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Kim HY, Shim JH, Kim BK, Heo CY. Vitamin D Attenuates Fibrotic Properties of Fibrous Dysplasia-Derived Cells for the Transit towards Osteocytic Phenotype. Int J Mol Sci 2024; 25:4954. [PMID: 38732172 PMCID: PMC11084186 DOI: 10.3390/ijms25094954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Fibrous dysplasia (FD) poses a therapeutic challenge due to the dysregulated extracellular matrix (ECM) accumulation within affected bone tissues. In this study, we investigate the therapeutic potential of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) in managing FD by examining its effects on FD-derived cells in vitro. Our findings demonstrate that 1,25(OH)2D3 treatment attenuates the pro-fibrotic phenotype of FD-derived cells by suppressing the expression of key pro-fibrotic markers and inhibiting cell proliferation and migration. Moreover, 1,25(OH)2D3 enhances mineralization by attenuating pre-osteoblastic cellular hyperactivity and promoting maturation towards an osteocytic phenotype. These results offer valuable insights into potential treatments for FD, highlighting the role of 1,25(OH)2D3 in modulating the pathological properties of FD-derived cells.
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Affiliation(s)
- Ha-Young Kim
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul 08826, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea;
| | - Jung-Hee Shim
- Department of Research Administration Team, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Baek-Kyu Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Chan-Yeong Heo
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul 08826, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
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2
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Bertin H, Moussa MS, Komarova S. Efficacy of antiresorptive agents in fibrous dysplasia and McCune Albright syndrome, a systematic review and meta-analysis. Rev Endocr Metab Disord 2023; 24:1103-1119. [PMID: 37632645 DOI: 10.1007/s11154-023-09832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
Fibrous dysplasia (FD) is a rare skeletal disorder in which normal bone is replaced by a fibro-osseous tissue, resulting in possible deformities and fractures. The aim of this systematic review and meta-analysis was to synthesize the available evidence on the use of antiresorptive drugs in FD in terms of changes in bone turnover markers (BTMs), bone mineral density (BMD), and reducing pain. Three databases were searched in October 2022, with an update in July 2023. Of the 1037 studies identified, 21 were retained after eligibility assessment. A random-effects model was used to calculate global effect size and the corresponding standard error. Pamidronate and Denosumab were the most reported drugs in a total of 374 patients assessed. The initiation of treatments was accompanied by an average reduction of 40.5% [CI95% -51.6, -29.3] in the bone resorption parameters, and 22.0% [CI95% -31.9, -12.1] in the parameters of bone formation after 6-12 months. BMD was increased in both FD lesions and in the unaffected skeleton. Pain was reduced by 32.7% [CI95% -52.7, -12.6] after 6-12 months of treatment, and by 44.5% [CI95% -65.3, -23.6] after a mean 41.2 months of follow-up. The variation in pain was highly correlated to variation in bone resorption (R2 = 0.08, p < 0.0001) and formation parameters (R2 = 0.17, p < 0.0001). This study supports the overall efficacy of antiresorptive therapies in terms of reducing bone remodeling, improving bone density, and pain in FD.
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Affiliation(s)
- Hélios Bertin
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, H3A 1G1, Canada.
- Nantes Université, CHU Nantes, Service de chirurgie maxillo-faciale et stomatologie, F-44000, Nantes, France.
- Nantes Université, UnivAngers, CHU Nantes, INSERM, CNRS, CRCI2NA, F-44000, Nantes, France.
