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Jodeh W, Katz AJ, Hart M, Warden SJ, Niziolek P, Alam I, Ing S, Polgreen LE, Imel EA, Econs MJ. Autosomal Dominant Osteopetrosis (ADO) caused by a Missense Variant in the TCIRG1 Gene. J Clin Endocrinol Metab 2024:dgae040. [PMID: 38261998 DOI: 10.1210/clinem/dgae040] [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: 08/04/2023] [Revised: 01/03/2024] [Accepted: 01/18/2024] [Indexed: 01/25/2024]
Abstract
CONTEXT Autosomal dominant osteopetrosis (ADO) is a rare genetic disorder due to impaired osteoclastic bone resorption. Clinical manifestations frequently include fractures, osteonecrosis (particularly of the jaw or maxilla), osteomyelitis, blindness, and/or bone marrow failure. ADO usually results from heterozygous missense variants in the Chloride Channel 7 gene (CLCN7) that cause disease by a dominant negative mechanism. Variants in the T cell immune regulator 1 gene (TCIRG1) are commonly identified in autosomal recessive osteopetrosis but have only been reported in one patient with ADO. CASE DESCRIPTION Here we report 3 family members with a single heterozygous missense variant (p.Gly579Arg) in TCIRG1 who have a phenotype consistent with ADO. Three of five protein prediction programs suggest this variant likely inhibits the function of TCIRG1. CONCLUSIONS This is the first description of adult presentation of ADO caused by a TCIRG1 variant. Similar to families with ADO from CLCN7 mutations, this variant in TCIRG1 results in marked phenotype variability, with two subjects having severe disease and the third having very mild disease. This family report implicates TCIRG1 missense mutations as a cause of ADO and demonstrates that the marked phenotypic variability in ADO may extend to disease caused by TCIRG1 missense mutations.
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Affiliation(s)
- Wade Jodeh
- Department of Medicine, Indiana University School of Medicine
| | - Amy J Katz
- Department of Medicine, Indiana University School of Medicine
| | - Marian Hart
- Department of Medicine, Indiana University School of Medicine
| | - Stuart J Warden
- Department of Physical Therapy, Indiana University School of Health & Human Sciences
| | - Paul Niziolek
- Department of Radiology, Indiana University School of Medicine
| | - Imranul Alam
- Department of Medicine, Indiana University School of Medicine
| | - Steven Ing
- Division of Endocrinology, Diabetes, and Metabolism, Ohio State University Wexner Medical Center
| | - Lynda E Polgreen
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center
| | - Erik A Imel
- Department of Medicine, Indiana University School of Medicine
- Department of Pediatrics, Indiana University School of Medicine
| | - Michael J Econs
- Department of Medicine, Indiana University School of Medicine
- Department of Medical and Molecular Genetics, Indiana University School of Medicine
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Bjornsdottir S, Ing S, Mitchell DM, Sikjaer T, Underbjerg L, Hassan-Smith Z, Sfeir J, Gittoes NJ, Clarke L BL. Epidemiology and Financial Burden of Adult Chronic Hypoparathyroidism. J Bone Miner Res 2022; 37:2602-2614. [PMID: 36054571 PMCID: PMC10087725 DOI: 10.1002/jbmr.4675] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 11/10/2022]
Abstract
Chronic hypoparathyroidism is characterized by low serum calcium, increased serum phosphorus, and inappropriately low or decreased serum parathyroid hormone. This rare disorder is associated with a variety of complications. The prevalence, incidence, mortality, financial burden, and epidemiology of complications of this disorder are not well understood. This narrative review summarizes current information on the epidemiology and complications of chronic hypoparathyroidism. The reported prevalence of chronic hypoparathyroidism ranges from 6.4-37/100,000, and the incidence is reported to be 0.8-2.3/100,000/year. Mortality is not increased in studies from Denmark or South Korea but was increased in studies from Scotland and Sweden. The financial burden of this disorder is substantial because of increased health care resource utilization in two studies but not well quantitated. Recognized complications include hypercalciuria, nephrocalcinosis, kidney stones, and chronic kidney disease; low bone turnover and possibly upper extremity fractures; cardiac and vascular calcifications; basal ganglia calcifications, cataracts, infections, neuropsychiatric complications, and difficulties with pregnancy. This review concludes that chronic hypoparathyroidism is a rare disorder associated with significant morbidity that may not increase overall mortality but is associated with a substantial financial burden. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
| | - Steven Ing
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | - Deborah M Mitchell
