Duration Of Corticosteroid Treatment Research Articles

Change in systemic steroid use and surgery rate in patients with inflammatory bowel disease: a Japanese real-world database analysis

BackgroundCorticosteroids are recommended only for induction of remission in inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD). This study aimed to evaluate the change in pharmacologic treatment use, particularly systemic corticosteroids, over approximately 30 years, and the impact of biologics on IBD treatment since their appearance in the 2000s.MethodsThis retrospective study conducted in Japan used data from the Phoenix cohort database (January 1990 to March 2021). Patients with disease onset at age ≥ 10 years who received treatment for UC or CD between January 1990 and March 2021 were included. Outcome measures were change in IBD treatments used, total cumulative corticosteroid doses, initial corticosteroid dose, duration of corticosteroid treatment, and surgery rate.ResultsA total of 1066 and 579 patients with UC and CD, respectively, were included. In UC, the rate of corticosteroid use as initial treatment was relatively stable regardless of the year of disease onset; however, in CD, its rate decreased in patients who had disease onset after 2006 (before 2006: 14.3–27.8% vs. after 2006: 6.6–10.5%). Compared with patients with disease onset before biologics became available, cumulative corticosteroid doses in both UC and CD, and the surgery rate in CD only, were lower in those with disease onset after biologics became available.ConclusionsSince biologics became available, corticosteroid use appears to have decreased, with more appropriate use. Furthermore, use of biologics may reduce surgery rates, particularly in patients with CD. UMIN Clinical Trials Registry; UMIN000035384.

Duration of corticosteroid treatment in hospitalized COVID-19 patients, less is more.

Duration of corticosteroid treatment in hospitalized COVID-19 patients, less is more.

MO215DEPRESSIVE DISORDER IN LUPIC PATIENTS WITH LUPUS NEPHRITIS: DATA FROM A POPULATION OF 67 PATIENTS WITH BIOPSY PROVEN LUPUS NEPHRITIS

Abstract Background and Aims Systemic lupus erythematosus is a multi-organ, multi-systemic autoimmune disease with significant burden on generally young patients. Renal involvement is relatively frequent, recent studies cite a prevalence of 15-60% of patients, and 25% develop end-stage renal disease after 10 years of disease onset. We studied the incidence of depressive disorders in a population of 67 patients with biopsy proven lupus nephritis. Data about depression in patients with renal involvement of lupus is still scarce. We identified variables associated with the development of depressive disorders in lupus patients. Method We concluded a single center transversal study to assess the incidence of depressive disorder in patients with biopsy proven lupus nephritis. We used the self-report Beck Depression/ Anxiety Inventory (BDI/ BAI), 1961/ 1990, translated in Romanian and validated in the Romanian population to diagnose depression. We also wanted to identify risk factors associated with depression in such patients. We used EpiInfo for the statistical analysis and data was extracted from medical records. Results We included in the study patients diagnosed with systemic lupus erythematosus, and had renal biopsy between January 2008 – December 2018. Patients were followe-up until May 2020. Beck Depression/Anxiety Inventory was administered a single time during the follow-up visit between (March 2019 – May 2020). In our study group, 58 patients were female (86.5%). Median age at diagnosis of lupus disease was 29 years (min 10 years, max 62 years). Median duration of the disease until the self-assessment inventory was 10 years (min 1.5 years, max 30 years). Median duration of corticosteroid treatment was 10.1 years (min 1.58 years, max 29). 1 patient had class I, 2 had class II, 12 had class III, 32 had class IV, 12 had class V, 1 had class VI, 1 had classes III+V, 1 had classes IV+V of lupus nephritis (ISN classification of lupus nephritis). 13 patients had normal scores of the Beck Inventory (0-9 points), 7 had mild depression (10 - 15 points), 37 had moderate depression (16- 23 points), 10 had severe depression (24-63 points). We identified female gender (p=0.009), duration of corticosteroid therapy (p=0.036), duration of the lupic disease (p=0.036) to be independently associated with depression development. Other variables, such as creatinine levels at the moment of the assessment, duration of maintenance therapy with mycofenolate mofetil or azathioprine, proteinuria, inflammatory markers were not associated significantly with depression. Conclusion We identified clinical variables associated with depression development in patients with lupus nephritis. The study brings data useful for the clinician, helping doctors focus on the variables that predict depression in lupus patients and making screening for depressive disorders more focused on the patients with risk factors.