| | - Mahmoud S Moussa
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, H3A 1G1, Canada
- Shriners Hospitals for Children - Canada, Montreal, QC, H4A 0A9, Canada
| | - Svetlana Komarova
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC, H3A 1G1, Canada
- Shriners Hospitals for Children - Canada, Montreal, QC, H4A 0A9, Canada
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3
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Kim HY, Shim JH, Heo CY. A Rare Skeletal Disorder, Fibrous Dysplasia: A Review of Its Pathogenesis and Therapeutic Prospects. Int J Mol Sci 2023; 24:15591. [PMID: 37958575 PMCID: PMC10650015 DOI: 10.3390/ijms242115591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Fibrous dysplasia (FD) is a rare, non-hereditary skeletal disorder characterized by its chronic course of non-neoplastic fibrous tissue buildup in place of healthy bone. A myriad of factors have been associated with its onset and progression. Perturbation of cell-cell signaling networks and response outputs leading to disrupted building blocks, incoherent multi-level organization, and loss of rigid structural motifs in mineralized tissues are factors that have been identified to participate in FD induction. In more recent years, novel insights into the unique biology of FD are transforming our understandings of its pathology, natural discourse of the disease, and treatment prospects. Herein, we built upon existing knowledge with recent findings to review clinical, etiologic, and histological features of FD and discussed known and potential mechanisms underlying FD manifestations. Subsequently, we ended on a note of optimism by highlighting emerging therapeutic approaches aimed at either halting or ameliorating disease progression.
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Affiliation(s)
- Ha-Young Kim
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul 08826, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea
| | - Jung-Hee Shim
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea;
- Department of Research Administration Team, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea
| | - Chan-Yeong Heo
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul 08826, Republic of Korea;
- Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul 03080, Republic of Korea
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam 13620, Republic of Korea;
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4
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Pharmacological Interventions Targeting Pain in Fibrous Dysplasia/McCune-Albright Syndrome. Int J Mol Sci 2023; 24:ijms24032550. [PMID: 36768871 PMCID: PMC9916440 DOI: 10.3390/ijms24032550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/03/2023] Open
Abstract
Fibrous dysplasia (FD) is a rare, non-inherited bone disease occurring following a somatic gain-of-function R201 missense mutation of the guanine-nucleotide binding protein alpha subunit stimulating activity polypeptide 1 (GNAS) gene. The spectrum of the disease ranges from a single FD lesion to a combination with extraskeletal features; an amalgamation with café-au-lait skin hyperpigmentation, precocious puberty, and other endocrinopathies defines McCune-Albright Syndrome (MAS). Pain in FD/MAS represents one of the most prominent aspects of the disease and one of the most challenging to treat-an outcome driven by (i) the heterogeneous nature of FD/MAS, (ii) the variable presentation of pain phenotypes (i.e., craniofacial vs. musculoskeletal pain), (iii) a lack of studies probing pain mechanisms, and (iv) a lack of rigorously validated analgesic strategies in FD/MAS. At present, a range of pharmacotherapies are prescribed to patients with FD/MAS to mitigate skeletal disease activity, as well as pain. We analyze evidence guiding the current use of bisphosphonates, denosumab, and other therapies in FD/MAS, and also discuss the potential underlying pharmacological mechanisms by which pain relief may be achieved. Furthermore, we highlight the range of presentation of pain in individual cases of FD/MAS to further describe the difficulties associated with employing effective pain treatment in FD/MAS. Potential next steps toward identifying and validating effective pain treatments in FD/MAS are discussed, such as employing randomized control trials and probing new pain pathways in this rare bone disease.
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Meier ME, Hagelstein-Rotman M, van de Ven AC, Van der Geest ICM, Donker O, Pichardo SEC, Hissink Muller PCE, van der Meeren SW, Dorleijn DMJ, Winter EM, van de Sande MAJ, Appelman-Dijkstra NM. A multidisciplinary care pathway improves quality of life and reduces pain in patients with fibrous dysplasia/McCune-Albright syndrome: a multicenter prospective observational study. Orphanet J Rare Dis 2022; 17:439. [PMID: 36528764 PMCID: PMC9758844 DOI: 10.1186/s13023-022-02588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) may cause pain, impaired ambulation and decreased quality of life (QoL). International guidelines advocate management of FD/MAS in a tertiary multidisciplinary care pathway, but no longitudinal data are available to support this recommendation. This multicenter prospective observational study aimed to evaluate effects of 1 year of treatment in the FD/MAS care pathway in 2 tertiary clinics on QoL and pain, assessed by change in Short Form 36 and Brief Pain Inventory between baseline and follow-up. Patients completing baseline questionnaires < 1 year after intake were classified as new referrals, others as under chronic care. RESULTS 92 patients were included, 61 females (66%). 