- Pediatric Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tanja Sikjaer
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Line Underbjerg
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Zaki Hassan-Smith
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - Jad Sfeir
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Neil J Gittoes
- Centre for Endocrinology, Diabetes, and Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - Bart L Clarke L
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
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McNabb-Baltar J, Manickavasagan HR, Conwell DL, Lu A, Yadav D, Hart PA, Lara LF, Cruz-Monserrate Z, Ing S, Hinton A, Mace TA, Bradley D, Shah ZK. A Pilot Study to Assess Opportunistic Use of CT-Scan for Osteoporosis Screening in Chronic Pancreatitis. Front Physiol 2022; 13:866945. [PMID: 35721529 PMCID: PMC9203029 DOI: 10.3389/fphys.2022.866945] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: CT scans are commonly performed in patients with chronic pancreatitis (CP). Osteopathy and fractures are recognized in CP but no osteoporosis screening guidelines are recommended. "Opportunistic" CT scan-derived bone density thresholds are assessed for identifying osteoporosis in CP. Methods: Retrospective pilot cohort study. CP subjects who had CT scans and dual-energy x-ray absorptiometry (DXA) within 1 year were included. CT-derived bone density was measured at the L1 level. Pearson's correlation was performed between age and CT-derived bone density in Hounsfield unit (HU). Univariate analysis using HU to identify osteoporosis was performed at various thresholds of bone density. The discriminatory ability of the model was evaluated with the area under the receiver operating characteristic (ROC) curve (AUC). Several HU thresholds were tested. Results: Twenty-seven CP subjects were included, of whom 11 had normal bone density, 12 osteopenia, and four osteoporosis on DXA. The mean age was 59.9 years (SD 13.0). There was a negative correlation of age with HU (r = -0.519, p = 0.006). CT-derived bone density predicted DXA-based osteoporosis in the univariable analysis (Odds Ratio (OR) = 0.97 95% Confidence Interval (CI) 0.94-1.00, p = 0.03). HU thresholds were tested. A threshold of 106 HU maximized the accuracy (AUC of 0.870). Conclusions: CT scan may be repurposed for "opportunistic" screening to rule out osteoporosis in CP. A larger study is warranted to confirm these results.
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Affiliation(s)
- Julia McNabb-Baltar
- Brigham and Women's Hospital, Harvard Medical School, Division of Gastroenterology, Hepatology, and Endoscopy, Boston, MA, United States
| | - Hanisha R Manickavasagan
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - Darwin L Conwell
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - Andrew Lu
- The Ohio State University Wexner Medical Center, Department of Radiology, Columbus, OH, United States
| | - Dhiraj Yadav
- University of Pittsburgh Medical Center, Division of GI, Hepatology and Nutrition, Columbus, OH, United States
| | - Philip A Hart
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - Luis F Lara
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - Zobeida Cruz-Monserrate
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - Steven Ing
- The Ohio State University Wexner Medical Center, Division of Endocrinology, Diabetes and Metabolism, Columbus, OH, United States
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, United States
| | - Thomas A Mace
- The Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology, and Nutrition, Columbus, OH, United States
| | - David Bradley
- The Ohio State University Wexner Medical Center, Division of Endocrinology, Diabetes and Metabolism, Columbus, OH, United States
| | - Zarine K Shah
- The Ohio State University Wexner Medical Center, Department of Radiology, Columbus, OH, United States
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Almquist NW, Eriksen HB, Wilhelmsen M, Hamarsland H, Ing S, Ellefsen S, Sandbakk Ø, Rønnestad BR, Skovereng K. No Differences Between 12 Weeks of Block- vs. Traditional-Periodized Training in Performance Adaptations in Trained Cyclists. Front Physiol 2022; 13:837634. [PMID: 35299664 PMCID: PMC8921659 DOI: 10.3389/fphys.2022.837634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/28/2022] [Indexed: 11/28/2022] Open
Abstract