Corticosteroid therapy for coronavirus disease 2019-related acute respiratory distress syndrome: a cohort study with propensity score analysis

BackgroundThe impact of corticosteroid therapy on outcomes of patients with coronavirus disease 2019 (COVID-19) is highly controversial. We aimed to compare the risk of death between COVID-19-related ARDS patients with corticosteroid treatment and those without.MethodsIn this single-center retrospective observational study, patients with ARDS caused by COVID-19 between January 20, 2020, and February 24, 2020, were enrolled. The primary outcome was 60-day in-hospital death. The exposure was prescribed systemic corticosteroids or not. Time-dependent Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for 60-day in-hospital mortality.ResultsA total of 382 patients [60.7 ± 14.1 years old (mean ± SD), 61.3% males] were analyzed. The median of sequential organ failure assessment (SOFA) score was 2.0 (IQR 2.0–3.0). Of these cases, 94 (24.6%) patients had invasive mechanical ventilation. The number of patients received systemic corticosteroids was 226 (59.2%), and 156 (40.8%) received standard treatment. The maximum dose of corticosteroids was 80.0 (IQR 40.0–80.0) mg equivalent methylprednisolone per day, and duration of corticosteroid treatment was 7.0 (4.0–12.0) days in total. In Cox regression analysis using corticosteroid treatment as a time-varying variable, corticosteroid treatment was associated with a significant reduction in risk of in-hospital death within 60 days after adjusting for age, sex, SOFA score at hospital admission, propensity score of corticosteroid treatment, comorbidities, antiviral treatment, and respiratory supports (HR 0.42; 95% CI 0.21, 0.85; p = 0.0160). Corticosteroids were not associated with delayed viral RNA clearance in our cohort.ConclusionIn this clinical practice setting, low-dose corticosteroid treatment was associated with reduced risk of in-hospital death within 60 days in COVID-19 patients who developed ARDS.

Treatment Patterns and Bleeding Events Among Patients with Immune Thrombocytopenia Based on Duration of Corticosteroid Treatment

Background: Oral corticosteroids (CS) are often the first line of therapy for immune thrombocytopenia (ITP). Recent guidelines recommend against prolonged CS use (>6 weeks) for adults with ITP and suggest switching to second-line treatments for non-responsive or CS-dependent patients. The duration and potential overuse of CS among newly treated with CS adult ITP patients has yet to be described in a real-world setting. This study quantified the real-world duration of CS use among adult ITP patients newly treated with CS and assessed the clinical and economic consequences of prolonged CS use. Objectives: 1) To describe treatment patterns, bleeding events, and side effects of CS among patients with ITP; 2) To describe healthcare resource utilization (HRU) and costs among patients with ITP treated with CS. Methods: A retrospective observational cohort study was conducted using claims contained in the IBM® MarketScan® Commercial and Medicare Databases. Adult patients with an ITP diagnosis between January 1, 2013 and June 30, 2018 were selected for the study. Patients were required to be newly treated with CS (prednisone, dexamethasone, methylprednisolone) (first CS claim=index date) with at least 12 months of continuous enrollment prior to and 12 months following index. Patients with a diagnosis for any other thrombocytopenia and evidence of causes of secondary thrombocytopenia were excluded. Patients were categorized into cohorts based on CS duration during the follow-up period: CS days' supply ≤6 weeks, >6 weeks to 8 weeks, or >8 weeks. Discontinuation was defined as a gap of >30 days of the index CS following the run-off date of the last observed claim. Bleeding events, incidence of CS side effects (defined as new events occurring during the follow-up period only), HRU and costs (2018 USD), and treatment patterns were described during the follow-up period. Results: Among 1,720 patients who met study inclusion criteria, 65% had ≤6 weeks of CS use, 6% had >6-8 weeks, and 29% had >8 weeks. Median age among all patients was 48 years and majority were female (61%). About three quarters (71%) of patients started on prednisone as the index CS treatment, 16% on methylprednisolone, and 13% on dexamethasone. Patients with higher CS duration of use (>6-8 and >8 week) had a shorter time to CS treatment start following ITP diagnosis (mean 69 and 92 days, respectively; median 5 days for both) compared to the ≤6 week cohort (mean 306, median 152 days). All but one patient discontinued their index CS therapy. Patients with >8 weeks of CS had higher CS restart rates following discontinuation (49%) compared to patients with ≤6 weeks (23%). Among patients who switched therapies following CS discontinuation, those in the ≤6 week cohort had higher utilization of second line ITP agents compared to the >8 week cohort, including eltrombopag (16% vs. 11%) and romiplostim (23% vs. 11%). Patients in the >8 week cohort had higher rates of switching to splenectomy (15%) and rituximab (33%) following CS discontinuation compared to the ≤6 cohort (6% and 26%). About a fifth (19%) of patients experienced a bleeding event during the follow-up period. Bleeding event rates were higher for those with >8 weeks of CS than those with ≤6 weeks (23% vs. 17%). Nearly 40% of all patients experienced a CS side effect and rates were similar among the three cohorts. Patients with greater use of CS (>8 weeks) had higher rates of inpatient admissions (34%) compared to the ≤6 week (22%) and >6-8 week (32%) cohorts. Mean annual all-cause costs were $24,800, $42,706, and $51,896 for the ≤6 week, >6-8 week, and >8 week cohorts, respectively. Conclusions: Patients with ≤6 weeks of CS had the shortest switch time to a non-CS ITP treatment, with higher utilization of thrombopoietin receptor agonists, as compared to patients with greater CS use. Patients with a higher duration of CS use had significantly higher inpatient and outpatient HRU and more than double the healthcare costs compared to patients with ≤6 weeks of CS. The rate of bleeding events was lowest among patients with ≤6 weeks of CS use. Approximately 35% of patients in this study were treated with >6 weeks of CS, indicating a need for earlier intervention with more effective ITP therapies that may reduce CS use and risk of bleeding events, and subsequently decrease the economic burden incurred by patients with prolonged CS exposure. Further study is needed to assess the clinical and economic outcomes related to duration of CS use. Figure Disclosures Hatfield: Amgen Inc.: Current Employment. Manjelievskaia:Amgen Inc.: Consultancy; IBM Watson Health: Current Employment. Evans:Amgen Inc.: Consultancy; IBM Watson Health: Current Employment. Chan:Amgen Inc.: Consultancy; IBM Watson Health: Current Employment. Shah:Amgen Inc.: Current Employment. Saad:Amgen Inc: Current Employment.

