UK; Birmingham Women's and Children's Hospital, Birmingham, UK
| | - M Z Mughal
- Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - T Randell
- Nottingham Children's Hospital, Nottingham, UK
| | - W Högler
- IMSR, University of Birmingham, Birmingham, UK; Johannes Kepler University, Linz, Austria
| | - R Santos
- Evelina London Children's Hospital, London, UK
| | - R Padidela
- Royal Manchester Children's Hospital, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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18
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Crowe FL, Mughal MZ, Maroof Z, Berry J, Kaleem M, Abburu S, Walraven G, Masher MI, Chandramohan D, Manaseki-Holland S. Vitamin D for Growth and Rickets in Stunted Children: A Randomized Trial. Pediatrics 2021; 147:peds.2020-0815. [PMID: 33386335 DOI: 10.1542/peds.2020-0815] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Accepted: 10/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vitamin D is essential for healthy development of bones, but little is known about the effects of supplementation in young stunted children. Our objective was to assess the effect of vitamin D supplementation on risk of rickets and linear growth among Afghan children. METHODS In this double-blind, placebo-controlled trial, 3046 children ages 1 to 11 months from inner-city Kabul were randomly assigned to receive oral vitamin D3 (100 000 IU) or placebo every 3 months for 18 months. Rickets Severity Score was calculated by using wrist and knee radiographs for 631 randomly selected infants at 18 months, and rickets was defined as a score >1.5. Weight and length were measured at baseline and 18 months by using standard techniques, and z scores were calculated. RESULTS Mean (95% confidence interval [CI]) serum 25-hydroxyvitamin D (seasonally corrected) and dietary calcium intake were insufficient at 37 (35-39) nmol/L and 372 (327-418) mg/day, respectively. Prevalence of rickets was 5.5% (placebo) and 5.3% (vitamin D): odds ratio 0.96 (95% CI: 0.48 to 1.92); P = .9. The mean difference in height-for-age z score was 0.05 (95% CI: -0.05 to 0.15), P = .3, although the effect of vitamin D was greater for those consuming >300 mg/day of dietary calcium (0.14 [95% CI: 0 to 0.29]; P = .05). There were no between-group differences in weight-for-age or weight-for-height z scores. CONCLUSIONS Except in those with higher calcium intake, vitamin D supplementation had no effect on rickets or growth.
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Affiliation(s)
- Francesca L Crowe
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.,Contributed equally as co-first authors
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom.,Contributed equally as co-first authors
| | - Zabihullah Maroof
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Aga Khan Health Service, Kabul, Afghanistan
| | - Jacqueline Berry
- Endocrinology and Diabetes Research Group, Institute of Human Development, University of Manchester, Manchester, United Kingdom
| | - Musa Kaleem
- Department of Radiology, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Sravya Abburu
- Department of Obstetrics and Gynaecology, New Cross Hospital, Wolverhampton, United Kingdom
| | - Gijs Walraven
- Aga Khan Development Network, Geneva, Switzerland; and
| | - Mohammad I Masher
- Department of Pediatrics, Kabul Medical University, Kabul, Afghanistan
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Semira Manaseki-Holland
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom; .,Aga Khan Health Service, Kabul, Afghanistan
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19
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Ferreira CR, Hackbarth ME, Ziegler SG, Pan KS, Roberts MS, Rosing DR, Whelpley MS, Bryant JC, Macnamara EF, Wang S, Müller K, Hartley IR, Chew EY, Corden TE, Jacobsen CM, Holm IA, Rutsch F, Dikoglu E, Chen MY, Mughal MZ, Levine MA, Gafni RI, Gahl WA. Prospective phenotyping of long-term survivors of generalized arterial calcification of infancy (GACI). Genet Med 2020; 23:396-407. [PMID: 33005041 PMCID: PMC7867608 DOI: 10.1038/s41436-020-00983-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [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: 07/06/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Generalized arterial calcification of infancy (GACI), characterized by vascular calcifications that are often fatal shortly after birth, is usually caused by deficiency of ENPP1. A small fraction of GACI cases result from deficiency of ABCC6, a membrane transporter. The natural history of GACI survivors has not been established in a prospective fashion. METHODS We performed deep phenotyping of 20 GACI survivors. RESULTS Sixteen of 20 subjects presented with arterial calcifications, but only 5 had residual involvement at the time of evaluation. Individuals with ENPP1 deficiency either had hypophosphatemic rickets or were predicted to develop it by 14 years of age; 14/16 had elevated intact FGF23 levels (iFGF23). Blood phosphate levels correlated inversely with iFGF23. For ENPP1-deficient individuals, the lifetime risk of cervical spine fusion was 25%, that of hearing loss was 75%, and the main morbidity in adults was related to enthesis calcification. Four ENPP1-deficient individuals manifested classic skin or retinal findings of PXE. We estimated the minimal incidence of ENPP1 deficiency at ~1 in 200,000 pregnancies. CONCLUSION GACI appears to be more common than previously thought, with an expanding spectrum of overlapping phenotypes. The relationships among decreased ENPP1, increased iFGF23, and rickets could inform future therapies.
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Affiliation(s)
- Carlos R Ferreira
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Mary E Hackbarth
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Shira G Ziegler
- Departments of Pediatrics and Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristen S Pan
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Mary S Roberts
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Douglas R Rosing
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Margaret S Whelpley
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Joy C Bryant
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ellen F Macnamara
- Undiagnosed Diseases Program, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Iris R Hartley
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Emily Y Chew
- Division of Epidemiology and Clinical Applications, Clinical Trials Branch, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Timothy E Corden
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christina M Jacobsen
- Divisions of Endocrinology and Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ingrid A Holm
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Genetics and Genomics and the Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA, USA
| | - Frank Rutsch
- Department of General Pediatrics, Muenster University Children's Hospital, Muenster, Germany
| | - Esra Dikoglu
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Y Chen
- Cardiovascular CT Laboratory, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Michael A Levine
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia and the Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rachel I Gafni
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - William A Gahl
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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20
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Agarwal N, Agarwal U, Alfirevic Z, Lim J, Kaleem M, Landes C, Mughal MZ, Ramakrishnan R. Skeletal abnormalities secondary to antenatal etidronate treatment for suspected generalised arterial calcification of infancy. Bone Rep 2020; 12:100280. [PMID: 32490054 PMCID: PMC7256299 DOI: 10.1016/j.bonr.2020.100280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/27/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022] Open
Abstract
Background Generalised arterial calcification of infancy (GACI) is a rare disorder characterised by the deposition of hydroxyapatite crystals within the vessel walls. It is associated with a high mortality rate. Bisphosphonates have been used with some success in the treatment of GACI. However, there is a paucity of data on the antenatal use of bisphosphonates for GACI. In this paper, we report development of the skeletal changes suggestive of hypophosphatasia (HPP) in an infant with GACI, whose mother was treated with etidronate during pregnancy. Case report A Caucasian infant boy had a suspected antenatal diagnosis of GACI based on the findings suggestive of calcification of the annulus of the tricuspid valve and wall of the right ventricular (RV) outflow tract and main pulmonary artery on foetal echocardiography and the genetic analysis which showed a pathogenic heterozygous mutation in ABCC6. Based on these findings, mother was started on etidronate treatment from 26 weeks of gestation. A healthy male baby was delivered at 38 weeks of gestation. Initial postnatal echocardiogram on day 1 of life was normal with good biventricular function; subtle changes suggestive of microcalcifications were detected on the CT angiography. Serum calcium, phosphate, alkaline phosphatase and renal profile were normal. Further, the serum inorganic pyrophosphate (PPi) level was significantly low. Skeletal changes suggestive of HPP were seen on the radiographs. The baby developed cardiac dysfunction on day 4 of life with evidence of ischaemic changes on electrocardiogram (ECG).Treatment with etidronate was started in view of probable evolving coronary calcifications. Despite treatment with cardiac supportive measures and bisphosphonate, he succumbed to death in the third week of life. Discussion We believe, this is the first report of skeletal changes suggestive of HPP, arising secondary to antenatal etidronate (first generation bisphosphonate) used for the treatment of suspected GACI due to a heterozygous ABCC6 mutation.