The purpose of this study was to compare the effects of 12 weeks load-matched block periodization (BP, n = 14), using weekly concentration of high- (HIT), moderate- (MIT), and low- (LIT) intensity training, with traditional periodization (TP, n = 16) using a weekly, cyclic progressive increase in training load of HIT-, MIT-, and LIT-sessions in trained cyclists (peak oxygen uptake: 58 ± 8 ml·kg−1·min−1). Red blood cell volume increased 10 ± 16% (p = 0.029) more in BP compared to TP, while capillaries around type I fibers increased 20 ± 12% (p = 0.002) more in TP compared to BP from Pre to Post12. No other group differences were found in time-trial (TT) performances or muscular-, or hematological adaptations. However, both groups improved 5 and 40-min TT power by 9 ± 9% (p < 0.001) and 8 ± 9% (p < 0.001), maximal aerobic power (Wmax) and power output (PO) at 4 mmol·L−1 blood lactate (W4mmol), by 6 ± 7 (p = 0.001) and 10 ± 12% (p = 0.001), and gross efficiency (GE) in a semi-fatigued state by 0.5 ± 1.1%-points (p = 0.026). In contrast, GE in fresh state and VO2peak were unaltered in both groups. The muscle protein content of β-hydroxyacyl (HAD) increased by 55 ± 58% in TP only, while both TP and BP increased the content of cytochrome c oxidase subunit IV (COXIV) by 72 ± 34%. Muscle enzyme activities of citrate synthase (CS) and phosphofructokinase (PFK) were unaltered. TP increased capillary-to-fiber ratio and capillary around fiber (CAF) type I by 36 ± 15% (p < 0.001) and 17 ± 8% (p = 0.025), respectively, while BP increased capillary density (CD) by 28 ± 24% (p = 0.048) from Pre to Post12. The present study shows no difference in performance between BP and “best practice”-TP of endurance training intensities using a cyclic, progressively increasing training load in trained cyclists. However, hematological and muscle capillary adaptations may differ.
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Affiliation(s)
- Nicki Winfield Almquist
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway.,Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hanne Berg Eriksen
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Malene Wilhelmsen
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Håvard Hamarsland
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Steven Ing
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Ellefsen
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Øyvind Sandbakk
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bent R Rønnestad
- Section for Health and Exercise Physiology, Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - Knut Skovereng
- Centre for Elite Sports Research, Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
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Briot K, Portale AA, Brandi ML, Carpenter TO, Cheong HI, Cohen-Solal M, Crowley RK, Eastell R, Imanishi Y, Ing S, Insogna K, Ito N, Jan de Beur S, Javaid MK, Kamenicky P, Keen R, Kubota T, Lachmann RH, Perwad F, Pitukcheewanont P, Ralston SH, Takeuchi Y, Tanaka H, Weber TJ, Yoo HW, Nixon A, Nixon M, Sun W, Williams A, Imel EA. Burosumab treatment in adults with X-linked hypophosphataemia: 96-week patient-reported outcomes and ambulatory function from a randomised phase 3 trial and open-label extension. RMD Open 2021; 7:rmdopen-2021-001714. [PMID: 34548383 PMCID: PMC8458321 DOI: 10.1136/rmdopen-2021-001714] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 04/27/2021] [Accepted: 08/16/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives To report the impact of burosumab on patient-reported outcomes (PROs) and ambulatory function in adults with X-linked hypophosphataemia (XLH) through 96 weeks. Methods Adults diagnosed with XLH were randomised 1:1 in a double-blinded trial to receive subcutaneous burosumab 1 mg/kg or placebo every 4 weeks for 24 weeks (NCT02526160). Thereafter, all subjects received burosumab every 4 weeks until week 96. PROs were measured using the Western Ontario and the McMaster Universities Osteoarthritis Index (WOMAC), Brief Pain Inventory-Short Form (BPI-SF) and Brief Fatigue Inventory (BFI), and ambulatory function was measured with the 6 min walk test (6MWT). Results Subjects (N=134) were randomised to burosumab (n=68) or placebo (n=66) for 24 weeks. At baseline, subjects experienced pain, stiffness, and impaired physical and ambulatory function. At week 24, subjects receiving burosumab achieved statistically significant improvement in some BPI-SF scores, BFI worst fatigue (average and greatest) and WOMAC stiffness. At week 48, all WOMAC and BPI-SF scores achieved statistically significant improvement, with some WOMAC and BFI scores achieving meaningful and significant change from baseline. At week 96, all WOMAC, BPI-SF and BFI achieved statistically significant improvement, with selected scores in all measures also achieving meaningful change. Improvement in 6MWT distance and percent predicted were statistically significant at all time points from 24 weeks. Conclusions Adults with XLH have substantial burden of disease as assessed by PROs and 6MWT. Burosumab treatment improved phosphate homoeostasis and was associated with a steady and consistent improvement in PROs and ambulatory function. Trial registration number NCT02526160.