IDIOPATHIC PULMONARY HEMOSIDEROSIS IN A DOWN SYNDROME PATIENT

SESSION TITLE: Fellows Diffuse Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Idiopathic Pulmonary Hemosiderosis (IPH) is a rare disease found primarily in children characterized by recurrent episodes of diffuse alveolar hemorrhage. The exact etiology and pathogenesis of IPH is unknown. Patients with Down Syndrome have a higher risk of developing pulmonary hemosiderosis. Additionally, in this population IPH manifests more severely. CASE PRESENTATION: Patient is 25 months old ex 36-week female with history of Trisomy 21, Atrial septal defect (ASDs) who has had a history of recurrent hemoptysis, anemia, and pulmonary infiltrates. Patient underwent extensive work-up including bronchoscopy and lung biopsy with the final diagnosis of Idiopathic Pulmonary Hemosiderosis (IPH). The patient presented to our PICU with acute alveolar hemorrhage and severe anemia secondary to RSV pneumonia and IPH recurrence despite being on maintenance therapy of prednisone and hydroxychloroquine. Patient required advanced respiratory support and was treated with a short course of pulse steroids. Patient eventually was placed on Azathioprine instead of Hydroxychloroquine with an increased Prednisone maintenance dose. DISCUSSION: IPH generally occurs in children below the age of 10 years, most commonly from 1 to 7 years. The classical triad of anemia, hemoptysis, and pulmonary infiltrates is a distinguishing characteristic of this disease; however, any one of them could be the initial manifestation. The estimated prevalence of IPH reaches 1.85 per 1,000,000 children, compared to 138.5 per 1,000,000 children with Down Syndrome. Patients with Down Syndrome tend to present earlier and more severely; they experience more dyspnea at diagnosis, more frequent secondary pulmonary hypertension (PAH), and an increased risk of fatal evolution. Systemic glucocorticoids are the mainstay of therapy for acute alveolar hemorrhage due to IPH. In a prior series of 23 children with IPH, low-dose oral prednisone was associated with prolonged survival compared with historical controls. In another series of 17 patients, long-term glucocorticoid therapy was associated with a five-year survival of 86 percent. The duration of corticosteroid treatment was variable among the patients based on clinical, radiological (alveolar infiltrates), and biological (hemoglobin, reticulocytes) evolution. Currently, there are no definitive guidelines directing use or choice of steroid-sparing medications in IPH; however, a few case reports describe the use of an immunosuppressant (cyclophosphamide, hydroxychloroquine, mycophenolate mofetil, azathioprine) in conjunction with oral glucocorticoids in the setting of respiratory failure. CONCLUSIONS: Additional studies investigating different therapeutic options are critical in order to reduce overall morbidity & mortality, particularly in children with Down Syndrome who are more predisposed to IPH relapse. Reference #1: Dr. Inderpal Randhawa Reference #2: Dr. Bugsu Ovunc Reference #3: Dr. Cyrus Shahriary DISCLOSURES: No relevant relationships by Yaron Fireizen, source=Web Response No relevant relationships by Nastasia Nianiaris, source=Web Response No relevant relationships by Inderpal Randhawa, source=Web Response No relevant relationships by Cyrus Shahriary, source=Web Response No relevant relationships by Dibanni Vasquez, source=Web Response