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Affiliation(s)
- Neha Agarwal
- Department of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Umber Agarwal
- Department of Obstetrics and Maternal-Fetal Medicine, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Zarko Alfirevic
- Department of Women's and Children's Health, Obstetrics, Maternal & Fetal Medicine, University of Liverpool and Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | - Joyce Lim
- Department of Paediatric Cardiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Musa Kaleem
- Department of Paediatric Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Caren Landes
- Department of Paediatric Radiology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Oxford Road, Manchester, UK
| | - R Ramakrishnan
- Department of Paediatric Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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21
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Ferizović N, Marshall J, Williams AE, Mughal MZ, Shaw N, Mak C, Gardiner O, Hossain P, Upadhyaya S. Exploring the Burden of X-Linked Hypophosphataemia: An Opportunistic Qualitative Study of Patient Statements Generated During a Technology Appraisal. Adv Ther 2020; 37:770-784. [PMID: 31865548 PMCID: PMC7004427 DOI: 10.1007/s12325-019-01193-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Indexed: 12/19/2022]
Abstract
Introduction Capturing the patient experience of living with a rare disease such as X-linked hypophosphataemia (XLH) is critical for a holistic understanding of the burden of a disease. The complexity of the disease coupled with the limited population makes elicitation of the patient burden methodologically challenging. This study used qualitative information direct from patient and caregiver statements to assess the burden of XLH. Methods A thematic analysis was conducted on statements received during a National Institute for Health and Care Excellence (NICE) online public open consultation from 15 June to 6 July 2018. Researchers and clinical experts generated themes and codes based on expected aspects of XLH burden. Statements were independently coded by two reviewers, adding additional codes as required, and analysed by frequency and co-reporting across age groups. Results The majority of responses were submitted from UK-based patients with some from the USA and Australia, and the statements related to children, adolescents and adults. The findings suggest that the greatest burden experienced by children is associated with conventional therapy, co-reported with dosing regimen, adherence, distress and pain. During adolescence, the burden becomes increasingly complex and multi-factorial, with an increasing psychological burden. In adults, conventional therapy co-reported with bone deformity and orthopaedic surgery, as well as pain, mobility, fatigue and dental problems, featured highly. Discussion Whilst our study was opportunistic in nature, it has highlighted the clear and distinctive evolution of the burden of XLH, transitioning from being therapy-oriented in childhood to multi-factorial in adolescence, and finally to adulthood with its high impact on need for other interventions, function and mobility. This qualitative thematic analysis enhances the understanding of the symptom and treatment burden of XLH.
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Affiliation(s)
| | | | | | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University Hospital's NHS Trust, Manchester, UK
| | - Nicholas Shaw
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, University of Birmingham, Birmingham, UK
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22
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Crabtree NJ, Adams JE, Padidela R, Shaw NJ, Högler W, Roper H, Hughes I, Daniel A, Mughal MZ. Growth, bone health & ambulatory status of boys with DMD treated with daily vs. intermittent oral glucocorticoid regimen. Bone 2018; 116:181-186. [PMID: 30055340 DOI: 10.1016/j.bone.2018.07.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/09/2018] [Accepted: 07/23/2018] [Indexed: 11/19/2022]
Abstract
Oral glucocorticoids (GC) preserve muscle strength and prolong walking in boys with Duchenne muscular dystrophy (DMD). Although vertebral fractures have been reported in boys taking GC, fracture rates for different GC regimes have not been investigated. The aim of this pragmatic longitudinal study was to compare growth, body mass, bone mineral density (BMD), vertebral fractures (VF) and ambulatory status in boys with DMD on daily (DAILY) or intermittent (INTERMITTENT), oral GC regimens. A convenience sample of 50 DMD boys from two centres was included in the study; 25 boys each were on the DAILY or INTERMITTENT regimen. Size adjusted lumbar spine BMD (LS BMAD), total body less head BMD (TBLH), by DXA and distal forearm bone densities by pQCT, GC exposure, VF assessment and ambulatory status were analysed at three time points; baseline, 1 and 2 years. At baseline, there were no differences in age, GC duration or any bone parameters. However, DAILY boys were shorter (height SDS DAILY = -1.4(0.9); INTERMITTENT = -0.8(1.0), p = 0.04) with higher BMI (BMI SDS DAILY = 1.5(0.9); INTERMITTENT = 0.8(1.0), p = 0.01). Over 2 years, DAILY boys got progressively shorter (delta height SDS DAILY = -0.9(1.1); INTERMITTENT = +0.1(0.6), p < 0.001). At their 2 year assessment, 5 DAILY and 10 INTERMITTENT boys were non-ambulant. DAILY boys had more VFs than INTERMITTENT boys (10 versus 2; χ2 p = 0.008). BMAD SDS remained unchanged between groups. TBLH and radius BMD declined significantly but the rate of loss was not different. In conclusion, there was a trend for more boys on daily GCs to remain ambulant but at the cost of more VFs, greater adiposity and markedly diminished growth. In contrast, boys on intermittent GCs had fewer vertebral fractures but there was a trend for more boys to loose independent ambulation.
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Affiliation(s)
- N J Crabtree
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
| | - J E Adams
- Radiology and Manchester Academic Health Science Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust and Centre for Imaging Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - R Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - N J Shaw
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - W Högler
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - H Roper
- Department of Paediatrics, Heartlands Hospital, Birmingham, UK
| | - I Hughes
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Manchester, UK
| | - A Daniel
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Z Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
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23
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Daniel AB, Saraff V, Shaw NJ, Yates R, Mughal MZ, Padidela R. Healthcare resource utilization in the management of hypophosphatasia in three patients displaying a spectrum of manifestations. Orphanet J Rare Dis 2018; 13:142. [PMID: 30115096 PMCID: PMC6097329 DOI: 10.1186/s13023-018-0869-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/03/2018] [Indexed: 01/09/2023] Open
Abstract
Background Hypophosphatasia (HPP) is a rare, heterogeneous disease caused by low tissue-nonspecific alkaline phosphatase activity and associated with a range of signs and symptoms, including bone mineralization defects, respiratory problems, seizures, premature tooth loss, and fractures. Data from patients with HPP and their healthcare resource utilization are lacking. We evaluated healthcare utilization for 3 patients with differing severities of HPP. Results Patient 1 had perinatal HPP (received enzyme replacement therapy asfotase alfa under a compassionate use program), Patient 2 had infantile HPP, and Patient 3 had childhood HPP. Healthcare resources used in the National Health Service, England, were identified from coded activities in the hospital database and detailed medical records. These data showed that healthcare utilization was directly related to disease severity. Patient 1 had respiratory complications necessitating prolonged admission for ventilation from birth. Over 2.5 years, this patient was hospitalized 725 days, with visits from 16 specialists. Patient 2 had HPP-associated signs and symptoms starting in infancy, was treated for craniosynostosis, experienced multiple fractures, and required outpatient management for > 18 years. Patient 3 developed signs and symptoms of HPP in childhood and received outpatient and day case treatment for dental, orthopedic, and cardiovascular problems over 24 years. Healthcare utilization varied with severity and complexity of disease manifestations between these patients. Conclusions With the recent approval of asfotase alfa for HPP, data from this analysis may help mobilize multidisciplinary healthcare resources for management of HPP by elucidating healthcare resource needs of patients who show a spectrum of clinical manifestations of HPP.
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Affiliation(s)
- Anjali B Daniel
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Vrinda Saraff
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Nick J Shaw
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Robert Yates
- Department of Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology & Metabolic Bone Diseases, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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24
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Khadilkar AV, Sanwalka N, Mughal MZ, Chiplonkar S, Khadilkar V. Indian girls have higher bone mineral content per unit of lean body than boys through puberty. J Bone Miner Metab 2018; 36:364-371. [PMID: 28580516 DOI: 10.1007/s00774-017-0843-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
Our aim is to describe changes in the muscle-bone unit assessed as a ratio of bone mineral content (BMC) to lean body mass (LBM) through puberty at total body and various skeletal sites in Indian boys and girls. A cross-sectional study was conducted (888 children, 480 boys, aged 5-17 years) in Pune, India. Pubertal staging was assessed. BMC, LBM and fat percentage at the arms, legs, android, gynoid and total body (less the head) were assessed by dual energy X-ray absorptiometry. The amount of BMC per unit LBM (BMC/LBM) was computed. Changes in mean BMC/LBM at 5 Tanner (pubertal) stages after adjustment for age and fat percentage were calculated. In boys, adjusted BMC/LBM was significantly higher with successive Tanner stages [legs (TS-II vs TS-I), android (TS-III vs TS-II, TS-IV vs TS-III) and gynoid region (TS-III vs TS-II and TS-II vs TS-I) (p < 0.05)]. In girls, adjusted BMC/LBM was significantly higher with successive Tanner stages at total body, legs and gynoid (TS-III vs TS-II; TS-II vs TS-I; TS-V vs TS-IV), arms (TS-I to TS-V) and android regions (TS-V vs TS-IV) (p < 0.05). Boys had significantly higher adjusted BMC/LBM than girls at earlier Tanner stages (TS-I to TS-III), whereas girls had significantly higher adjusted BMC/LBM than boys at later Tanner stages (TS-IV, TS-V) (p < 0.05). Indian boys and girls showed higher total and regional body, and age- and fat percentage-adjusted BMC/LBM with successive pubertal stages. Girls had higher BMC/LBM than boys which may possibly act as a reservoir for later demands of pregnancy and lactation.