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Affiliation(s)
- Karine Briot
- Department of Rheumatology, Hôpital Cochin, Paris, France
| | - Anthony A Portale
- Department of Pediatrics, Division of Nephrology, University of California, San Francisco, California, USA
| | | | - Thomas O Carpenter
- Department of Pediatrics and Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Hae Ii Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Martine Cohen-Solal
- Department of Rheumatology, Hôpital Lariboisière, Paris, France.,INSERM U1132 BIOSCAR, University of Paris, Paris, France
| | - Rachel K Crowley
- Department of Endocrinology, St Vincent's University Hospital, Dublin, Ireland.,University College Dublin School of Medicine, Dublin, Ireland
| | - Richard Eastell
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Yasuo Imanishi
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Steven Ing
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Karl Insogna
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nobuaki Ito
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Suzanne Jan de Beur
- Division of Endocrinology and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Peter Kamenicky
- Endocrine Physiology and Pathophysiology, INSERM, Paris-Saclay University, Paris, France.,Hospital Bicetre, Paris, France
| | - Richard Keen
- Metabolic Bone Disease Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Takuo Kubota
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Farzana Perwad
- Department of Pediatrics, Division of Nephrology, University of California, San Francisco, California, USA
| | - Pisit Pitukcheewanont
- Department of Pediatric Endocrinology, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Stuart H Ralston
- Rheumatology and Bone Diseases Unit, Medical Research Council Institute of Genetics and Molecular Medicine, The University of Edinburgh, Edinburgh, UK
| | | | - Hiroyuki Tanaka
- Department of Pediatrics, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Thomas J Weber
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | | | | | - Wei Sun
- Biostatistics Department, Kyowa Kirin Pharmaceutical Development, Inc, Princeton, New Jersey, USA
| | - Angela Williams
- Health Economics and Outcomes Research Department, Kyowa Kirin International PLC, Marlow, UK
| | - Erik A Imel
- Department of Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Adly H, Ing S. Radiotherapy-Associated Pelvic Insufficiency Fracture Treated by Romosozumab: Course of L1 and L5 Vertebral Body CT Attenuation. J Endocr Soc 2021. [PMCID: PMC8089160 DOI: 10.1210/jendso/bvab048.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: Radiotherapy is a risk factor for osteoporosis and insufficiency fractures via osteoblast apoptosis and vascular injury. PTH analogs teriparatide and abaloparatide are contraindicated in patients with prior exposure to radiotherapy crossing bone due to the increased risk of osteosarcoma. Patients with radiotherapy-associated fractures or osteoporosis were eligible only for antiresorptive agents until romosozumab was recently FDA-approved. Current International Society for Clinical Densitometry (ISCD) guidelines include assessment of “opportunistic CT” as a surrogate for DXA scan using L1 vertebral body attenuation: >150 Hounsfield units (HU) is normal and <100 HU signifies osteoporosis.
Clinical Case: A 60 year old female patient with history of endometrial cancer diagnosed at age of 57 and treated with hysterectomy and bilateral salpingo-oophorectomy, chemotherapy, then pelvic radiotherapy, was referred to endocrinology for pelvic insufficiency fractures evaluation. Two years after completing chemoradiotherapy, she complained of right groin and low back pain with difficulty walking. MRI pelvis showed bilateral sacral ala and right pubic ramus insufficiency fractures. She had normal serum mineral concentration, 25-OH vitamin D sufficiency, normal PTH, eGFR, liver function tests and 24-hour urine calcium excretion. Screening for celiac disease and multiple myeloma was negative. DXA scan BMD T-score showed osteoporosis, -3.0 at the right femoral neck. L1-L4 T-score was +0.4 but unreliable due to presence of degenerative changes. Four months after onset of pain, patient started romosozumab 210mg SQ monthly for a total of 12 doses, after which she started oral alendronate. Pain essentially resolved within 6 months of romosozumab therapy. C-telopeptide (CTX) and procollagen type 1 N-terminal propeptide (P1NP) were obtained at baseline, 3 and 12 months after romosozumab initiation. CTX was 362, 247 and 258 pg/mL (reference range, >49 years: not established), and P1NP was 82, 178 and 62 mcg/L (reference range, 20 - 108), respectively. Attenuation of L1 and L5 vertebral body was measured using CT abdomen and pelvis scans before and 5 months after radiotherapy, and before and after completion of romosozumab therapy. L1 attenuation measured 161, 132, 127 and 179 HU, and L5 measured 150, 46, 50 and 86 HU, respectively.