Corticosteroid Usage in Giant Cell Arteritis

ABSTRACT Giant cell arteritis (GCA) is a condition that can cause irreversible visual loss if untreated. While corticosteroids remain the mainstay of treatment to prevent visual loss, the type, dose, route, and duration of corticosteroid treatment of GCA remain controversial. Our study surveyed neuro-ophthalmologists to determine commonly prescribed dosages of corticosteroids for the treatment of GCA with or without visual loss. For patients with acute visual loss, 52% would use intravenous (IV), 46% would use IV or oral and 2% would use oral corticosteroids. Seventy-three per cent would use 500 to 1000 mg IV methylprednisolone in this group. For patients with GCA without acute visual loss, 67% would use the oral route, 30% would use IV or oral, and 3% indicated they would use IV route of treatment. Seventy-five per cent would use 1.0 to 1.5 mg/kg oral prednisone in this group. Our results suggest a majority but not a complete consensus for route and dose of corticosteroid treatment in GCA and confirm conventional recommendations for high dose IV corticosteroids for GCA with visual loss and lower dose oral regimens for GCA without visual loss.

Reduction of corticosteroid use in outpatient treatment of exacerbated COPD\xa0- Study protocol for a randomized, double-blind, non-inferiority study, (The RECUT-trial)

BackgroundChronic obstructive pulmonary disease (COPD) is a major public health issue affecting approximately 4% to 7% of the Swiss population. According to current inpatient guidelines, systemic corticosteroids are important in the treatment of acute COPD exacerbations and should be given for 5 to 7 days. Several studies suggest that corticosteroids accelerate the recovery of FEV1 (forced expiratory volume in 1 second), enhance oxygenation, decrease the duration of hospitalization, and improve clinical outcomes. However, the additional therapeutic benefit regarding FEV1 recovery appears to be most apparent in the first 3 to 5 days. No data are available on the optimum duration of corticosteroid treatment in primary-care patients with acute COPD exacerbations. Given that many COPD patients are treated as outpatients, there is an urgent need to improve the evidence base on COPD management in this setting. The aim of this study is to investigate whether a 3-day treatment with orally administered corticosteroids is non-inferior to a 5-day treatment in acute exacerbations of COPD in a primary-care setting.Methods/designThis study is a prospective double-blind randomized controlled trial conducted in a primary-care setting. It is anticipated that 470 patients with acutely exacerbated COPD will be recruited. Participants are randomized to receive systemic corticosteroid treatment of 40 mg prednisone daily for 5 days (conventional arm, n = 235) or for 3 days followed by 2 days of placebo (experimental arm, n = 235). Antibiotic treatment for 7 days is given to all patients with CRP ≥ 50 mg/l, those with a known diagnosis of bronchiectasis, or those presenting with Anthonisen type I exacerbation. Additional treatment after inclusion is left at the discretion of the treating general practitioner. Follow-up visits are performed on days 3 and 7, followed by telephone interviews on days 30, 90, and 180 after inclusion in the study. The primary endpoint is the time to next exacerbation during the 6-month follow-up period.DiscussionThe study is designed to assess whether a 3-day course of corticosteroid treatment is not inferior to the conventional 5-day treatment course in outpatients with exacerbated COPD regarding time to next exacerbation. Depending on the results, this trial may lead to a reduction in the cumulative corticosteroid dose in COPD patients.Trial registrationClinicalTrials.gov, NCT02386735. Registered on 12 March 2015.

A Review of Multiple Sclerosis for Urologists and Urogynecologists with an Emphasis on Management

Multiple sclerosis is a common immune-mediated condition of the central nervous system. It remains one of the most disabling conditions affecting young people, and there is significant cost associated with managing this condition. Revisions of the diagnostic criteria have contributed to better identification and diagnosis of the condition, but consensus approaches to managing the condition are not fully established. Approaches to managing acute demyelination, chronic demyelination, and symptomatic treatments are reviewed. The most common treatment for acute demyelination continues to be the use of corticosteroids via the intravenous or oral routes. Duration of corticosteroid treatment is variable, but high dose treatment is commonly administered over 3 to 7 days. There is a growing arsenal of medications to treat chronic demyelination that includes the use of self-administered injections, daily oral immunomodulation, and intravenous infusions each with their own set of pros and cons. While it is important to address both acute and chronic demyelination, symptomatic treatment should always be addressed to increase the overall quality of activities of daily living. Individuals with multiple sclerosis are all phenotypically different, and careful consideration should be used to individualize therapy for those living with this disease state. As with other autoimmune conditions, not all patients with multiple sclerosis will require long-term chronic therapy. However, chronic immunomodulatory treatments should be offered to all patients to prevent future disease activity until reliable biomarkers are established. Much remains unknown about the pathophysiology of this condition, but advancements in treatment suggest the future is promising for those affected by this condition.