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Affiliation(s)
- Anuradha V Khadilkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Block 5, Lower Ground Floor, 32, Sassoon Road, Pune, 411001, Maharashtra, India.
| | | | - M Zulf Mughal
- Royal Manchester Children's Hospital, Manchester, UK
| | - Shashi Chiplonkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Block 5, Lower Ground Floor, 32, Sassoon Road, Pune, 411001, Maharashtra, India
| | - Vaman Khadilkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Block 5, Lower Ground Floor, 32, Sassoon Road, Pune, 411001, Maharashtra, India
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25
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Balasubramanian M, Padidela R, Pollitt RC, Bishop NJ, Mughal MZ, Offiah AC, Wagner BE, McCaughey J, Stephens DJ. P4HB recurrent missense mutation causing Cole-Carpenter syndrome. J Med Genet 2017; 55:158-165. [DOI: 10.1136/jmedgenet-2017-104899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/03/2022]
Abstract
BackgroundCole-Carpenter syndrome (CCS) is commonly classified as a rare Osteogenesis Imperfecta (OI) disorder. This was following the description of two unrelated patients with very similar phenotypes who were subsequently shown to have a heterozygous missense mutation in P4HB.ObjectivesHere, we report a 3-year old female patient with severe OI who on exome sequencing was found to carry the same missense mutation in P4HB as reported in the original cohort. We discuss the genetic heterogeneity of CCS and underlying mechanism of P4HB in collagen production.MethodsWe undertook detailed clinical, radiological and molecular phenotyping in addition, to analysis of collagen in cultured fibroblasts and electron microscopic examination in the patient reported here.ResultsThe clinical phenotype appears consistent in patients reported so far but interestingly, there also appears to be a definitive phenotypic clue (crumpling metadiaphyseal fractures of the long tubular bones with metaphyseal sclerosis which are findings that are uncommon in OI) to the underlying genotype (P4HB variant).DiscussionP4HB (Prolyl 4-hydroxylase, betasubunit) encodes for PDI (Protein Disulfide isomerase) and in cells, in its tetrameric form, catalyses formation of 4-hydroxyproline in collagen. The recurrent variant in P4HB, c.1178A>G, p.Tyr393Cys, sits in the C-terminal reactive centre and is said to interfere with disulphide isomerase function of the C-terminal reactive centre. P4HB catalyses the hydroxylation of proline residues within the X-Pro-Gly repeats in the procollagen helical domain. Given the inter-dependence of extracellular matrix (ECM) components in assembly of a functional matrix, our data suggest that it is the organisation and assembly of the functional ECM that is perturbed rather than the secretion of collagen type I per se.ConclusionsWe provide additional evidence of P4HB as a cause of a specific form of OI-CCS and expand on response to treatment with bisphosphonates in this rare disorder.
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Kuter H, Das G, Mughal MZ. Vitamin D status of gastrostomy-fed children with special needs: a cross-sectional pilot study. Acta Paediatr 2017; 106:2038-2041. [PMID: 28862805 DOI: 10.1111/apa.14054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/09/2017] [Accepted: 08/28/2017] [Indexed: 11/28/2022]
Abstract
AIM To assess the vitamin D status of gastrostomy-fed children. METHODS Vitamin D status was measured in 32 children aged five to 16 years recruited from special schools in Manchester, UK (53° 48' N). All children were receiving a nutritionally complete, commercially prepared enteral feed via gastrostomy, and had been established on this regimen for over 12 months. Serum concentrations of 25-hydroxyvitamin D (25OHD) were measured at the end of winter. Children with serum concentrations of 25OHD >50 nmol/L were considered to be sufficient, and those with concentrations <25 nmol/L were considered to be deficient. RESULTS Approximately 83% of subjects had sufficient concentrations of serum 25OHD (>50 nmol/L). One subject was vitamin D deficient (serum 25OHD <25 nmol/L), and four were vitamin D insufficient (serum 25OHD >25 nmol/L - <50 nmol/L). The median vitamin D derived from enteral feeds was 9.45 μg/day; range 3.5-30; 13 children (41%) received less than 10 μg of vitamin D per day from their enteral feed. CONCLUSION Nutritionally complete gastrostomy feeds may be protective against vitamin D deficiency in the majority of children with special needs. We recommend that all children over 1 year of age receive 10 μg (400 IU) of vitamin D, as recommended by the Scientific Advisory Committee on Nutrition (SACN).
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Affiliation(s)
- Hayley Kuter
- Department of Community Paediatric Dietetics; Royal Manchester Children's Hospital; Manchester UK
| | - Geeta Das
- Department of Paediatric Endocrinology; Royal Manchester Children's Hospital; Manchester UK
| | - M. Zulf Mughal
- Department of Paediatric Endocrinology; Royal Manchester Children's Hospital; Manchester UK
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Chinoy A, Skae M, Babiker A, Kendall D, Mughal MZ, Padidela R. Impact of intercurrent illness on calcium homeostasis in children with hypoparathyroidism: a case series. Endocr Connect 2017; 6:589-594. [PMID: 28993435 PMCID: PMC5633055 DOI: 10.1530/ec-17-0234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/06/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypoparathyroidism is characterised by hypocalcaemia, and standard management is with an active vitamin D analogue and adequate oral calcium intake (dietary and/or supplements). Little is described in the literature about the impact of intercurrent illnesses on calcium homeostasis in children with hypoparathyroidism. METHODS We describe three children with hypoparathyroidism in whom intercurrent illnesses led to hypocalcaemia and escalation of treatment with alfacalcidol (1-hydroxycholecalciferol) and calcium supplements. RESULTS Three infants managed with standard treatment for hypoparathyroidism (two with homozygous mutations in GCMB2 gene and one with Sanjad-Sakati syndrome) developed symptomatic hypocalcaemia (two infants developed seizures) following respiratory or gastrointestinal illnesses. Substantial increases in alfacalcidol doses (up to three times their pre-illness doses) and calcium supplementation were required to achieve acceptable serum calcium concentrations. However, following resolution of illness, these children developed an increase in serum calcium and hypercalciuria, necessitating rapid reduction to pre-illness dosages of alfacalcidol and oral calcium supplementation. CONCLUSION Intercurrent illness may precipitate symptomatic hypocalcaemia in children with hypoparathyroidism, necessitating increase in dosages of alfacalcidol and calcium supplements. Close monitoring is required on resolution of the intercurrent illness, with timely reduction of dosages of active analogues of vitamin D and calcium supplements to prevent hypercalcaemia, hypercalciuria and nephrocalcinosis.
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Affiliation(s)
- A Chinoy
- Royal Manchester Children's HospitalManchester, UK
| | - M Skae
- Royal Manchester Children's HospitalManchester, UK
| | - A Babiker
- King Abdullah Specialized Children's HospitalRiyadh, Saudi Arabia
| | | | - M Z Mughal
- Royal Manchester Children's HospitalManchester, UK
| | - R Padidela
- Royal Manchester Children's HospitalManchester, UK
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Högler W, Scott J, Bishop N, Arundel P, Nightingale P, Mughal MZ, Padidela R, Shaw N, Crabtree N. The Effect of Whole Body Vibration Training on Bone and Muscle Function in Children With Osteogenesis Imperfecta. J Clin Endocrinol Metab 2017; 102:2734-2743. [PMID: 28472303 DOI: 10.1210/jc.2017-00275] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 01/28/2017] [Accepted: 04/28/2017] [Indexed: 01/08/2023]
Abstract
CONTEXT Osteogenesis imperfecta (OI) is associated with reduced muscle size, dynamic muscle function, and mobility. OBJECTIVE To assess the effect of whole body vibration (WBV) on bone density and geometry, muscle size and function, mobility, and balance in children with OI. DESIGN Randomized controlled pilot trial. SETTING Tertiary pediatric research center. PARTICIPANTS Twenty-four children (5 to 16 years) with OI types 1, 4, and limited mobility [Child Health Assessment Questionnaire (CHAQ) score ≥ 0.13] recruited in sex- and pubertal stage-matched pairs. Incident fractures in two boys (WBV arm) led to exclusion of two prepubertal pairs. INTERVENTION Five months of WBV training (3 × 3 minutes twice daily) or regular care. MAIN OUTCOME MEASURES Bone and muscle variables measured by dual-energy X-ray absorptiometry (spine, hip, total body) and peripheral quantitative computed tomography (tibia). Mobility assessed by 6-minute walk tests and CHAQ; dynamic muscle function by mechanography. RESULTS All participants had reduced walking distances and muscle function (P < 0.001). Body mass index z score was associated with higher CHAQ scores (ρ + 0.552; P = 0.005) and lower walking and two-leg jumping performance (ρ - 0.405 to -0.654, P < 0.05). The WBV and control groups did not differ in the 5-month changes in bone. Total lean mass increased more in the WBV group [+1119 g (+224 to +1744)] compared with controls [+635 g (-951 to +1006)], P = 0.01, without improving mobility, muscle function, or balance. CONCLUSIONS The increase in lean mass without changes in muscle function or bone mass suggests reduced biomechanical responsiveness of the muscle-bone unit in children with OI.