Conclusion: Pelvic radiotherapy was associated with a decline in L1 CT attenuation and even greater magnitude of decrease at L5. Romosozumab was associated with clinical improvement, restoration of L1 CT attenuation and diminishment of regain at L5. Although L5 attenuation has not been previously assessed for osteoporosis, this site may be of predictive value in patients who receive pelvic radiotherapy.
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Affiliation(s)
- Hussein Adly
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Steven Ing
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Koehler K, Atway S, Pipes J, Ing S. Diagnosis of Hypophosphatasia in Adults Presenting With Metatarsal Stress Fracture: Proof-of-Concept for a Case-Finding Strategy. JBMR Plus 2021; 5:e10495. [PMID: 34189384 PMCID: PMC8216134 DOI: 10.1002/jbm4.10495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/16/2021] [Accepted: 03/17/2021] [Indexed: 11/18/2022] Open
Abstract
Hypophosphatasia (HPP) is caused by loss‐of‐function mutations in ALPL resulting in decreased alkaline phosphatase (ALP) activity. Metatarsal stress fracture (MSF) is a common clinical feature of hypophosphatasia in adults. In this study, the primary objectives were to determine whether new cases of ALPL variants could be identified in patients with MSF and who also had serum ALP concentration below the reference range and to phenotype their clinical course. Electronic health records were queried for adult patients with MSF using International Classification of Disease codes (ICD‐9, ICD‐10CM) and ALP measurements. Patients with ALP levels below the normal limit were invited to receive mutational analysis of ALPL and to complete the following surveys: the Short Form 36 version 2 (SF36v2), the Brief Pain Inventory‐Short Form (BPI), and the Health Assessment Questionnaire Disability Index (HAQ‐DI). Cases with and controls without ALPL pathogenic variants were compared by survey scores and clinical variables relevant to fracture. In 1611 patients with MSF presenting to a podiatry clinic (10/1/2011–10/1/2017), 937 had ALP measurement, of whom 13 (1.4%) had ALP levels below the lower normal limit. In eight patients consenting to participate, two had heterozygous pathogenic ALPL variants. ALPL variants were found in 2 of 1611 patients (0.12%) with MSF, 2 patients of 937 (0.21%) in those with MSF and any ALP measurement, and 2 of 13 patients (15%) in MSF and decreased ALP level. Cases versus controls rated lower scores on eight of eight SF36v2 scales (range, 0–100); higher scores for worst pain (8.0 vs. 0.8) and average pain (6.0 vs. 0.7) on the BPI (range, 0–10); and higher standard disability score (1.4 vs. 0) on the HAQ‐DI (range, 0–3). These data provide proof‐of‐concept for HPP case identification in patients presenting to a podiatry clinic with MSF, suggesting a search for historically low ALP levels may be a useful step for consideration of HPP diagnosis, and supports a prospective study to determine an optimal case‐finding strategy. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Kenna Koehler
- Ohio State University College of Medicine Columbus OH USA
| | - Said Atway
- Division of Podiatry Ohio State University Wexner Medical Center Columbus OH USA
| | - James Pipes
- Division of Podiatry Ohio State University Wexner Medical Center Columbus OH USA
| | - Steven Ing
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism Ohio State University Wexner Medical Center Columbus OH USA
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Portale AA, Carpenter TO, Brandi ML, Briot K, Cheong HI, Cohen-Solal M, Crowley R, Jan De Beur S, Eastell R, Imanishi Y, Imel EA, Ing S, Ito N, Javaid M, Kamenicky P, Keen R, Kubota T, Lachmann R, Perwad F, Pitukcheewanont P, Ralston SH, Takeuchi Y, Tanaka H, Weber TJ, Yoo HW, Zhang L, Theodore-Oklota C, Mealiffe M, San Martin J, Insogna K. Continued Beneficial Effects of Burosumab in Adults with X-Linked Hypophosphatemia: Results from a 24-Week Treatment Continuation Period After a 24-Week Double-Blind Placebo-Controlled Period. Calcif Tissue Int 2019; 105:271-284. [PMID: 31165191 DOI: 10.1007/s00223-019-00568-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
Burosumab, a fully human monoclonal antibody to FGF23, is the only approved treatment for X-linked hypophosphatemia (XLH), a rare genetic disorder characterized by renal phosphate wasting and substantial cumulative musculoskeletal morbidity. During an initial 24-week randomized, controlled trial, 134 adults with XLH received burosumab 1 mg/kg (n = 68) or placebo (n = 66) every 4 weeks. After 24 weeks, all subjects received open-label burosumab until week 48. This report describes the efficacy and safety of burosumab during the open-label treatment period. From weeks 24-48, serum phosphorus concentrations remained normal in 83.8% of participants who received burosumab throughout and were normalized in 89.4% who received burosumab after placebo. By week 48, 63.1% of baseline fractures/pseudofractures healed fully with burosumab, compared with 35.2% with burosumab after placebo. In both groups, burosumab was associated with clinically significant and sustained improvement from baseline to week 48 in scores for patient-reported outcomes of stiffness, pain, physical function, and total distance walked in 6 min. Rates of adverse events were similar for burosumab and placebo. There were no fatal adverse events or treatment-related serious adverse events. Nephrocalcinosis scores did not change from baseline by more than one grade at either week 24 or 48. These data demonstrate that in participants with XLH, continued treatment with burosumab is well tolerated and leads to sustained correction of serum phosphorus levels, continued healing of fractures and pseudofractures, and sustained improvement in key musculoskeletal impairments.