22 patients (24%) had monostotic disease, 16 (17%) isolated craniofacial FD, 27 (40%) polyostotic FD and 17 (19%) MAS. 26 were new referrals (28%) and 66 chronic patients (72%). Median age at baseline was 47 years (Q1-Q3 36-56). Skeletal burden correlated with baseline Physical Function (rs = - 0.281, p = 0.007). QoL was in all domains lower compared to the general population. New referrals reported clinically important differences (CID) over time in domains Physical Function (mean 67 ± SD24 to 74 ± 21, effect size (ES) 0.31, p = 0.020), Role Physical (39 ± 41 to 53 ± 43, ES 0.35, p = 0.066), Social Functioning (64 ± 24 to 76 ± 23, ES 0.49, p = 0.054), and Health Change (39 ± 19 to 53 ± 24, ES 0.76, p = 0.016), chronic patients in Physical Function (52 ± 46 to 66 ± 43, ES 0.31, p = 0.023) and Emotional Wellbeing (54 ± 27 to 70 ± 15, ES 0.59, p < 0.001). New referrals reported a CID of 1 point in maximum pain, average pain and pain interference, chronic patients reported stable scores. Change in pain interference and Role Physical were correlated (rs = - 0.472, p < 0.001). Patients with limited disease extent improved more than patients with severe disease. Patients receiving FD-related therapy had lower baseline scores than patients not receiving therapy and reported improvements in QoL after 1 year. Yet also patients without FD-related therapy improved in Physical Function. CONCLUSIONS All FD-subtypes may induce pain and reduced QoL. A multidisciplinary care pathway for FD/MAS may improve pain and QoL, mainly in new referrals without MAS comorbidities with low baseline scores. Therefore, we recommend referral of patients with all subtypes of FD/MAS to specialized academic centers.
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Affiliation(s)
- Maartje E. Meier
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marlous Hagelstein-Rotman
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Annenienke C. van de Ven
- grid.10417.330000 0004 0444 9382Department of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ingrid C. M. Van der Geest
- grid.10417.330000 0004 0444 9382Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olav Donker
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarina E. C. Pichardo
- grid.10419.3d0000000089452978Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Petra C. E. Hissink Muller
- grid.508552.fDepartment of Paediatric Rheumatology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Stijn W. van der Meeren
- grid.10419.3d0000000089452978Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Desirée M. J. Dorleijn
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M. Winter
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel A. J. van de Sande
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Natasha M. Appelman-Dijkstra
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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Hung C, Shibli-Rahhal A. Denosumab Use in Adults With Fibrous Dysplasia: Case Reports and Review of the Literature. Endocr Pract 2022; 28:1196-1201. [PMID: 35952985 DOI: 10.1016/j.eprac.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In fibrous dysplasia (FD) of the bone, a gain-of-function mutation in the G-nucleotide binding protein alpha subunit results in constitutively active cyclic adenosine monophosphate. Downstream effects include formation of disorganized cortex and bone marrow fibrosis. Patients with FD experience bone pain and are at risk of fracture. Bisphosphonates are traditionally used to manage pain with mixed results. We sought to report denosumab use in patients with FD at our institution and summarized the existing literature on denosumab use in FD. METHODS We retrospectively identified patients with FD who were treated with denosumab at our institution, describing patient characteristics and outcomes. We reviewed the existing literature on denosumab use in patients with FD. RESULTS Patient 1 was diagnosed with FD at the age of 17 years and took bisphosphonates with initial improvement in pain. Pain eventually worsened; therefore, she received 4 doses of denosumab. Patient 2 was diagnosed with FD after a fall and was treated with bisphosphonates, reporting some initial improvement in bone pain. A few years later, the pain recurred, and he received 3 doses of denosumab. Both patients tolerated denosumab well but experienced no improvement in pain. On literature review, although some serious side effects were noted, patients experienced a decline in bone turnover markers, and most reported improvement in bone pain with denosumab. CONCLUSION Denosumab is a promising therapy for managing symptoms of FD. Further studies are needed to determine the optimal dose and duration of treatment. Its long-term effect on FD lesions remains unclear.