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Affiliation(s)
- Wolfgang Högler
- Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham B4 6NH, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Janis Scott
- Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham B4 6NH, United Kingdom
| | - Nick Bishop
- Academic Unit of Child Health, Sheffield Children's Hospital, Sheffield S10 2TH, United Kingdom
| | - Paul Arundel
- Academic Unit of Child Health, Sheffield Children's Hospital, Sheffield S10 2TH, United Kingdom
| | - Peter Nightingale
- Wellcome Trust Clinical Research Facility, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom
| | - M Zulf Mughal
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester M13 9WL, United Kingdom
| | - Raja Padidela
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester M13 9WL, United Kingdom
| | - Nick Shaw
- Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham B4 6NH, United Kingdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Nicola Crabtree
- Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham B4 6NH, United Kingdom
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Perchard R, Magee L, Whatmore A, Ivison F, Murray P, Stevens A, Mughal MZ, Ehtisham S, Campbell J, Ainsworth S, Marshall M, Bone M, Doughty I, Clayton PE. A pilot interventional study to evaluate the impact of cholecalciferol treatment on HbA1c in type 1 diabetes (T1D). Endocr Connect 2017; 6:225-231. [PMID: 28381562 PMCID: PMC5632717 DOI: 10.1530/ec-17-0045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/05/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Higher 25(OH)D3 levels are associated with lower HbA1c, but there are limited UK interventional trials assessing the effect of cholecalciferol on HbA1c. AIMS (1) To assess the baseline 25(OH)D3 status in a Manchester cohort of children with type 1 diabetes (T1D). (2) To determine the effect of cholecalciferol administration on HbA1c. METHODS Children with T1D attending routine clinic appointments over three months in late winter/early spring had blood samples taken with consent. Participants with a 25(OH)D3 level <50 nmol/L were treated with a one-off cholecalciferol dose of 100,000 (2-10 years) or 160,000 (>10 years) units. HbA1c levels before and after treatment were recorded. RESULTS Vitamin D levels were obtained from 51 children. 35 were Caucasian, 11 South Asian and 5 from other ethnic groups. 42 were vitamin D deficient, but 2 were excluded from the analysis. All South Asian children were vitamin D deficient, with mean 25(OH)D3 of 28 nmol/L. In Caucasians, there was a negative relationship between baseline 25(OH)D3 level and HbA1c (r = -0.484, P < 0.01). In treated participants, there was no significant difference in mean HbA1c at 3 months (t = 1.010, P = 0.328) or at 1 year (t = -1.173, P = 0.248) before and after treatment. One-way ANCOVA, controlling for age, gender, ethnicity, BMI and diabetes duration showed no difference in Δ HbA1c level. CONCLUSION We report important findings at baseline, but in children treated with a stat dose of cholecalciferol, there was no effect on HbA1c. Further studies with larger sample sizes and using maintenance therapy are required.
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Affiliation(s)
- R Perchard
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - L Magee
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - A Whatmore
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - F Ivison
- Department of BiochemistryCentral Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - P Murray
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - A Stevens
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - M Z Mughal
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - S Ehtisham
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - J Campbell
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - S Ainsworth
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - M Marshall
- Department of BiochemistryCentral Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - M Bone
- Department of General PaediatricsRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - I Doughty
- Department of General PaediatricsRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - P E Clayton
- Division of Developmental Biology & MedicineSchool of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
- Department of Paediatric EndocrinologyRoyal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
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Emmerson AJB, Dockery KE, Mughal MZ, Roberts SA, Tower CL, Berry JL. Vitamin D status of White pregnant women and infants at birth and 4 months in North West England: A cohort study. Matern Child Nutr 2017; 14. [PMID: 28421711 DOI: 10.1111/mcn.12453] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 11/29/2022]
Abstract
The prevalence of vitamin D deficiency in pregnant white-skinned women (WSW) and their infants has not been investigated at northern latitudes in a developed county. A 2-year observational cohort study was undertaken in the North West of England to determine 25-hydroxyvitamin D (25OHD) levels in WSW and their infants during pregnancy and 4 months postdelivery and to explore factors associated with these levels. Nutritional and lifestyle questionnaires were completed and 25OHD levels measured at 28 weeks and 4 months postdelivery. Twenty-seven percent and 7% of WSW had insufficient and deficient levels of 25OHD during pregnancy and 48% and 11% four months postdelivery. WSW with Fitzpatrick skin-type I (FST I) have significantly lower 25OHD than other skin types after controlling for time spent outside and vitamin D intake. Twenty-four percent and 13% of infants had insufficient and deficient 25OHD levels at 4 months. Unsupplemented breast-fed infants have the highest level of insufficiency (67%) compared with formula-fed infants (2%). Factors associated with infant serum 25OHD levels at 4 months included breast feeding, supplementation, and time outside. WSW have a high prevalence of insufficiency and deficiency during pregnancy which doubles 4 months after birth. Breast-fed infants of WSW are rarely considered at risk of vitamin D insufficiency but have high rates compared with formula-fed infants. This is the first study to show the finding that FST I WSW have significantly lower levels of 25OHD than those with FST II-IV (difference adjusted for diet and time outside 14 (95%CI 7-21) nmol/L).
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Affiliation(s)
- Anthoney J B Emmerson
- Departments of Newborn Intensive Care, and Obstetrics, St Mary's Hospital, & Manchester Health Sciences Centre, Central Manchester Foundation Trust, Manchester, UK
| | - Karen Elizabeth Dockery
- Departments of Newborn Intensive Care, and Obstetrics, St Mary's Hospital, & Manchester Health Sciences Centre, Central Manchester Foundation Trust, Manchester, UK
| | - M Z Mughal
- Vitamin D Research Group, University of Manchester, Manchester, UK
| | | | - Clare Louise Tower
- Departments of Newborn Intensive Care, and Obstetrics, St Mary's Hospital, & Manchester Health Sciences Centre, Central Manchester Foundation Trust, Manchester, UK
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Crabtree NJ, Shaw NJ, Bishop NJ, Adams JE, Mughal MZ, Arundel P, Fewtrell MS, Ahmed SF, Treadgold LA, Högler W, Bebbington NA, Ward KA. Amalgamated Reference Data for Size-Adjusted Bone Densitometry Measurements in 3598 Children and Young Adults-the ALPHABET Study. J Bone Miner Res 2017; 32:172-180. [PMID: 27490028 PMCID: PMC5453244 DOI: 10.1002/jbmr.2935] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [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: 12/21/2015] [Revised: 07/28/2016] [Accepted: 08/02/2016] [Indexed: 01/24/2023]
Abstract
The increasing use of dual-energy X-ray absorptiometry (DXA) in children has led to the need for robust reference data for interpretation of scans in daily clinical practice. Such data need to be representative of the population being studied and be "future-proofed" to software and hardware upgrades. The aim was to combine all available pediatric DXA reference data from seven UK centers to create reference curves adjusted for age, sex, ethnicity, and body size to enable clinical application, using in vivo cross-calibration and making data back and forward compatible. Seven UK sites collected data on GE Lunar or Hologic Scanners between 1996 and 2012. Males and females aged 4 to 20 years were recruited (n = 3598). The split by ethnic group was white 2887; South Asian 385; black Afro-Caribbean 286; and mixed heritage 40. Scans of the total body and lumbar spine (L1 to L4 ) were obtained. The European Spine Phantom was used to cross-calibrate the 7 centers and 11 scanners. Reference curves were produced for L1 to L4 bone mineral apparent density (BMAD) and total body less head (TBLH) and L1 to L4 areal bone mineral density (aBMD) for GE Lunar Prodigy and iDXA (sex- and ethnic-specific) and for Hologic (sex-specific). Regression equations for TBLH BMC were produced using stepwise linear regression. Scans of 100 children were randomly selected to test backward and forward compatibility of software versions, up to version 15.0 for GE Lunar and Apex 4.1 for Hologic. For the first time, sex- and ethnic-specific reference curves for lumbar spine BMAD, aBMD, and TBLH aBMD are provided for both GE Lunar and Hologic scanners. These curves will facilitate interpretation of DXA data in children using methods recommended in ISCD guidelines. The databases have been created to allow future updates and analysis when more definitive evidence for the best method of fracture prediction in children is agreed. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Nicola J Crabtree
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - Nicholas J Shaw
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - Nicholas J Bishop
- Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - Judith E Adams
- Radiology and Manchester Academic Health Science Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - M Zulf Mughal
- Department of Endocrinology, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Paul Arundel
- Academic Unit of Child Health, University of Sheffield, Sheffield, UK
| | - Mary S Fewtrell
- Childhood Nutrition Research Centre, University College London, Institute of Child Health, London, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Royal Hospital for Sick Children, Glasgow, UK
| | - Laura A Treadgold
- Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - Natalie A Bebbington
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - Kate A Ward
- Nutrition and Bone Health, MRC Human Nutrition Research, Cambridge, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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Moon RJ, Harvey NC, Cooper C, D'Angelo S, Crozier SR, Inskip HM, Schoenmakers I, Prentice A, Arden NK, Bishop NJ, Carr A, Dennison EM, Eastell R, Fraser R, Gandhi SV, Godfrey KM, Kennedy S, Mughal MZ, Papageorghiou AT, Reid DM, Robinson SM, Javaid MK. Determinants of the Maternal 25-Hydroxyvitamin D Response to Vitamin D Supplementation During Pregnancy. J Clin Endocrinol Metab 2016; 101:5012-5020. [PMID: 27788053 PMCID: PMC5155676 DOI: 10.1210/jc.2016-2869] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT Current approaches to antenatal vitamin D supplementation do not account for interindividual differences in 25-hydroxyvitamin D (25(OH)D) response. OBJECTIVE We assessed which maternal and environmental characteristics were associated with 25(OH)D after supplementation with cholecalciferol. DESIGN Within-randomization-group analysis of participants in the Maternal Vitamin D Osteoporosis Study trial of vitamin D supplementation in pregnancy. SETTING Hospital antenatal clinics. PARTICIPANTS A total of 829 pregnant women (422 placebo, 407 cholecalciferol). At 14 and 34 weeks of gestation, maternal anthropometry, health, and lifestyle were assessed and 25(OH)D measured. Compliance was determined using pill counts at 19 and 34 weeks. INTERVENTIONS 1000 IU/d of cholecalciferol or matched placebo from 14 weeks of gestation until delivery. MAIN OUTCOME MEASURE 25(OH)D at 34 weeks, measured in a single batch (Diasorin Liaison). RESULTS 25(OH)D at 34 weeks of gestation was higher in the women randomized to vitamin D (mean [SD], 67.7 [21.3] nmol/L) compared with placebo (43.1 [22.5] nmol/L; P < .001). In women randomized to cholecalciferol, higher pregnancy weight gain from 14 to 34 weeks of gestation (kg) (β = -0.81 [95% confidence interval -1.39, -0.22]), lower compliance with study medication (%) (β = -0.28 [-0.072, -0.48]), lower early pregnancy 25(OH)D (nmol/L) (β = 0.28 [0.16, 0.40]), and delivery in the winter vs the summer (β = -10.5 [-6.4, -14.6]) were independently associated with lower 25(OH)D at 34 weeks of gestation. CONCLUSIONS Women who gained more weight during pregnancy had lower 25(OH)D in early pregnancy and delivered in winter achieved a lower 25(OH)D in late pregnancy when supplemented with 1000 IU/d cholecalciferol. Future studies should aim to determine appropriate doses to enable consistent repletion of 25(OH)D during pregnancy.