Systemic and inhaled glucocorticosteroids in acute obstructive laryngotracheitis

Acute laryngotracheitis (croup) is an acute condition that most commonly affects children of the first 6 years. Croup is caused by viral infection of the upper airway, predominantly by parainfluenza virus. Croup is characterized by the signs of subglottic stenosis, which determines croup severity. Corticosteroids are the mainstay of croup treatment due to a strong anti-inflammatory effect. Typically, duration of corticosteroid treatment in croup does not exce ed several days. Even short-course systemic corticosteroids are associated with a number of adverse effects: nausea, vomiting, behavioral changes and sleep disturbance, etc. According to Russian clinical guidelines for croup management inhaled corticosteroid budesonide is the first line therapy. Budesonide efficacy in croup has been proved in numerous clinical trials. Based on similar effectiveness of inhaled and systemic corticosteroids in croup patients, budesonide is the preferred treatment option, because it helps to minimize the risk of adverse effects.

Saliva as a Monitoring Fluid for Hormonal Activity in Systemic Lupus Erythematosus

Saliva is a remarkable diagnostic fluid being used to monitor a wide range of local and systemic diseases. Autoimmune diseases represent a major health threat to women worldwide with sexual hormones acting as co-factors for these pathologies and interfering with the normal immune response. The main aim of our study was to evaluate salivary levels of testosterone (T2) and 17-b estradiol (E2) in several autoimmune diseases with a special focus on systemic lupus erythematosus (SLE). The study included 45 SLE patients, 15 patients with other autoimmune diseases and 10 healthy subjects. Salivary T2 and E2 levels were determined using ELISA assays. Salivary E2 levels in female SLE patients were significantly increased versus vasculitis female patients. Positive correlations have been found between salivary E2 levels and important clinical parameters such as age at inclusion and duration of corticosteroid treatment. E2 salivary level was also identified as an independent predictor of lupus renal nephritis. Regarding T2, salivary levels were found to be significantly lower in SLE female patients compared to respective controls. Furthermore, positive statistical correlations were found between T2 and E2 salivary levels. Collectively, these results promote the use of saliva as a monitoring fluid for hormonal activity in SLE.

HCP-17RETROSPECTIVE ANALYSIS OF PNEUMOCYSTIS JIROVECI IN BRAIN TUMOR PATIENTS

Pneumocystis jiroveci pneumonia (PCP) can be a highly lethal infection in patients with HIV or other immunodeficiencies, with a mortality rate estimated at 50%. The use of corticosteroids has been associated with 80-94% of PCP cases in the non-HIV population. In two-thirds of cases, the infection clinically presents during the tapering of steroids, likely reflecting an infection that is unmasked as the patient regains the ability to mount an immune response. The precise influence of dose and duration of corticosteroid treatment regarding susceptibility to PCP infection remains a controversial question. Some studies suggest that patients with brain tumors on steroids for more than 5 weeks are at high risk of PCP, especially during the tapering period. Generally, patients who receive steroid treatment for more than 4 weeks at a dose equivalent to 20 mg of prednisone per day are considered for PCP prophylaxis at most cancer centres, but there is variability across institutions. At the Pencer Brain Tumor Centre at Princess Margaret, there is no established protocol regarding PCP prophylaxis in glioma patients on corticosteroids, as it is felt that the incidence of PCP is rare and side effects of prophylaxis can impact patient's overall well being during treatment. Retrospective assessment of our cohort of patients with primary brain tumors from January 1st 2008 to December 31st 2013 will help determine the incidence of PCP infection in this population in the absence of prophylaxis and will allow evaluation of factors associated with PCP infection, including the dose and the duration of corticosteroid treatment, CD4 count and systemic therapy. We will also determine the proportion of patients who needed to stop their PCP prophylaxis due to side effects and the correlation between PCP infections and the duration/dose of steroid treatment. Results will be available for the SNO meeting.

Key advances in the clinical approach to ANCA-associated vasculitis.