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Affiliation(s)
- Chermaine Hung
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
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Wang Y, Luo Y, Min L, Zhou Y, Wang J, Zhang Y, Lu M, Duan H, Tu C. The West China Hospital radiographic classification for fibrous dysplasia in femur and adjacent bones: A retrospective analysis of 205 patients. Orthop Surg 2022; 14:2096-2108. [PMID: 35924702 PMCID: PMC9483050 DOI: 10.1111/os.13404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 02/05/2023] Open
Abstract
Objective This study aims to investigate the reliability and clinical outcome of a newly developed classification system for patients with fibrous dysplasia (FD) of the femur and adjacent bones, optimizing its evaluation and management. Methods A total of 205 patients (121 female and 84 male) with FD in the femur and adjacent bones were included in this retrospective study. All affected femurs were measured and treated based on this classification at our institution between 2009 and 2019. Based on previous studies and extensive clinical follow‐up, we cautiously proposed the West China Hospital radiographic classification for FD in femur and adjacent bones following corresponding treatment options. There are five types with five radiographic features, including proximal femur bone loss, coxa vara, femoral shaft deformity, genu valgum, and hip arthritis. The intraobserver and interobserver reproducibility of this classification was assessed by four observers using the Cohen kappa statistic. The clinical outcome was evaluated using the criteria of Guille. Results At a median follow‐up of 60 months (range 6–120), 205 patients (median 34.8 years old, range 18–73 years old) were categorized into the following five types: Type I 31.7%, Type II 30.2%, Type III 20.5%, Type IV 10.2%, and Type V 7.3%. The mean interobserver and intraobserver kappa scores were 0.85 (range 0.77–0.89) and 0.85 (range 0.79–0.92), respectively. For clinical outcomes, there was no significant difference in the postoperative Guille score for Type I patients (mean 9.01 ± 1.22). There was a significant increase in the postoperative Guille score in Type II, III, IV, and V, compared to the preoperative values (P < 0.01). For complications, two Type III patients reported pain, and one Type III patient had mild‐to‐moderate Trendelenburg gait. One Type IV patient had a mild Trendelenburg gait. And two Type V patients still had mild limping. Conclusion This classification is reproducible and serves as a tool for evaluating and treating FD in the femur and adjacent bones. Therefore, we recommend this classification for the diagnosis and treatment of FD‐related deformities in the femur and adjacent bones.
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Affiliation(s)
- Yitian Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Yi Luo
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Li Min
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Yong Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Jie Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Yuqi Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Minxun Lu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Hong Duan
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China
| | - Chongqi Tu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P. R. China.,Bone and Joint 3D-Printing & Biomechanical Laboratory, Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
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8
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Spencer TL, Watts L, Soni A, Pinedo-Villanueva R, Heegaard AM, Boyce AM, Javaid MK. Neuropathic-like Pain in Fibrous Dysplasia/McCune-Albright Syndrome. J Clin Endocrinol Metab 2022; 107:e2258-e2266. [PMID: 35262711 PMCID: PMC9113795 DOI: 10.1210/clinem/dgac120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Pain is a major symptom in adults with fibrous dysplasia/McCune-Albright syndrome (FD/MAS) and response to current treatments, including bisphosphonates and standard analgesics (nonsteroidal anti-inflammatory drugs and opiates) is unpredictable. No studies have explored whether the type of pain is variable in this patient group. OBJECTIVE To determine the frequency of neuropathic-like pain in patients with FD/MAS. DESIGN Retrospective, dual registry study. SETTING Community. PATIENTS FD/MAS online registries: the US-based Familial Dysautonomia Foundation (FDF) and the UK-based Rare and Undiagnosed Diseases (RUDY) study. INTERVENTION Subjects completed questionnaires to evaluate the presence of features of neuropathic-like pain (painDETECT) and the impact on sleep quality (Pittsburgh Sleep Quality Index) and mental health (Hospital Anxiety and Depression Scale). Descriptive statistics were used to characterize the prevalence and associated burden of neuropathic-like pain. MAIN OUTCOME MEASURES Incidence of neuropathic, nociceptive, and unclear pain. RESULTS Of 249 participants, one third experienced neuropathic-like pain. This group had statistically significantly (P < 0.001) worse mental well-being and sleep in comparison to those with predominately nociceptive pain. CONCLUSIONS Neuropathic-like pain is common in patients with FD/MAS and associated with worse quality of life. Evaluation of pain in patients with FD/MAS should include assessment of neuropathic-like pain to guide personalized approaches to treatment and inform future research.