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Affiliation(s)
| | | | | | | | - Hae Ii Cheong
- Seoul National University Children's Hospital, Seoul, Korea
| | | | - Rachel Crowley
- St Vincent's University Hospital Elm Park, Dublin, Ireland
| | | | | | - Yasuo Imanishi
- Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Erik A Imel
- Indiana University Department of Medicine, Indianapolis, IN, USA
| | - Steven Ing
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Nobuaki Ito
- The University of Tokyo Hospital, Tokyo, Japan
| | | | | | - Richard Keen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | | | | | - Farzana Perwad
- University of California San Francisco, San Francisco, CA, USA
| | - Pisit Pitukcheewanont
- Children's Hospital of Los Angeles, Los Angeles, CA, USA
- Ascendis Pharma, Palo Alto, CA, USA
| | | | | | | | | | | | - Lin Zhang
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
| | | | - Matt Mealiffe
- Ultragenyx Pharmaceutical Inc., Novato, CA, USA
- MyoKardia, South San Francisco, CA, USA
| | | | - Karl Insogna
- Yale University School of Medicine, New Haven, CT, USA
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Belany P, Zachariadou C, Aguirre SE, Salvador A, Yu JS, Kalmar JR, Rotenberg SA, Ing S. MON-513 Osteonecrosis after Successful Osseointegrated Dental Implantation. J Endocr Soc 2019. [PMCID: PMC6551153 DOI: 10.1210/js.2019-mon-513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a rare complication of antiresorptive medications. Although typically occurring after invasive dental procedures, there is limited data suggesting MRONJ risk in patients with a successfully osseointegrated dental implant. In this case report, we present the clinical presentation, radiological, pathological, and biochemical data of MRONJ presenting years after successful dental implantation while taking antiresorptive medication for the treatment of osteoporosis. Case Presentation: 77 year-old woman underwent titanium dental implant installation to replace a missing mandibular right first molar with uncomplicated postoperative course in 2011, which healed well. Her rheumatologist prescribed ibandronate in 2010 for treatment of osteopenia. In 11/2014 switched to denosumab 60 mg SQ every 6 months. In 2015, she was referred for evaluation of hyperparathyroidism and also transferred osteoporosis care. With adequate clinical response and tolerance to denosumab, she continued the medication. In 6/2018 she had parathyroidectomy to treat primary hyperparathyroidism after an episode of flank pain suspicious for nephrolithiasis. She experienced no further dental complications until jaw pain developed in 2/2018. Periapical radiographs in 4/2018 showed no signs of bone loss or pathology. However, soft tissue papillae between the implant and the mandibular right second molar was inflamed and bled on contact. Despite removal of granulation tissue, the gingiva continued to bleed. Oral antibiotics were empirically prescribed. Cone beam CT scan in 6/2018 showed an altered osseous trabecular pattern without frank bone loss between the implant and right second mandibular molar, suggestive of MRONJ. Denosumab was discontinued(last dose 5/2018). In 7/2018, the dental implant was removed and bone attached to the implant was submitted for histologic evaluation, demonstrating chronic mucositis and sequestra consistent with MRONJ. In 9/2018, the patient developed purulent drainage at the removal site despite oral antibiotic therapy. On repeat CT scan, progressive bone loss and soft tissue proliferation was noted at the prior site of implant and extending slightly more posterior near the right second mandibular molar. She started IV antibiotics with complete resolution of symptoms to date. This case demonstrates osteonecrosis occurring at the site of a previously successful 7-year-old osseointegrated dental implant in a patient on uninterrupted antiresorptive therapy for 8 years.