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. Horm Res Paediatr 2016; 85:83-106. [PMID: 26741135 DOI: 10.1159/000443136] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [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: 04/24/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Mughal MZ, Thacher TD, Specker BL, Shaw NJ, Kiely M, Munns CF, Högler W. Response to the letter by Sugiyama and Oda. J Clin Endocrinol Metab 2016; 101:L97-L98. [PMID: 27702314 DOI: 10.1210/jc.2016-3059] [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: 11/19/2022]
Affiliation(s)
- M Z Mughal
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - T D Thacher
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - B L Specker
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - N J Shaw
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - M Kiely
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - C F Munns
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
| | - W Högler
- Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, United Kingdom; College of Medicine (T.D.T.), Mayo Clinic, Rochester, Minnesota; Ethel Austin Martin Program (B.L.S.), South Dakota State University, Brookings, South Dakota; Department of Endocrinology and Diabetes (N.J.S., W.H.), Birmingham Children's Hospital, Birmingham, United Kingdom; Vitamin D Research Group (M.K.), School of Food and Nutritional Sciences, and Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland; Department of Endocrinology and Diabetes (C.F.M.), The Children's Hospital at Westmead, Sydney, Australia; and Institute of Metabolism and Systems Research (W.H.), University of Birmingham, Birmingham, United Kingdom
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Pollitt RC, Saraff V, Dalton A, Webb EA, Shaw NJ, Sobey GJ, Mughal MZ, Hobson E, Ali F, Bishop NJ, Arundel P, Högler W, Balasubramanian M. Phenotypic variability in patients with osteogenesis imperfecta caused byBMP1mutations. Am J Med Genet A 2016; 170:3150-3156. [DOI: 10.1002/ajmg.a.37958] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 08/18/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Rebecca C. Pollitt
- Sheffield Diagnostic Genetics Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
- Academic Unit of Child Health; Department of Oncology and Metabolism; University of Sheffield; Sheffield UK
| | - Vrinda Saraff
- Department of Endocrinology and Diabetes; Birmingham Children's Hospital; Birmingham UK
| | - Ann Dalton
- Sheffield Diagnostic Genetics Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
| | - Emma A. Webb
- Department of Endocrinology and Diabetes; Birmingham Children's Hospital; Birmingham UK
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
| | - Nick J. Shaw
- Department of Endocrinology and Diabetes; Birmingham Children's Hospital; Birmingham UK
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
| | - Glenda J. Sobey
- National EDS Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
| | - M. Zulf Mughal
- Department of Paediatric Endocrinology; Royal Manchester Children's Hospital; Central Manchester University Hospitals; Manchester UK
| | - Emma Hobson
- Department of Clinical Genetics; Chapel Allerton Hospital; Leeds UK
| | - Farhan Ali
- Department of Paediatric Orthopaedic Surgery; Royal Manchester Children's Hospital; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - Nicholas J. Bishop
- Academic Unit of Child Health; Department of Oncology and Metabolism; University of Sheffield; Sheffield UK
- Department of Paediatric Endocrinology; Royal Manchester Children's Hospital; Central Manchester University Hospitals; Manchester UK
| | - Paul Arundel
- Highly Specialised Severe; Complex and Atypical OI Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes; Birmingham Children's Hospital; Birmingham UK
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
| | - Meena Balasubramanian
- Highly Specialised Severe; Complex and Atypical OI Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
- Sheffield Clinical Genetics Service; Sheffield Children's NHS Foundation Trust; Sheffield UK
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Farrar MD, Mughal MZ, Adams JE, Wilkinson J, Berry JL, Edwards L, Kift R, Marjanovic E, Vail A, Webb AR, Rhodes LE. Sun Exposure Behavior, Seasonal Vitamin D Deficiency, and Relationship to Bone Health in Adolescents. J Clin Endocrinol Metab 2016; 101:3105-13. [PMID: 27228370 DOI: 10.1210/jc.2016-1559] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Vitamin D is essential for bone health in adolescence, when there is rapid bone mineral content accrual. Because cutaneous sun exposure provides vitamin D, there is no recommended oral intake for UK adolescents. OBJECTIVE Our objective was to assess seasonal vitamin D status and its contributors in white Caucasian adolescents and examine bone health in those found deficient. DESIGN Prospective cohort study was undertaken. SETTING Six schools in Greater Manchester, UK, were included. PARTICIPANTS Participants were 131 adolescents between 12 and 15 years of age. INTERVENTION(S) Seasonal assessment of circulating 25-hydroxyvitamin D (25OHD), personal sun exposure, and dietary vitamin D. Adolescents deficient (25OHD <10 ng/ml/25 nmol/liter) in at least one season underwent dual-energy X-ray absorptiometry (lumbar spine, femoral neck), with bone mineral apparent density correction for size, and peripheral quantitative computed tomography (distal radius) for volumetric bone mineral density (BMD). MAIN OUTCOME MEASURE Serum 25OHD and BMD measurements. RESULTS Mean 25OHD was highest in September: 24.1 (SD, 6.9) ng/ml and lowest in January: 15.5 (5.9) ng/ml. Over the year, 16% were deficient in ≥ one season and 79% insufficient (25OHD <20 ng/ml/50 nmol/liter) including 28% in September. Dietary vitamin D was low year-round, whereas personal sun exposure was seasonal and predominantly across the school week. Holidays accounted for 17% variation in peak 25OHD (P < .001). Nineteen adolescents underwent bone assessment, which showed low femoral neck bone mineral apparent density vs matched reference data (P = .0002), three with Z less than or equal to -2.0 distal radius trabecular volumetric BMD. CONCLUSIONS Sun exposure levels failed to provide adequate vitamin D, with approximately one-quarter of adolescents insufficient even at summer peak. Seasonal vitamin D deficiency was prevalent and those affected had low BMD. Recommendations on vitamin D acquisition are indicated in this age-group.
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Affiliation(s)
- Mark D Farrar
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - M Zulf Mughal
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Judith E Adams
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Jack Wilkinson
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Jacqueline L Berry
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Lisa Edwards
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Richard Kift
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Elizabeth Marjanovic
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Andy Vail
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Ann R Webb
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
| | - Lesley E Rhodes
- Centre for Dermatology (M.D.F., L.E., E.M., L.E.R.), Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK; Department of Paediatric Endocrinology (M.Z.M.), Royal Manchester Children's Hospital, Manchester, UK; Clinical Radiology (J.E.A.), Manchester Royal Infirmary and Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK; Centre for Biostatistics (J.W., A.V.), Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Endocrinology and Diabetes Research Group (J.L.B.), Institute of Human Development, University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK; School of Earth, Atmospheric and Environmental Sciences (R.K., A.R.W.), University of Manchester, Manchester, UK
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Thacher TD, Pludowski P, Shaw NJ, Mughal MZ, Munns CF, Högler W. Nutritional rickets in immigrant and refugee children. Public Health Rev 2016; 37:3. [PMID: 29450045 PMCID: PMC5810111 DOI: 10.1186/s40985-016-0018-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/01/2016] [Indexed: 11/10/2022] Open
Abstract
Immigrant and refugee populations bring public health challenges to host nations. In the current global refugee crisis, children are the most vulnerable subpopulation. Diseases that were considered rare in the host nation may be highly prevalent among immigrant children. The prevalence of nutritional rickets is increasing in high-income countries, largely driven by an influx of immigrant populations. Nutritional rickets is a bone disease in early childhood resulting in bone pain, delayed motor development, and bending of the bones, caused by vitamin D deficiency and/or inadequate dietary calcium intake. The consequences of nutritional rickets include stunted growth, developmental delay, lifelong bone deformities, seizures, cardiomyopathy, and even death. Nutritional rickets is most commonly seen in children from the Middle East, Africa, and South Asia in high-income countries. Dark skin pigmentation, sun avoidance, covering the skin, and prolonged breast feeding without vitamin D supplementation, are important risk factors for vitamin D deficiency, and combined with a lack of dairy products in the diet, these deficiencies can result in insufficient calcium supply for bone mineralization. We recommend screening all immigrant and refugee children under 5 years of age from these ethnic groups for nutritional rickets, based on clinical features, and confirming the diagnosis with radiographs of the wrists and knees. Because nutritional rickets is entirely preventable, public health policies must address the need for universal vitamin D supplementation and adequate dietary calcium to protect children from this scourge. Vitamin D supplementation of all infants and children with 400 IU/d during the first year of life and dietary or supplemental intakes of at least 600 IU/d of vitamin D and 500 mg/d of calcium thereafter, will effectively prevent nutritional rickets. We call on national health authorities of host countries to implement health check lists and prevention programs that include screening for micronutrient deficiencies, in addition to assessing infections and vaccination programs. Due to their high prevalence of vitamin D deficiency, refugee children of all ages from these ethnic groups should be supplemented with vitamin D, beginning upon arrival.