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Affiliation(s)
- Tiahna L Spencer
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Laura Watts
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
| | - Anushka Soni
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Rafael Pinedo-Villanueva
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne-Marie Heegaard
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - M Kassim Javaid
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Correspondence: Muhammad K. Javaid, PhD, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX4 2UH, UK.
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9
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Golden E, Zhang F, Selen DJ, Ebb D, Romo L, Drubach LA, Shah N, O'Donnell LJ, Lemme JD, Myers R, Cay M, Kronenberg HM, Westin CF, Boyce AM, Kaban LB, Upadhyay J. Case Report: The Imperfect Association Between Craniofacial Lesion Burden and Pain in Fibrous Dysplasia. Front Neurol 2022; 13:855157. [PMID: 35370900 PMCID: PMC8966612 DOI: 10.3389/fneur.2022.855157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/08/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with fibrous dysplasia (FD) often present with craniofacial lesions that affect the trigeminal nerve system. Debilitating pain, headache, and migraine are frequently experienced by FD patients with poor prognosis, while some individuals with similar bone lesions are asymptomatic. The clinical and biological factors that contribute to the etiopathogenesis of pain in craniofacial FD are largely unknown. We present two adult females with comparable craniofacial FD lesion size and location, as measured by 18F-sodium fluoride positron emission tomography/computed tomography (PET/CT), yet their respective pain phenotypes differed significantly. Over 4 weeks, the average pain reported by Patient A was 0.4/0–10 scale. Patient B reported average pain of 7.8/0–10 scale distributed across the entire skull and left facial region. Patient B did not experience pain relief from analgesics or more aggressive treatments (denosumab). In both patients, evaluation of trigeminal nerve divisions (V1, V2, and V3) with CT and magnetic resonance imaging (MRI) revealed nerve compression and displacement with more involvement of the left trigeminal branches relative to the right. First-time employment of diffusion MRI and tractography suggested reduced apparent fiber density within the cisternal segment of the trigeminal nerve, particularly for Patient B and in the left hemisphere. These cases highlight heterogeneous clinical presentation and neurobiological properties in craniofacial FD and also, the disconnect between peripheral pathology and pain severity. We hypothesize that a detailed phenotypic characterization of patients that incorporates an advanced imaging approach probing the trigeminal system may provide enhanced insights into the variable experiences with pain in craniofacial FD.
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Affiliation(s)
- Emma Golden
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Fan Zhang
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Daryl J Selen
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - David Ebb
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Laura Romo
- Head and Neck Imaging, Department of Radiology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Laura A Drubach
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Nehal Shah
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Lauren J O'Donnell
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Jordan D Lemme
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Rachel Myers
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Mariesa Cay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Henry M Kronenberg
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Carl-Fredrik Westin
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Alison M Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Leonard B Kaban
- Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA, United States
| | - Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Psychiatry, McLean Hospital and Harvard Medical School, Belmont, MA, United States
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10
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Vyas A, Godara A, Kumar N, Singhal S, Bhattacherjee D. Fibrous Dysplasia of Proximal Femur: A Case Report of Treatment With Single-Stage Valgus Osteotomy With Dynamic Hip Screw and Fibular Strut Graft. Cureus 2022; 14:e21496. [PMID: 35223273 PMCID: PMC8860356 DOI: 10.7759/cureus.21496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 11/29/2022] Open
Abstract
Fibrous dysplasia is a rare benign intramedullary fibro-osseous lesion characterized by fibro-osseous proliferation with intervening areas of normal or immature bone. It can either be a monostotic or a polyostotic presentation. The etiology of fibrous dysplasia has been linked with a missense mutation in the GNAS1 gene on chromosome 20. The most common fibrous dysplasia is first diagnosed in children or young adults. There is no gender predilection. Overall, fibrous dysplasia constitutes 5% of all benign bone lesions.The monostotic form is the most frequent, accounting for 75% to 80% of fibrous dysplasia cases. We report a case of unilateral monostotic fibrous dysplasia in a 30-year-old male in the proximal femur with Shepherd's crook deformity. The patient underwent a single-stage procedure of curettage of lesion and valgus osteotomy with dynamic hip screw (DHS) fixation and fibular strut graft. The lesion resulted in alteration of hip joint anatomy with a decrease in the neck-shaft angle to 114 degrees and leading to coxa vara. After surgical correction, the neck-shaft angle was restored to 130 degrees. The patient was followed up in the outpatient department (OPD), x-rays were taken, and signs of radiological healing were seen at three months. Partial weight-bearing was allowed at three months postoperatively and full weight-bearing at six months with no restriction in the activity. After six months, the patient was able to perform all activities without any difficulty, and shortening of 1.5 cm was compensated with footwear modification. No evidence of recurrence was noted in the follow-up x-ray. Fibrous dysplasia of proximal femur treated with curettage and bone grafting and supported with an osteotomy to correct mechanical alignment provides excellent results. DHS, though old hardware, provides a versatile option to support osteotomy and helps in maintaining the correction. To support the neck femur after curettage, the fibula strut graft provides an excellent option. When the procedure is done in a single stage, it gives good functional and radiological outcomes along with early rehabilitation.