The updated nomenclature for vasculitis defines this varied group of disorders by aetiology, specific features of pathogenesis and clinical symptoms; diagnostic and classification criteria for clinical practice are in development. Here, I review some important advances in the management of vasculitis within the category of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), which encompasses microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA). The clinical approach to the management of the patient with AAV should include testing for ANCA specificity; proteinase 3 (PR3)-specific ANCAs are most often associated with GPA, whereas myeloperoxidase (MPO)-ANCAs are usually associated with MPA. Also important to the management of AAV is an assessment of the disease stage and severity, to enable tailored treatment based on an algorithm derived from controlled-trial data. Remaining questions pertain to the dosage and duration of corticosteroid treatment, the selection of patients for, and duration of, maintenance treatment after induction of remission, and the identification of safer and more effective therapies than are currently in use. Outcome measures should assess not only disease activity, but also damage and quality of life. Infections, cardiovascular events and malignancies also contribute to outcome, and their prevention should therefore be part of the clinical approach to managing patients with AAV.

Bone mineral density, vitamin D, and nutritional status of children submitted to hematopoietic stem cell transplantation

ObjectiveThe aim of the study was to evaluate the effect of allogeneic hematopoietic stem cell transplantation (HSCT) on bone mineral density (BMD), serum vitamin D levels, and nutritional status of 50 patients between ages 4 and 20 y. MethodsWe conducted pre-HSCT and 6-mo post-HSCT evaluations. We measured BMD at the lumbar spine (LS) and total body (TB) by dual energy x-ray absorptiometry (DXA); body composition by bioimpedance analysis, and dietary intakes of calcium and vitamin D using the 24-h recall and semiquantitative food frequency questionnaire methods. ResultsWe observed a significant reduction in BMD 6 mo post-HSCT. Nearly half (48%) of patients had reductions at the LS (average −9.6% ± 6.0%), and patients who developed graft-versus-host disease (GVHD) had the greatest reductions (−5.6% versus 1.2%, P < 0.01). We also found reductions in serum levels of 25-hydroxyvitamin D (25-OHD), from 25.6 ± 10.9 ng/dL to 20.4 ± 11.4 ng/dL (P < 0.05), and in body weight. Corticosteroid treatment duration, severity of chronic GVHD, serum 25-OHD levels, and family history of osteoporosis were all risk factors associated with variations in BMD at the LS. ConclusionHSCT in children and adolescents negatively effects their BMD, nutritional status, and vitamin D levels. We suggest that early routine assessment be done to permit prevention and treatment.

Therapeutic strategy for granulomatous lobular mastitis: a clinicopathological study of 12 patients.

Granulomatous lobular mastitis (GLM) is a rare inflammatory pseudotumor. No therapeutic modality for this disease has been established because of its rarity. The purpose of this study is to evaluate the treatment strategies of GLM. Twelve women who met the histological criteria for GLM were retrospectively studied. The clinical data and the presentation, histopathology, and management of the disease were analyzed by reviewing the patients' medical records. The diagnosis of GLM was confirmed histologically by core needle biopsy in 9 cases, by vacuum-assisted biopsy in 2 cases, and by excisional biopsy in 1 case. Ten patients received corticosteroid treatment and another two patients were treated with local excision or incision and drainage. The median initial dosage of corticosteroid (Prednisolone) was 30 mg/day (range: 15-60 mg/day), and the dosages were tapered according to improvement. The median duration of corticosteroid treatment was 5 months (range: 1-12 months). The median follow-up period was 22 months (range: 6-104 months), and no patient treated with corticosteroid demonstrated recurrence. However, patients treated with excision or incision and drainage had recurrences. These results suggest that steroid treatment may be the first choice in treatment strategies for GLM.

Health care for osteoporosis in inflammatory bowel disease: Unmet needs in care of male patients?

Background and aimsOsteoporosis is a frequent complication of inflammatory bowel disease (IBD). It may be related to IBD itself or to its therapy. In this study, the quality of care regarding diagnosis and treatment of osteoporosis was examined. MethodsIn this retrospective, monocentric study 293 consecutive patients with IBD (98 ulcerative colitis, 195 Crohn's disease) were included. Information on age, gender, weight, nicotine abuse, course, disease pattern and medication was assessed, results of dual X-ray absorptiometry (DEXA-scan) were evaluated. ResultsDEXA-scan was performed in 174 patients (59 male, 115 female). Bone mineral density (BMD) was impaired in 38.5% of these patients. Male patients were diagnosed more often with osteopenia or osteoporosis than females (55.9% vs. 29.6%, p=0.03) and had a risk of bone disease comparable to postmenopausal women. Additionally, duration of corticosteroid treatment and IBD were identified as risk factors for osteoporosis. Follow up DEXA-scan demonstrated an overall deterioration of BMD in patients with normal baseline results. ConclusionsWhile in general, women are considered at higher risk for osteoporosis, male patients had a higher risk of impaired BMD, especially when under treatment with corticosteroids. The high incidence of reduced BMD supports the recommendation to screen patients with IBD at an early stage of disease, although a possible bias has to be considered for patients at a tertial referral centre for IBD. Patients with normal baseline DEXA-scan were still at risk to develop bone disease and it seems advisable to monitor patients with IBD for reduced BMD continually.

