Exploring the impact of paediatric localized scleroderma on health-related quality of life: focus groups with youth and caregivers.

BACKGROUND: Paediatric localized scleroderma (LS) can negatively impact health-related quality of life (HRQoL) by causing skin fibrosis, abnormal limb development, disfigurement, and side-effects from immunosuppressive treatment. Studies to date have rarely included qualitative data gathered directly from paediatric patients with LS. OBJECTIVES: To assess the impact of LS on HRQoL among affected youth and their caregivers using qualitative description. METHODS: Youth with all subtypes of LS and their caregivers were purposively sampled to participate in age-appropriate focus groups (younger children, early adolescents, adolescents). Each group started with a drawing exercise followed by in-depth discussion of topics including skin symptoms (e.g. itch, pain, tightness), functional impairment, physical appearance, family and peer relationships, and treatment burden. Focus groups were transcribed verbatim and co-coded, with adjudication of differentially applied codes. The study findings were triangulated via comparison with adult reports and published literature. RESULTS: Eleven youth aged 9-16 years and 16 caregivers participated in three focus groups each. Major identified areas of impact included uncomfortable skin symptoms, physical functioning limitations, extracutaneous manifestations, body image, bullying and teasing, unwanted questioning from others, and treatment side-effects and burden. CONCLUSIONS: This is the first qualitative study of HRQoL in LS to include all major LS subtypes. We identified domains of HRQoL impacted by LS, some of which replicate earlier findings and some of which were novel. As impact also changed with developmental stage, our findings support the need for ongoing, formal evaluation of HRQoL in children and adolescents with LS. What is already known about this topic? Paediatric localized scleroderma (LS) negatively impacts health-related quality of life (HRQoL) via skin fibrosis, musculoskeletal and other extracutaneous manifestations from the disease process, and side-effects of systemic immunosuppression. The full impact of LS and its treatment on HRQoL is incompletely understood, with only one published qualitative study of youth with LS, which was limited to facial involvement. There are no qualitative studies of HRQoL in other LS subtypes to date. What does this study add? This is the first qualitative evaluation of HRQoL in youth with LS inclusive of all disease subtypes. Our study confirms that LS affects HRQoL across multiple distinct domains, including uncomfortable skin sensations, impacts on body image, bullying and teasing from peers, unwanted intrusive questioning, physical limitations, extracutaneous manifestations and high treatment burden. These results indicate the need for ongoing clinical assessment of paediatric patients in these domains. What are the clinical implications of the work? These results support the need to care for patients with LS holistically by synthesizing cutaneous, musculoskeletal and extracutaneous disease assessments with multidimensional evaluation of psychosocial impact and adverse effects of treatments. The development of an LS-specific HRQoL measure would advance such efforts.

Urea metabolism in beef steers fed tall fescue, orchardgrass, or gamagrass hays.

Two experiments were conducted to assess effects of endophyte treatments (Exp. 1), forage species (Exp. 2), and supplementation (Exp. 2) on urea production, excretion, and recycling in beef steers. Infusion of (15,15)N-urea and enrichment of urea in urine samples were used to calculate urea-N entry and recycling to the gut. Acceptably stable enrichment of (15)N-urea in urine was obtained after 50 h of intrajugular infusion of (15,15)N-urea, indicating that valid data on urea metabolism can be obtained from steers fed forages twice daily. After adjustment by covariance for differences in N intake among treatments in Exp. 1, steers fed endophyte-infected tall fescue had less (P<0.10) urea-N entry, recycling to the gut, and return of recycled urea-N to the ornithine cycle than those fed endophyte-free or novel endophyte-infected tall fescue. However, urea-N urinary excretion or return to the gut was similar among endophyte treatments when expressed as a proportion of urea-N entry. Urea-N entry and return to the gut in Exp. 2 was similar in steers fed gamagrass or orchardgrass hay after adjustment by covariance for differences in N intake. Less (P<0.01) urinary excretion, expressed as grams per day or as a proportion of urea-N entry, with gamagrass than with orchardgrass was associated with faster in vitro NDF-N digestion with gamagrass. Supplementation of gamagrass or orchardgrass with 1.76 kg/d of readily fermentable fiber and starch decreased urea entry (P<0.06) and urinary excretion of urea (P<0.01). Interactions between hay source and supplement reflected a greater response to supplementation for steers fed orchardgrass than for those fed gamagrass. After adjustment for differences among treatments in N supply, results of both experiments support the concept of improved N use in response to increased carbohydrate fermentability in the rumen, due either to inherent differences in forage fiber or to supplementation with readily fermentable carbohydrate (starch or fiber). Closer coordination of ruminal fermentation of carbohydrate and N sources provided greater and more efficient capture of dietary N as tissue protein in forage-fed steers.

Bone anabolic effects of subcutaneous treatment with basic fibroblast growth factor alone and in combination with estrogen in osteopenic ovariectomized rats.

Although basic fibroblast growth factor (bFGF) is a potent stimulator of bone formation when administered intravenously, less is known regarding the effects of this peptide on bone following subcutaneous (s.c.) administration. In addition, it is unknown whether coadministration of estrogen enhances the bone response to treatment with bFGF. Therefore, the purpose of this study was (1) to characterize the skeletal response to s.c. injection of a high dose of bFGF, and (2) to determine whether concurrent administration of estrogen affects the skeletal response to bFGF treatment. Female Sprague-Dawley rats were ovariectomized (ovx) or sham-operated (sham) at 3 months of age and left untreated for 2 months to establish cancellous osteopenia in the ovx group. The sham rats (n=10) and one group of ovx rats (n=9) were then injected s.c. with vehicle alone for 3 weeks. Two additional groups of ovx rats were injected s.c. with bFGF (n=10) or with bFGF + estrogen (n=10) for 3 weeks. bFGF was administered s.c. at a daily dose of 1 mg/kg/day and estrogen was administered s.c. 4 days per week at a dose of 10 microg/kg for the 3-week duration of treatment. Lumbar vertebrae were collected and processed undecalcified for quantitative bone histomorphometry. Cancellous bone volume was lower and cancellous bone turnover was higher in vehicle-treated ovx rats than in vehicle-treated sham rats. Subcutaneous treatment of ovx rats with bFGF for 3 weeks resulted in a 4-fold increase in osteoblast surface and an 8-fold increase in osteoid surface in comparison to vehicle treatment of ovx rats. Osteoid volume was also markedly increased in the bFGF-treated ovx rats (7 +/- 4%) in comparison to vehicle-treated ovx rats (<0.1%). Osteoblast surface, osteoid surface, and osteoid volume were nearly identical in ovx rats treated with bFGF alone and with bFGF + estrogen. Although the majority of the osteoid in bFGF- and bFGF + estrogen-treated animals was deposited along mineralized bone surfaces, osteoid spicules without any connections to preexisting bone surfaces were also detected, providing definitive proof for bone formation within bone marrow in response to bFGF administration. Osteoclast surface, an index of bone resorption, was not affected by bFGF treatment. However, cotreatment of ovx rats with bFGF + estrogen resulted in lower osteoclast surface in comparison to treatment of ovx rats with either vehicle or bFGF alone. In summary, these findings indicate that administration of a high dose of bFGF via s.c. injection markedly increases bone formation and may be a useful treatment for cancellous osteopenia in the estrogen-deplete skeleton. The anabolic effects of bFGF on bone are not enhanced by concurrent treatment with estrogen at the replacement dose used in this study.