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11
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Raborn LN, Burke AB, Ebb DH, Collins MT, Kaban LB, Boyce AM. Denosumab for craniofacial fibrous dysplasia: duration of efficacy and post-treatment effects. Osteoporos Int 2021; 32:1889-1893. [PMID: 33772327 DOI: 10.1007/s00198-021-05895-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
Denosumab has been advocated as a potential treatment for the rare skeletal disorder fibrous dysplasia (FD); however, there is limited data to support safety and efficacy, particularly after drug discontinuation. We report a case of successful treatment of aggressive craniofacial FD with denosumab, highlighting novel insights into the duration of efficacy, surrogate treatment markers, and discontinuation effects. A 13-year-old girl presented with persistent pain and expansion of a maxillary FD lesion, which was not responsive to repeated surgical procedures or bisphosphonates. Pre-treatment biopsy showed high RANKL expression and localization with proliferation markers. Denosumab therapy was associated with improved pain, decreased bone turnover markers, and increased lesion density on computed tomography scan. During 3.5 years of treatment, the patient developed increased non-lesional bone density, and after denosumab discontinuation, she developed hypercalcemia managed with bisphosphonates. Pain relief and lesion stability continued for 2 years following treatment, and symptom recurrence coincided with increased bone turnover markers and decreased lesion density back to pre-treatment levels. This case highlights the importance of considering the duration of efficacy when treating patients with FD and other nonresectable skeletal neoplasms that require long-term management.
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Affiliation(s)
- L N Raborn
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - A B Burke
- Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA, USA
| | - D H Ebb
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - M T Collins
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - L B Kaban
- Department of Oral & Maxillofacial Surgery, Massachusetts General Hospital, Harvard School of Dental Medicine, Boston, MA, USA
| | - A M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, 30 Convent Drive, Building 30, Room 228, MSC 4320, Bethesda, MD, 20892-4320, USA.
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12
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Pan KS, Boyce AM. Denosumab Treatment for Giant Cell Tumors, Aneurysmal Bone Cysts, and Fibrous Dysplasia-Risks and Benefits. Curr Osteoporos Rep 2021; 19:141-150. [PMID: 33616817 PMCID: PMC9533232 DOI: 10.1007/s11914-021-00657-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW This review summarizes current understanding of the role of denosumab, an inhibitor of receptor activator of nuclear kappa-B ligand (RANKL), in the management of 3 skeletal neoplasms: giant cell tumors, aneurysmal bone cysts, and fibrous dysplasia. RECENT FINDINGS A growing body of literature supports denosumab use in giant cell tumors, a neoplasm in which RANKL plays a clear pathogenic role. Comparatively less data is available in aneurysmal bone cysts and fibrous dysplasia; however, the pathogenic similarity of these disorders to giant cell tumors, as well as encouraging preliminary data, suggests denosumab may be useful. Denosumab's inhibitory effects on bone turnover are fully reversible after drug discontinuation. This raises important unanswered questions for clinical management, including potential risks of tumor recurrence and bone turnover rebound. Denosumab is a promising potential treatment for skeletal neoplasms. However, its clinical use is impacted by ongoing safety concerns related to postdiscontinuation rebound, particularly in children. There is a critical need to understand denosumab treatment and discontinuation effects on tumor recurrence and to develop strategies for long-term treatment in patients who cannot be managed surgically.