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Affiliation(s)
- Paul Belany
- The Ohio State University, Columbus, OH, United States
| | - C Zachariadou
- The Ohio State University, Columbus, OH, United States
| | - SE Aguirre
- The Ohio State University, Columbus, OH, United States
| | - A Salvador
- The Ohio State University, Columbus, OH, United States
| | - JS Yu
- The Ohio State University, Columbus, OH, United States
| | - JR Kalmar
- The Ohio State University, Columbus, OH, United States
| | - SA Rotenberg
- The Ohio State University, Columbus, OH, United States
| | - Steven Ing
- Div of Endo/Diabetes/Metab, The Ohio State University, Columbus, OH, United States
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10
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Jia K, Southerland L, Phieffer L, Stephens J, Ing S. SAT-LB089 Incorporation of a Patient Navigator into a Secondary Fracture Prevention Program Identifies Barriers to Patient Care. J Endocr Soc 2019. [PMCID: PMC6552020 DOI: 10.1210/js.2019-sat-lb089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Incorporation of a Patient Navigator into a Secondary Fracture Prevention Program Identifies Barriers to Patient Care Abstract Introduction: Patient navigation has emerged as a valuable component to improve patient outcomes in the outpatient setting. We investigated the effect of patient navigation in transitioning patients hospitalized for acute fracture to an outpatient clinic for secondary fracture prevention, and explored factors associated with successful transition. Methods: This study was a retrospective chart review of patients, age 50+ from April to October, 2016 hospitalized with fragility fracture at our medical center who were contacted by a patient navigator. We created an electronic tool that extracted data from the electronic medical record alerting the patient navigator to contact the patient by phone to schedule an outpatient appointment into an osteoporosis clinic as well as a Dual-energy X-ray Absorptiometry (DXA) scan. Patient outcomes of transition from hospital to outpatient clinic, completion of DXA scan, completion of all five osteoporosis-associated laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal function, liver function), and osteoporosis medication prescription and adherence, as well other patient characteristics were compared to patients from a historical control period (2014-2015). This group consisted of a similar patient population seen without assistance of a patient navigator. Categorical variables were compared using Chi-square or Fisher’s Exact tests and continuous variables were compared with a two-sample t-test or a Wilcoxon Rank Sum test. We also explored potential factors which might predict barriers to successful outpatient clinic transition using a univariate logistic regression. Results: The proportion of patients who successfully transitioned to osteoporosis clinic modestly improved with the use of a patient navigator versus control (53% vs. 48%, p=0.048). DXA scan completion was higher with patient navigation (90% vs. 67%, p=0.006). No difference in osteoporosis medication initiation within 3 months post discharge (73% vs. 65%, p=0.387) or medication adherence at 6 months (68% vs. 71%, p=0.777) was found between the two groups. Patients who followed up in clinic lived closer (11 vs. 43 miles, p<0.001) and were also more likely to follow up in orthopedic surgery clinic for post-fracture care (95% vs. 61%, p<0.001). Conclusion: A modest improvement in the proportion of patients who transitioned to an outpatient clinic for osteoporosis care was achieved with the use of patient navigation compared controls. We found a longer travel distance may be a barrier to transitioning to clinic. Identifying such barriers may help inform future refinements for fracture liaison and patient navigation service programs resulting in changes in best practices that improve patient outcomes. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.