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Affiliation(s)
- Tom D Thacher
- 1Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Pawel Pludowski
- 2Department of Biochemistry, Radioimmunology and Experimental Medicine, The Children's Memorial Health Institute, Warsaw, Poland
| | - Nick J Shaw
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - M Zulf Mughal
- 4Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Craig F Munns
- 5The Children's Hospital at Westmead, Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Wolfgang Högler
- 3Department of Endocrinology & Diabetes, Birmingham Children's Hospital, Birmingham, UK.,6Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Abstract
A five-food item food frequency questionnaire (FFQ) and a 3-day food diary (3DFD) were used to estimate daily dietary calcium (Ca) intake in 32 patients aged 1-17 years. Median and IQR of Ca intake from 3DFD was 840 mg and 438 mg while from FFQ it was 700 mg and 987 mg, respectively. The non-parametrical Bland-Altman limits of agreement plot between two methods showed that most of the values fell between the limits of agreement at +794 mg and -388 mg. The FFQ had a specificity of 93% in identifying children who consumed inadequate amount of dietary Ca and a sensitivity of 78% in identifying children whose dietary Ca intake exceeded UK's Reference Nutrient Intake. Thus the FFQ allows rapid estimation of children with low daily dietary Ca intake in the clinic setting; however it does not replace 3DFD.
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Affiliation(s)
- Mikaela Nordblad
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Fiona Graham
- Department of Paediatric Therapy and Dietetics, Royal Manchester Children's Hospital, Manchester, UK
| | - M Zulf Mughal
- Faculty of Life Sciences, University of Manchester, Manchester, UK Department of Paediatric Endocrinology and Metabolic Bone Diseases, Royal Manchester Children's Hospital, Manchester, UK
| | - Raja Padidela
- Faculty of Life Sciences, University of Manchester, Manchester, UK Department of Paediatric Endocrinology and Metabolic Bone Diseases, Royal Manchester Children's Hospital, Manchester, UK
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Cooper C, Harvey NC, Bishop NJ, Kennedy S, Papageorghiou AT, Schoenmakers I, Fraser R, Gandhi SV, Carr A, D'Angelo S, Crozier SR, Moon RJ, Arden NK, Dennison EM, Godfrey KM, Inskip HM, Prentice A, Mughal MZ, Eastell R, Reid DM, Javaid MK. Maternal gestational vitamin D supplementation and offspring bone health (MAVIDOS): a multicentre, double-blind, randomised placebo-controlled trial. Lancet Diabetes Endocrinol 2016; 4:393-402. [PMID: 26944421 PMCID: PMC4843969 DOI: 10.1016/s2213-8587(16)00044-9] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [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: 12/30/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Maternal vitamin D status has been associated with bone mass of offspring in many, but not all, observational studies. However, maternal vitamin D repletion during pregnancy has not yet been proven to improve offspring bone mass in a randomised controlled trial. We aimed to assess whether neonates born to mothers supplemented with vitamin D during pregnancy have greater whole-body bone mineral content (BMC) at birth than those of mothers who had not received supplementation. METHODS The Maternal Vitamin D Osteoporosis Study (MAVIDOS) was a multicentre, double-blind, randomised, placebo-controlled trial that recruited pregnant women from three study sites in the UK (Southampton, Oxford, and Sheffield). Eligible participants were older than 18 years, with a singleton pregnancy, gestation of less than 17 weeks, and a serum 25-hydroxyvitamin D (25[OH]D) concentration of 25-100 nmol/L at 10-17 weeks' gestation. P'articipants were randomly assigned (1:1), in randomly permuted blocks of ten, to either cholecalciferol 1000 IU/day or matched placebo, taken orally, from 14 weeks' gestation (or as soon as possible before 17 weeks' gestation if recruited later) until delivery. Participants and the research team were masked to treatment allocation. The primary outcome was neonatal whole-body BMC, assessed within 2 weeks of birth by dual-energy x-ray absorptiometry (DXA), analysed in all randomly assigned neonates who had a usable DXA scan. Safety outcomes were assessed in all randomly assigned participants. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN 82927713, and the European Clinical Trials Database, EudraCT 2007-001716-23. FINDINGS Between Oct 10, 2008, and Feb 11, 2014, we randomly assigned 569 pregnant women to placebo and 565 to cholecalciferol 1000 IU/day. 370 (65%) neonates in the placebo group and 367 (65%) neonates in the cholecalciferol group had a usable DXA scan and were analysed for the primary endpoint. Neonatal whole-body BMC of infants born to mothers assigned to cholecalciferol 1000 IU/day did not significantly differ from that of infants born to mothers assigned to placebo (61·6 g [95% CI 60·3-62·8] vs 60·5 g [59·3-61·7], respectively; p=0·21). We noted no significant differences in safety outcomes, apart from a greater proportion of women in the placebo group with severe post-partum haemorrhage than those in the cholecalciferol group (96 [17%] of 569 mothers in the placebo group vs 65 [12%] of 565 mothers in the cholecalciferol group; p=0·01). No adverse events were deemed to be treatment related. INTERPRETATION Supplementation of women with cholecalciferol 1000 IU/day during pregnancy did not lead to increased offspring whole-body BMC compared with placebo, but did show that 1000 IU of cholecalciferol daily is sufficient to ensure that most pregnant women are vitamin D replete, and it is safe. These findings support current approaches to vitamin D supplementation in pregnancy. Results of the ongoing MAVIDOS childhood follow-up study are awaited. FUNDING Arthritis Research UK, Medical Research Council, Bupa Foundation, and National Institute for Health Research.
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Affiliation(s)
- Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Oxford, UK.
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicholas J Bishop
- Academic Unit of Child Health, Sheffield Children's Hospital, University of Sheffield, Sheffield, UK
| | - Stephen Kennedy
- Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Inez Schoenmakers
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - Robert Fraser
- Sheffield Hospitals NHS Trust, University of Sheffield, Sheffield, UK
| | - Saurabh V Gandhi
- Sheffield Hospitals NHS Trust, University of Sheffield, Sheffield, UK
| | - Andrew Carr
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Oxford, UK
| | - Stefania D'Angelo
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Sarah R Crozier
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Rebecca J Moon
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Nigel K Arden
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Oxford, UK
| | - Elaine M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Keith M Godfrey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Hazel M Inskip
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Ann Prentice
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospitals, Manchester, UK
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - David M Reid
- School of Medicine and Dentistry, Medical School, University of Aberdeen, Aberdeen, UK
| | - M Kassim Javaid
- Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Oxford, UK
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Patel P, Mughal MZ, Patel P, Yagnik B, Kajale N, Mandlik R, Khadilkar V, Chiplonkar SA, Phanse S, Patwardhan V, Patel A, Khadilkar A. Dietary calcium intake influences the relationship between serum 25-hydroxyvitamin D3 (25OHD) concentration and parathyroid hormone (PTH) concentration. Arch Dis Child 2016; 101:316-9. [PMID: 26359508 DOI: 10.1136/archdischild-2015-308985] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 05/16/2015] [Accepted: 08/21/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether dietary calcium intake will modify the relationship between serum 25-hydroxyvitamin D3 (25OHD) with intact serum parathyroid hormone (PTH) concentrations in apparently healthy Indian adolescents. STUDY DESIGN Cross-sectional study. SETTING AND PARTICIPANTS Apparently healthy adolescents aged 10-14 years (n=181), from Gujarat, western India. Study conducted from January 2012 to March 2014. METHODS Serum 25OHD concentrations and intact serum PTH concentrations (both using chemiluminescent microparticle immunoassay) were measured. Diet was recorded through 24 h diet recall and calcium intake was computed (C-diet V.2.1). To assess relationship between 25OHD and PTH, data were dichotomised according to median calcium intakes (520 mg/day) and relationship between serum 25OHD and PTH in the two subgroups was plotted. RESULTS Subjects with calcium intakes above median (>520 mg/day) had lower intact serum PTH values for given serum 25OHD concentration while those with calcium intakes below median (<520 mg/day) had higher intact serum PTH values for given serum 25OHD concentration. Serum 25OHD concentration was negatively correlated with intact serum PTH concentration at lower as well as higher calcium intakes (r=- 0.606 and -0.483, respectively, p<0.01 for both). Using a regression analysis, predicted values for intact serum PTH concentration for the given serum 25OHD concentrations were plotted. The plot revealed a negative shift with increasing calcium intake. CONCLUSIONS Dietary calcium intake modifies the relationship between serum 25OHD concentrations and intact serum PTH concentrations. Thus, dietary calcium intake should be taken into account when assessing an individual's vitamin D status.