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Affiliation(s)
- Kristen S Pan
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Building 30 Room 228 MSC 4320, Bethesda, MD, 20892, USA.
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.
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13
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Pain Phenotypes in Rare Musculoskeletal and Neuromuscular Diseases. Neurosci Biobehav Rev 2021; 124:267-290. [PMID: 33581222 DOI: 10.1016/j.neubiorev.2021.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/18/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
For patients diagnosed with a rare musculoskeletal or neuromuscular disease, pain may transition from acute to chronic; the latter yielding additional challenges for both patients and care providers. We assessed the present understanding of pain across a set of ten rare, noninfectious, noncancerous disorders; Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Fibrodysplasia Ossificans Progressiva, Fibrous Dysplasia/McCune-Albright Syndrome, Complex Regional Pain Syndrome, Duchenne Muscular Dystrophy, Infantile- and Late-Onset Pompe disease, Charcot-Marie-Tooth Disease, and Amyotrophic Lateral Sclerosis. Through the integration of natural history, cross-sectional, retrospective, clinical trials, & case studies we described pathologic and genetic factors, pain sources, phenotypes, and lastly, existing therapeutic approaches. We highlight that while rare diseases possess distinct core pathologic features, there are a number of shared pain phenotypes and mechanisms that may be prospectively examined and therapeutically targeted in a parallel manner. Finally, we describe clinical and research approaches that may facilitate more accurate diagnosis, monitoring, and treatment of pain as well as elucidation of the evolving nature of pain phenotypes in rare musculoskeletal or neuromuscular illnesses.
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14
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Jensen AR, Sperling JW. Shoulder arthroplasty in the setting of polyostotic fibrous dysplasia. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:69-73. [PMID: 37588631 PMCID: PMC10426535 DOI: 10.1016/j.xrrt.2020.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Andrew R. Jensen
- Department of Orthopaedic Surgery, University of California, Los Angeles, CA, USA
| | - John W. Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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15
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Lame CA, Loum B, Diallo TB, Ndiaye CB, Diouf KMA, Fall A. [Craniofacial fibrous dysplasia: about six cases]. Pan Afr Med J 2020; 37:271. [PMID: 33598085 PMCID: PMC7864254 DOI: 10.11604/pamj.2020.37.271.21350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/02/2020] [Indexed: 12/04/2022] Open
Abstract
La dysplasie fibreuse osseuse (DFO) est une maladie osseuse bénigne, congénitale et rare, dans laquelle l´os normal est remplacé par du tissu fibro-osseux entraînant des lésions osseuses déformantes. Tous les os peuvent être concernés, cependant la localisation crânio-faciale se particularise par ses manifestations cliniques, son évolution et ses difficultés thérapeutiques. L´objectif de notre travail était de décrire les aspects diagnostiques, thérapeutiques et évolutifs des DFO crânio-faciales. Nous rapportons six observations de patients suivis au service d´ORL de l´Hôpital Principal de Dakar pour DFO crânio-faciale. L´âge moyen des patients était de 26,16 ans avec des extrêmes de 11 et 58 ans. Le sexe féminin était prédominant dans 83% des cas. Les circonstances de découverte étaient dominées par la déformation osseuse. Un patient a consulté pour obstruction nasale unilatérale avec épistaxis. Le scanner a permis dans tous les cas de faire le diagnostic et le bilan topographique. Deux patientes ont bénéficié d´un traitement chirurgical. Un cas de récidive a été observé. La DFO crânio-faciale est une pathologie osseuse rare qui peut se manifester par de graves troubles sensoriels et fonctionnels. Elle pose de réelles difficultés thérapeutiques et fait appel à une bonne collaboration interdisciplinaire.