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Affiliation(s)
- Kelly Jia
- Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Lauren Southerland
- Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Laura Phieffer
- Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Julie Stephens
- Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven Ing
- Div of Endo/Diabetes/Metab, Ohio State University Wexner Medical Center, Columbus, OH, United States
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11
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Rosko AE, Hade EM, Li W, Ing S, Jackson RD, Paskett ED, Naughton MJ. Bone Health and Survival in Women With Multiple Myeloma. Clin Lymphoma Myeloma Leuk 2018; 18:597-602.e1. [PMID: 30049515 DOI: 10.1016/j.clml.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Multiple myeloma (MM) is a disease of aging adults resulting in osteolytic and/or osteoporotic bone disease. Primary osteoporosis is also highly prevalent in aging adults and is associated with increased mortality. It is unknown how concurrent osteoporosis is associated with outcomes in patients who develop MM. PATIENTS AND METHODS We identified 362 women with MM of the 161,808 enrolled in the Women's Health Initiative (WHI) dataset and evaluated bone health using the Fracture Risk Assessment Tool (FRAX) to identify clinical factors that affect overall MM survival in post-menopausal women, as measured from the time of diagnosis. RESULTS Of the 362 participants who developed incident MM, with an average 10.5 years of follow-up, 226 died, including 71 with high FRAX scores and 155 with low FRAX scores. On average, women with high FRAX scores were 8.3 years older at enrollment (95% confidence interval [CI], 7.2-9.3 years) and 8.0 years older at time of MM diagnosis (95% CI, 7.0-9.2 years) compared with those with low FRAX scores. MM mortality for women with high FRAX scores was greater (covariate-adjusted hazard ratio scores [aHR] 1.51; 95% CI, 1.01-2.25; P = .044) compared with those with low FRAX scores. CONCLUSION Higher fracture risk, measured by FRAX, was associated with higher MM mortality in post-menopausal women, independent of many other clinical factors.
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Affiliation(s)
- Ashley E Rosko
- Division of Hematology, The Ohio State University, Columbus, OH.
| | - Erinn M Hade
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Wenjun Li
- Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Steven Ing
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University, Columbus, OH
| | - Rebecca D Jackson
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University, Columbus, OH
| | - Electra D Paskett
- Cancer Prevention and Control, The Ohio State University, Columbus, OH
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Zhang X, Lindwall E, Gauthier C, Lyman J, Spencer N, Alarakhia A, Fraser A, Ing S, Chen M, Webb-Detiege T, Zakem J, Davis W, Choi YS, Quinet R. Circulating CXCR5+CD4+helper T cells in systemic lupus erythematosus patients share phenotypic properties with germinal center follicular helper T cells and promote antibody production. Lupus 2015; 24:909-17. [PMID: 25654980 DOI: 10.1177/0961203314567750] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 12/18/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of autoantibodies. Recently, a specific highly activated T helper cell subset, follicular helper T (Tfh) cell, has emerged as a key immunoregulator of germinal center (GC) formation and high-affinity antibody production. To identify the pathophysiological role of Tfh cells in SLE patients, we compared the phenotypic and functional properties of circulating Tfh-like cells in lupus patients to GC-Tfh cells, and correlated the percentage of Tfh-like cells with autoantibody production and SLE disease activity. METHODS Peripheral blood was collected from 29 lupus patients and 25 healthy controls. Tonsils were obtained surgically from non-SLE controls and used as a source of GC-Tfh cells. Tfh cells were defined by their signature surface markers (CXCR5, ICOS, CD57, PD-1 and BTLA) via flow cytometry. IL-21 expression levels from Tfh cells were measured by real-time PCR and intracellular staining. The function of Tfh cells was carried out by co-culture of Tfh cells and autologous B cells in vitro. IgG in the culture supernatant was detected by ELISA. RESULTS The frequency of circulating Tfh-like cells was significantly increased in SLE patients compared to healthy controls (p < 0.05). The Tfh-like cells not only display similar phenotypes and signature cytokines with GC-Tfh cells, but also are capable of driving B cells to differentiate into IgG-secreting plasma cells in vitro. In addition, the frequency of Tfh-like cells correlated positively with the percentage of circulating plasmablasts, levels of serum anti-dsDNA antibodies and ANA. CONCLUSION The accumulated circulating Tfh-like cells in lupus patients share phenotypic and functional properties with GC-Tfh cells. Tfh-like cells may serve as perpetuators in the pathogenesis of SLE by enhancing the self-reactive B cell clones to further differentiate into auto antibody-producing plasmablasts, and ultimately cause autoimmunity.
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Affiliation(s)
- X Zhang
- Institute of Translational Research, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - E Lindwall
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - C Gauthier
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - J Lyman
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - N Spencer
- Institute for Applied Cancer Science, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Alarakhia
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - A Fraser
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - S Ing
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - M Chen
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - T Webb-Detiege
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA The Univeristy of Queensland, School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA
| | - J Zakem
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - W Davis
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA The Univeristy of Queensland, School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA
| | - Y Sung Choi
- Institute of Translational Research, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - R Quinet
- Department of Rheumatology, Ochsner Medical Center, New Orleans, Louisiana, USA The Univeristy of Queensland, School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA
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Affiliation(s)
- E Ing
- University of Western Ontario, London, Ont
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