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Affiliation(s)
- Prerna Patel
- Department of Biotechnology, Hemchandracharya North Gujarat University, Patan, Gujarat, India
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Pinal Patel
- Department of Biotechnology, Hemchandracharya North Gujarat University, Patan, Gujarat, India
| | - Bhrugu Yagnik
- Department of Biochemistry, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
| | - Neha Kajale
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Rubina Mandlik
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Shashi A Chiplonkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Supriya Phanse
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Vivek Patwardhan
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
| | - Ashish Patel
- Department of Biotechnology, Hemchandracharya North Gujarat University, Patan, Gujarat, India
| | - Anuradha Khadilkar
- Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, Maharashtra, India
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Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, Michigami T, Tiosano D, Mughal MZ, Mäkitie O, Ramos-Abad L, Ward L, DiMeglio LA, Atapattu N, Cassinelli H, Braegger C, Pettifor JM, Seth A, Idris HW, Bhatia V, Fu J, Goldberg G, Sävendahl L, Khadgawat R, Pludowski P, Maddock J, Hyppönen E, Oduwole A, Frew E, Aguiar M, Tulchinsky T, Butler G, Högler W. Global Consensus Recommendations on Prevention and Management of Nutritional Rickets. J Clin Endocrinol Metab 2016; 101:394-415. [PMID: 26745253 PMCID: PMC4880117 DOI: 10.1210/jc.2015-2175] [Citation(s) in RCA: 611] [Impact Index Per Article: 76.4] [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] [Indexed: 12/16/2022]
Abstract
BACKGROUND Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describe the strength of the recommendation and the quality of supporting evidence. PROCESS Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required.
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Parthasarathy LS, Khadilkar VV, Chiplonkar SA, Zulf Mughal M, Khadilkar AV. Bone status of Indian children and adolescents with type 1 diabetes mellitus. Bone 2016; 82:16-20. [PMID: 25956533 DOI: 10.1016/j.bone.2015.04.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 04/20/2015] [Accepted: 04/29/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Low bone mineral density has been reported in children and adolescents with type 1 diabetes (T1DM). The aims of this cross-sectional study were to study growth, serum IGF1 concentrations and bone health parameters assessed by Dual Energy X-ray Absorptiometry (DXA). METHODS Height was measured and converted to Z scores (HAZ). Serum IGF1 concentrations were measured (ELISA) in a subset. Bone mineral content for total body (less head) (TBBMC) and lumbar spine was measured (n=170, 77 boys, 6-16years old) and converted to Z scores using local normative data. RESULT Mean age was 11.1±3.8years, disease duration was 2.2±2.5years and HbA1C was 10.1±1.8%. Diabetic children were shorter than reference population (HAZ -0.6±1.1); Z scores for height and total body bone area (TBBA) for height were <-2SD in 12% & 6% respectively. Serum IGF1 Z scores were lower amongst group with longer disease duration (-1.58±1.3 vs -2.63±0.7; P=0.037). Disease duration (β=-0.180, P=0.000) and metabolic control (HbA1C; β=-0.096, P=0.042) were negative predictors of HAZ and TBBA for height Z in younger children. Using the Molgaard approach, children with longer disease duration had lower HAZ (-0.31±0.92 vs -1.28±1.11; P=0.000; "short bones") and TBBA for height Z scores (0.12±1.62 vs -0.53±0.94; P=0.044; "slender bones"). Older children (tanner stages 4 and 5) had lower BMC and BA as compared to reference population possibly due to delayed growth spurt. CONCLUSION Longer duration of diabetes was associated with shorter and slender but appropriately mineralized bones. Small and slender bones in diabetic children may increase risk of fragility fractures in the future. This article is part of a Special Issue entitled "Bone and diabetes".
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Affiliation(s)
- Lavanya S Parthasarathy
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
| | - Vaman V Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
| | - Shashi A Chiplonkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.
| | - Anuradha V Khadilkar
- Growth and Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
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Hannan FM, Howles SA, Rogers A, Cranston T, Gorvin CM, Babinsky VN, Reed AA, Thakker CE, Bockenhauer D, Brown RS, Connell JM, Cook J, Darzy K, Ehtisham S, Graham U, Hulse T, Hunter SJ, Izatt L, Kumar D, McKenna MJ, McKnight JA, Morrison PJ, Mughal MZ, O'Halloran D, Pearce SH, Porteous ME, Rahman M, Richardson T, Robinson R, Scheers I, Siddique H, Van't Hoff WG, Wang T, Whyte MP, Nesbit MA, Thakker RV. Adaptor protein-2 sigma subunit mutations causing familial hypocalciuric hypercalcaemia type 3 (FHH3) demonstrate genotype-phenotype correlations, codon bias and dominant-negative effects. Hum Mol Genet 2015; 24:5079-92. [PMID: 26082470 PMCID: PMC4550820 DOI: 10.1093/hmg/ddv226] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [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: 05/01/2015] [Accepted: 06/12/2015] [Indexed: 12/05/2022] Open
Abstract
The adaptor protein-2 sigma subunit (AP2σ2) is pivotal for clathrin-mediated endocytosis of plasma membrane constituents such as the calcium-sensing receptor (CaSR). Mutations of the AP2σ2 Arg15 residue result in familial hypocalciuric hypercalcaemia type 3 (FHH3), a disorder of extracellular calcium (Ca2+o) homeostasis. To elucidate the role of AP2σ2 in Ca2+o regulation, we investigated 65 FHH probands, without other FHH-associated mutations, for AP2σ2 mutations, characterized their functional consequences and investigated the genetic mechanisms leading to FHH3. AP2σ2 mutations were identified in 17 probands, comprising 5 Arg15Cys, 4 Arg15His and 8 Arg15Leu mutations. A genotype–phenotype correlation was observed with the Arg15Leu mutation leading to marked hypercalcaemia. FHH3 probands harboured additional phenotypes such as cognitive dysfunction. All three FHH3-causing AP2σ2 mutations impaired CaSR signal transduction in a dominant-negative manner. Mutational bias was observed at the AP2σ2 Arg15 residue as other predicted missense substitutions (Arg15Gly, Arg15Pro and Arg15Ser), which also caused CaSR loss-of-function, were not detected in FHH probands, and these mutations were found to reduce the numbers of CaSR-expressing cells. FHH3 probands had significantly greater serum calcium (sCa) and magnesium (sMg) concentrations with reduced urinary calcium to creatinine clearance ratios (CCCR) in comparison with FHH1 probands with CaSR mutations, and a calculated index of sCa × sMg/100 × CCCR, which was ≥ 5.0, had a diagnostic sensitivity and specificity of 83 and 86%, respectively, for FHH3. Thus, our studies demonstrate AP2σ2 mutations to result in a more severe FHH phenotype with genotype–phenotype correlations, and a dominant-negative mechanism of action with mutational bias at the Arg15 residue.
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Affiliation(s)
- Fadil M Hannan
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah A Howles
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Angela Rogers
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Treena Cranston
- Oxford Molecular Genetics Laboratory, Churchill Hospital, Oxford, UK
| | - Caroline M Gorvin
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Valerie N Babinsky
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Anita A Reed
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Clare E Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Detlef Bockenhauer
- Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Rosalind S Brown
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - John M Connell
- School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Jacqueline Cook
- Clinical Genetics Department, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Ken Darzy
- Queen Elizabeth II Hospital, Welwyn Garden City, UK
| | - Sarah Ehtisham
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Una Graham
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Tony Hulse
- Department of Paediatrics, Evelina London Children's Hospital, St. Thomas' Hospital, London, UK
| | - Steven J Hunter
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Louise Izatt
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - Dhavendra Kumar
- Institute of Cancer and Genetics, University Hospital of Wales, Cardiff, UK
| | - Malachi J McKenna
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland
| | - John A McKnight
- Metabolic Unit, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Patrick J Morrison
- Centre for Cancer Research and Cell Biology, Queens University of Belfast, Belfast, UK, Department of Genetic Medicine, Belfast HSC Trust, Belfast, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | | | - Simon H Pearce
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Mary E Porteous
- SE Scotland Genetic Service, Western General Hospital, Edinburgh, UK
| | - Mushtaqur Rahman
- Department of Endocrinology, Northwick Park Hospital, London, UK
| | - Tristan Richardson
- Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Robert Robinson
- Department of Endocrinology, Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire, UK
| | - Isabelle Scheers
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Haroon Siddique
- Department of Endocrinology, Russells Hall Hospital, Dudley, UK
| | - William G Van't Hoff
- Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Timothy Wang
- Department of Clinical Biochemistry, Frimley Park Hospital, Surrey, UK and
| | - Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, Missouri, USA
| | - M Andrew Nesbit
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK,
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Franceschi R, Vincenzi M, Camilot M, Antoniazzi F, Freemont AJ, Adams JE, Laine C, Makitie O, Mughal MZ. Idiopathic Juvenile Osteoporosis: Clinical Experience from a Single Centre and Screening of LRP5 and LRP6 Genes. Calcif Tissue Int 2015; 96:575-9. [PMID: 25783012 DOI: 10.1007/s00223-015-9983-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/04/2015] [Indexed: 11/28/2022]
Abstract
We report clinical findings, bone mineral density (BMD) and bone biopsy data in ten children with features of classic idiopathic juvenile osteoporosis (IJO). We also screened the patients for mutations in LRP5 and LRP6. We found low BMD in the lumbar spine, the hip and distal radius. In the spine and distal radius, the reduction in BMD was more marked in the trabecular compartment. Biopsy confirmed that the trabecular compartment is more severely involved with reduction in bone formation and increase in bone resorption. No mutations in LRP5 and LRP6 could be identified. IJO is likely to be a heterogeneous bone disorder, and next-generation genomic sequencing studies may help reveal causative genes.