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Affiliation(s)
- Cheikh Ahmedou Lame
- Service d´ Otorhinolaryngologie (ORL) et de Chirurgie Cervico-Faciale, Hôpital Principal de Dakar, Dakar, Sénégal
| | - Birame Loum
- Service d´ Otorhinolaryngologie (ORL) et de Chirurgie Cervico-Faciale, Hôpital Principal de Dakar, Dakar, Sénégal
| | - Thierno Boubacar Diallo
- Service d´ Otorhinolaryngologie (ORL) et de Chirurgie Cervico-Faciale, Hôpital Principal de Dakar, Dakar, Sénégal
| | - Cheikhna Ba Ndiaye
- Service d´ Otorhinolaryngologie (ORL) et de Chirurgie Cervico-Faciale, Hôpital Principal de Dakar, Dakar, Sénégal
| | - Khady Marie Agnès Diouf
- Service d´ Otorhinolaryngologie (ORL) et de Chirurgie Cervico-Faciale, Hôpital Principal de Dakar, Dakar, Sénégal
| | - Amat Fall
- Département d´Imagerie Médicale, Hôpital Principal de Dakar, Dakar, Sénégal
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16
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de Castro LF, Ovejero D, Boyce AM. DIAGNOSIS OF ENDOCRINE DISEASE: Mosaic disorders of FGF23 excess: Fibrous dysplasia/McCune-Albright syndrome and cutaneous skeletal hypophosphatemia syndrome. Eur J Endocrinol 2020; 182:R83-R99. [PMID: 32069220 PMCID: PMC7104564 DOI: 10.1530/eje-19-0969] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
Fibrous dysplasia/McCune-Albright Syndrome (FD/MAS), arising from gain-of-function mutations in Gαs, and cutaneous skeletal hypophosphatemia syndrome (CSHS), arising from gain-of-function mutations in the Ras/MAPK pathway, are strikingly complex, mosaic diseases with overlapping phenotypes. Both disorders are defined by mosaic skin and bone involvement, and both are complicated by increased FGF23 production. These similarities have frequently led to mis-diagnoses, primarily in patients with CSHS who are often assumed to have FD/MAS. The intriguing similarities in skeletal involvement in these genetically distinct disorders have led to novel insights into FGF23 physiology, making an understanding of FD/MAS and CSHS relevant to both clinicians and researchers interested in bone and endocrine disorders. This review will give an overview of FD/MAS and CSHS, focusing on the roles of mosaicism and FGF23 in the pathogenesis and clinical presentation of these disorders.
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Affiliation(s)
- Luis F de Castro
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Diana Ovejero
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
- Musculoskeletal Research Unit, Hospital del Mar Institute of Medical Investigation (IMIM), Barcelona, Spain
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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17
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Bhadada SK, Pal R, Sood A, Dhiman V, Saini UC. Co-administration of Systemic and Intralesional Zoledronic Acid in a Case of Fibrous Dysplasia: A Potentially Novel Therapy. Front Endocrinol (Lausanne) 2019; 10:803. [PMID: 31803145 PMCID: PMC6877477 DOI: 10.3389/fendo.2019.00803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022] Open
Abstract
Fibrous dysplasia (FD) is a benign bone lesion characterized by replacement of normal bone with abnormal fibrous tissue, clinically manifesting as deformities, bone pains, and pathological fractures. The standard medical management for FD includes systemic bisphosphonate therapy. The efficacy of systemic bisphosphonate is however limited with minimal functional improvement and pain relief. Keeping the above lacunae in mind, we have made a solitary attempt at treating FD with locally administered zoledronic acid. A 25-year-old gentleman had presented to our institute with swelling and pain involving the left thigh and left lower leg. He was diagnosed as having polyostotic FD, confirmed on bone histopathology. He was administered 4 mg of zoledronic acid intravenously while 1 mg of the drug was injected locally into the femoral lesion under ultrasound and fluoroscopy guidance. There were no peri-procedural complications. At 6 months follow-up, there was marked improvement in pain scores at the left thigh, while that at the left leg remained unchanged. In addition, repeat bone scintigraphy showed a 20.8% and 25.3% reduction in anterior and posterior uptake values, respectively, at the left femur while that at the left tibia remained unaltered.
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Affiliation(s)
- Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- *Correspondence: Sanjay Kumar Bhadada
| | - Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Sood
- Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vandana Dhiman
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Uttam Chand Saini
- Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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