Muscle atrophy and preferential loss of myosin in prolonged critically ill patients*

Muscle weakness contributes to prolonged rehabilitation and adverse outcome of critically ill patients. Distinction between a neurogenic and/or myogenic underlying problem is difficult using routine diagnostic tools. Preferential loss of myosin has been suggested to point to a myogenic component. We evaluated markers of muscle atrophy and denervation, and the myosin/actin ratio in limb and abdominal wall skeletal muscle of prolonged critically ill patients and matched controls in relation to insulin therapy and known risk factors for intensive care unit-acquired weakness. Secondary analysis of two large, prospective, single-center randomized clinical studies. University hospital surgical and medical intensive care unit. Critically ill patients and matched controls. Intensive care unit patients had been randomized to blood glucose control to 80-110 mg/dL with insulin infusion or conventional glucose management, where insulin was only administered when glucose levels rose above 215 mg/dL. As compared with controls, rectus abdominis and vastus lateralis muscle of critically ill patients showed smaller myofiber size, decreased mRNA levels for myofibrillar proteins, increased proteolytic enzyme activities, and a lower myosin/actin ratio, virtually irrespective of insulin therapy. Increased forkhead box O1 action may have played a role. Most alterations were more severe in patients treated with corticosteroids. Duration of corticosteroid treatment, independent of duration of intensive care unit stay or other risk factors, was a dominant risk factor for a low myosin/actin ratio. The immature acetylcholine receptor subunit γ messenger RNA expression was elevated in vastus lateralis, independent of the myosin/actin ratio. Both limb and abdominal wall skeletal muscles of prolonged critically ill patients showed downregulation of protein synthesis at the gene expression level as well as increased proteolysis. This affected myosin to a greater extent than actin, resulting in a decreased myosin/actin ratio. Muscle atrophy was not ameliorated by intensive insulin therapy, but possibly aggravated by corticosteroids.

Cataract and glaucoma in Korean children with chronic glomerulonephritis receiving systemic corticosteroid treatment

Editor, In paediatric chronic glomerulonephritis, systemic corticosteroid treatment is administered for a long period of time. Therefore, there is a high probability of steroid-induced ocular complications such as cataracts and glaucoma. We examined the association of ocular complications with systemic corticosteroid treatment through clinical reports conducted on a large number of Korean children with chronic glomerulonephritis. We retrospectively analysed medical records of 238 Korean children with chronic glomerulonephritis who received systemic corticosteroid treatment between January 2000 and December 2006 in the Department of Pediatrics at Kyung-Hee University Medical Center. Systemic corticosteroid treatment is divided into methylprednisolone pulse treatment and long-term low-dose oral prednisolone treatment. The number of pulse treatment cycles given depended on the degree of proteinuria improvement. After pulse treatment, low-dose oral prednisolone was administered and slowly tapered. The duration of the corticosteroid administration was calculated at the time the intraocular complications developed. If the intraocular complications did not develop in the patients, the duration was calculated at the time of last observation. The total corticosteroid dose was calculated based on the sum of corticosteroid used for methylprednisolone pulse treatment and low-dose oral corticosteroid treatment during the entire treatment period. All patients were examined for the occurrence of cataracts and measurement of intraocular pressure (IOP) before and every 3–6 months after starting corticosteroid treatment. The association of cataract and glaucoma with dose and duration of corticosteroid treatment was analysed statistically by using the binary logistic regression analysis. Cataracts occurred in 74 patients, an incidence of 31%. In cataract cases, there was a statistically significant association with the frequency of intravenous methylprednisolone pulse treatment (Table 1). So exposure to high-dose corticosteroid may accelerate the onset of corticosteroid-induced cataract formation. Several reports especially have investigated the relationship between corticosteroid pulse treatment and cataracts. Nakamura et al. (2003) reported that in postrenal transplant, corticosteroid pulse treatment is considered to be a risk factor for developing steroid cataracts. Nerome et al. (2008) reported that in paediatric patients, frequency of intravenous methylprednisolone pulse treatment was a significant risk factor for inducing cataracts. But considering that total corticosteroid dose, total corticosteroid dose per weight was not associated with cataract formation, the duration of high-dose corticosteroid treatment may be a more significant risk factor for inducing cataract than high dose of corticosteroid. Pavlin et al. (1977) reported that in 62 recipients of renal transplants, a positive correlation was found between the development of cataracts and the number of days on which the dose exceeded 100 mg. Therefore, extensive high-dose corticosteroid exposure, such as a high frequency of intravenous methylprednisolone pulse treatment, encourages cataract formation and needs comprehensive ophthalmic examination. Regarding IOP, based on a cut-off of 21 mmHg, 92 patients (39%) showed elevation of IOP. In elevated IOP cases, the reverse relationship to corticosteroid treatment duration was showed (Table 2). To our knowledge, there are no reports in the literature that suggested reverse relationship between elevated IOP and corticosteroid treatment duration. It is thought that this implies the presence of specific children whose IOP is elevated even though corticosteroid was used only for a short period of time, as well as specific children whose IOP was not elevated despite the use of corticosteroids for a long time. It may be closely related to the individual susceptibility (Niaudet 1994; Loke et al. 1997). We conclude that, in 238 Korean children with chronic glomerulonephritis receiving systemic corticosteroid treatment, the incidence of cataract was associated with the frequency of intravenous methylprednisolone pulse treatment. Comprehensive ophthalmic examination may be suggested when frequent intravenous methylprednisolone pulse treatment is administered.