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Affiliation(s)
- Roberto Franceschi
- Department of Mother and Child, Biology-Genetics, Section of Pediatrics, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy,
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Giri D, Ramakrishnan R, Hayden J, Brook L, Das U, Mughal MZ, Selby P, Dharmaraj P, Senniappan S. Denosumab Therapy for Refractory Hypercalcemia Secondary to Squamous Cell Carcinoma of Skin in Epidermolysis Bullosa. World J Oncol 2015; 6:345-348. [PMID: 29147430 PMCID: PMC5649725 DOI: 10.14740/wjon907w] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2015] [Indexed: 11/18/2022] Open
Abstract
Hypercalcemia secondary to malignancy is rare in children and the majority is caused by tumor-produced parathyroid hormone-related protein (PTHrP). We report a case of hypercalcemia refractory to bisphosphonate and corticosteroid therapy, but responsive to denosumab. A 17-year-old boy with epidermolysis bullosa (EB) and advanced squamous cell carcinoma (SCC) of the left leg was referred with severe hypercalcemia (serum calcium, 4.2 mmol/L). The serum parathyroid hormone (PTH) was 0.7 pmol/L (1.1 - 6.9 pmol/L). The hypercalcemia was initially managed with hyperhydration, prednisolone and pamidronate. Following two infusions of pamidronate (1 mg/kg/dose), serum calcium fell to 2.87 mmol/L. However the hypercalcemia relapsed within a week (serum calcium, 3.61 mmol/L) needing aggressive management with intravenous fluids, prednisolone and two further doses of pamidronate. The serum calcium fell to 2.58 mmol/L over the first 4 days, but rose to 3.39 mmol/L 3 days later. As the hypercalcemia was refractory to bisphosphonate treatment, a trial dose of subcutaneous denosumab (60 mg) was administered following which the calcium fell to 2.86 mmol/L within 24 h and normocalcemia was sustained 4 days later. We report a case of refractory hypercalcemia secondary to malignant SCC, which responded well to denosumab therapy. To our knowledge, this is the first case of hypercalcemia of malignancy in an adolescent managed with denosumab.
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Affiliation(s)
- Dinesh Giri
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Renuka Ramakrishnan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - James Hayden
- Department of Paediatric Oncology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Lynda Brook
- Department of Paediatric Palliative Care, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - Urmi Das
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - M Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Rd, Manchester M13 9WL, UK
| | - Peter Selby
- Department of Medicine, Manchester Royal Infirmary, Manchester M139WL, UK
| | - Poonam Dharmaraj
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK.,The authors contributed equally to this manuscript
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool L12 2AP, UK.,The authors contributed equally to this manuscript
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Abstract
This chapter deals with a few of the important childhood bone disorders associated with high bone mass as well as conditions associated with fragility fractures and limb deformities that have not been addressed in previous chapters. A couple of skeletal dysplasias that can sometimes be confused with rickets are also dealt with in this chapter.
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Gould M, Farrar MD, Kift R, Berry JL, Mughal MZ, Bundy C, Vail A, Webb AR, Rhodes LE. Sunlight exposure and photoprotection behaviour of white Caucasian adolescents in the UK. J Eur Acad Dermatol Venereol 2014; 29:732-7. [PMID: 25185510 DOI: 10.1111/jdv.12669] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 02/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sun exposure has positive and negative effects on health, yet little is known about the sun exposure behaviour of UK adolescents, including those more prone or less prone to sunburn. OBJECTIVE To examine sun exposure behaviour of UK white Caucasian adolescents including time spent outdoors, holiday behaviour, use of sunscreen and clothing, with assessment for differences between sun-reactive skin type groups. METHODS White Caucasian adolescents (12-15 years) attending schools in Greater Manchester completed a two-page questionnaire to assess sun exposure and photoprotective behaviour. RESULTS A total of 133 adolescents (median age 13.4 years; 39% skin type I/II, 61% skin type III/IV) completed the questionnaire. In summer, adolescents spent significantly longer outdoors at weekends (median 4 h/day, range 0.25-10) than on weekdays (2, 0.25-6; P < 0.0001). When at home in the UK during summer, 44% reported never wearing sunscreen compared to just 1% when on a sunny holiday. Sunscreen use was also greater (frequency/coverage) when on a sunny holiday than at home in the UK summer (P < 0.0001). Adolescents of skin types I/II (easy burning) spent significantly less time outdoors than skin types III/IV (easy tanning) on summer weekends (P < 0.001), summer weekdays (P < 0.05) and on a sunny holiday (P = 0.001). Furthermore, skin types I/II reported greater sunscreen use during summer in the UK and on sunny holiday (both P < 0.01), and wore clothing covering a greater skin area on a sunny holiday (P < 0.01) than skin types III/IV. There was no difference in sun exposure behaviour/protection between males and females. CONCLUSION The greater sun-protective measures reported by adolescents of sun-reactive skin type group I/II than III/IV suggest those who burn more easily are aware of the greater need to protect their skin. However, use of sunscreen during the UK summer is low and may need more effective promotion in adolescents.
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Affiliation(s)
- M Gould
- Centre for Dermatology, Institute of Inflammation and Repair, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Salford Royal NHS Foundation Hospital, Manchester, UK
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48
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Abstract
Children with moderate to severe cerebral palsy are at increased risk of sustaining fracture following minimal trauma. Such fractures predominantly occur in lower limb bones and are associated with low bone mineral density. Risk factors for fracture in this group include nonambulatory status, anticonvulsant use, presence of a joint contractures, immobilization after surgery, and poor nutrition. Aims of this review are to describe the prevalence and pathogenesis of fractures in nonambulant children with cerebral palsy. Interventions and treatments that improve low bone mineral density and which may help to reduce the fracture risk in this population are also discussed.
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Affiliation(s)
- M Zulf Mughal
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK,
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49
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Affiliation(s)
- Jeremy Allgrove
- Consultant Paediatric Endocrinologist, Barts Health NHS Trust, Royal London Hospital, London, UK Honorary Consultant Paediatric Endocrinologist, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - M Zulf Mughal
- Consultant in Paediatric Bone Disorders & Honorary Professor of Child Health, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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50
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Bianchi ML, Leonard MB, Bechtold S, Högler W, Mughal MZ, Schönau E, Sylvester FA, Vogiatzi M, van den Heuvel-Eibrink MM, Ward L. Bone health in children and adolescents with chronic diseases that may affect the skeleton: the 2013 ISCD Pediatric Official Positions. J Clin Densitom 2014; 17:281-94. [PMID: 24656723 DOI: 10.1016/j.jocd.2014.01.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 12/11/2022]
Abstract
The aim of this Task Force was to review the use of dual-energy X-ray absorptiometry (DXA) in children and adolescents with underlying chronic diseases that pose risk factors for compromised bone health, such as inflammation, glucocorticoid therapy, or decreased mobility. The Task Force systematically analyzed more than 270 studies, with an emphasis on those published in the interval since the original 2007 Position Statements. Important developments over this period included prospective cohort studies demonstrating that DXA measures of areal bone mineral density (aBMD) predicted incident fractures and the development of robust reference data and strategies to adjust for bone size in children with growth impairment. In this report, we summarize the current literature on the relationship between DXA-based aBMD and both fracture (vertebral and non-vertebral) outcomes and non-fracture risk factors (e.g., disease characteristics, ambulatory status, and glucocorticoid exposure) in children with chronic illnesses. Most publications described the aBMD profile of children with underlying diseases, as well as the cross-sectional or longitudinal relationship between aBMD and clinically relevant non-fracture outcomes. Studies that addressed the relationship between aBMD and prevalent or incident fractures in children with chronic illnesses are now emerging. In view of these updated data, this report provides guidelines for the use of DXA-based aBMD in this setting. The initial recommendation that DXA is part of a comprehensive skeletal healthy assessment in patients with increased risk of fracture is unchanged. Although the prior guidelines recommended DXA assessment in children with chronic diseases at the time of clinical presentation with ongoing monitoring, this revised Position Statement focuses on the performance of DXA when the patient may benefit from interventions to decrease their elevated risk of a clinically significant fracture and when the DXA results will influence that management.
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Affiliation(s)
- Maria Luisa Bianchi
- Experimental Laboratory for Children's Bone Metabolism Research, Istituto Auxologico Italiano IRCCS, Milano, Italy.
| | - Mary B Leonard
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Susanne Bechtold
- Department of Pediatrics, Medical University Munich, Munich, Germany
| | - Wolfgang Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - M Zulf Mughal
- Department of Paediatric Medicine, Royal Manchester Children's Hospital, Manchester, UK
| | - Eckhart Schönau
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinik Köln, Köln, Germany
| | | | - Maria Vogiatzi
- Department of Pediatric Endocrinology, Weill Medical College of Cornell University, New York, NY, USA
| | | | - Leanne Ward
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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