Prospective Assessment of Bone Turnover and Clinical Bone Diseases After Allogeneic Hematopoietic Stem-Cell Transplantation

Bone complications after hematopoietic stem-cell transplantation (HSCT) are relatively frequent. Evaluation of biomarkers of bone turnover and dual energy x-ray absorptiometry (DEXA) are not known in this context. We prospectively evaluated bone mineral density, biomarkers of bone turnover, and the cumulative incidence of bone complications after allogeneic HSCT. One hundred forty-six patients were included. Bone mineral density was measured by DEXA 2-month and 1-year post-HSCT. The markers of bone turnover were serum C-telopeptide (C-TP), 5 tartrate-resistant acid phosphatase (bone resorption), and osteocalcin (bone formation) determined pre-HSCT and 2 months and 1 year thereafter. Potential association between osteoporosis at 2 months, osteoporotic fracture or avascular necrosis and, individual patient's characteristics and biologic markers were tested. C-TP was high before and 2 months after transplant. At 2 months, DEXA detected osteoporosis in more than half the patients tested. Male sex, median age less than or equal to 15 years, and abnormal C-TP before HSCT were risk factors significantly associated with osteoporosis. Three-year cumulative incidences of fractures and avascular necrosis were 8% and 11%, respectively. Children were at higher risk of fracture, whereas corticosteroid treatment duration was a significant risk factor for developing a clinical bone complication post-HSCT. Bone complications and osteoporosis are frequent after HSCT. Bone biologic markers and DEXA showed that subclinical bone abnormalities appeared early post-HSCT. The risk factors, age, gender, and C-TP easily available at the time of transplantation were identified. Biphosphonates should probably be given to patients with those risk factors.

Aortic aneurysms in systemic lupus erythematosus: a meta-analysis of 35 cases in the literature and two different pathogeneses

Aortic aneurysms including dissection are uncommon complications of systemic lupus erythematosus, but the incidence has been increasing with an improved prognosis for this disease. However, the mechanisms contributing to aneurysm formation in systemic lupus erythematosus have not been fully clarified. A meta-analysis of published cases was conducted to clarify the patient characteristics that may contribute to aneurysm formation in systemic lupus erythematosus. A search of relevant studies published over the past 40 years (1969-2008) was carried out in the publications on aortic aneurysms with systemic lupus erythematosus, and 35 cases were identified. The contributing factors to aneurysm formation as well as the patient prognosis were searched for sex, age, duration of corticosteroid treatment, aneurysm site (thoracic and/or abdominal), mortality, evidence of atherosclerotic involvement, and presence or absence of an operation, rupture, dissection, cystic medial degeneration, vasculitis, and hypertension. Each of these factors was assigned to each point score. Based on the point scores, a statistical analysis of rank correlation was thereafter performed. The factors correlating with the presence of thoracic or abdominal lesions differed significantly. The presence of thoracic aneurysms correlated with dissection and cystic medial degeneration, whereas abdominal lesions correlated with the finding of atherosclerosis. Thoracic lesions showed a high rate of death, while abdominal lesions were associated with a relatively favorable prognosis. Abdominal lesions were related to the duration of steroid therapy. The other correlations among the various factors were also evaluated, with the finding of cystic medial degeneration associated with vasculitis. Two principal patterns emerged from this analysis. One was the fatal nonatherosclerotic thoracic aneurysm which was associated with cystic medial degeneration and probably due to vasculitis. The other was atherosclerotic abdominal aneurysm which was complicated by long-term steroid treatment and it showed a relatively favorable prognosis.