Management of cardiac involvement in muscular dystrophies: paediatric versus adult forms

Muscular dystrophies are a group of genetic disorders characterized by muscle degeneration and consequent substitution by fat and fibrous tissue. Cardiac involvement is an almost constant feature in a great part of these diseases, as both primary myocardial involvement and secondary involvement due to respiratory insufficiency, pulmonary hypertension or reduced mobility. Primary myocardial involvement usually begins more precociously compared to the secondary involvement. In fact the first signs of cardiomyopathy can be observed in the first decade of life in muscular dystrophies with childhood onset and later in adult form of muscular dystrophies as myotonic dystrophy type 1. At least an annual cardiac follow-up is recommended in these patients including clinical and instrumental examination (ECG, 24h Holter monitoring, ECHO), to detect cardiac involvement. A more frequent monitoring may be required according to the type of cardiomyopathy and the patient's needs. In this short review practical guide-lines are shown for physicians routinely involved in the management of these patients.

Congenital muscular dystrophy and epilepsy: a prospective case series of pediatric patients

Congenital Muscular Dystrophies (CMDs) can be considered as a heterogeneous group of diseases characterized by marked weakness, generalized hypotonia and joint contractures. They are divided into pure and classical forms, without ocular and cerebral involvement, and complex forms, which are associated with cerebral abnormalities. Seizures have rarely been described in the pure forms while they seem to occur more frequently in complex forms. The aim of our study was to evaluate the incidence of seizure in CMD. Herein, the authors describe 16 cases of congenital muscular dystrophy (CMD) associated with different kinds of epileptic events, in order to study the pathogenic connection between the two clinical manifestations. In all described patients we reviewed the clinical, neurophysiologic, and neuroimaging data to determine any associations with epilepsy. The patients were divided into two groups: 14 cases with merosin positive CMD in one group and 2 patients with Walker Warburg syndrome (WWS) in the second group. In our study we found that in the first group, one benign myoclonic epilepsy (BME), one benign febrile convulsions had occurred. Also in one patient, the EEG revealed a moderately high voltage slow background with diffuse sharp waves reaching 300mV in amplitude with no clinical signs. In the merosin positive CMD patients, the presence of two different epileptic diseases, benign myoclonic epilepsy (BME) in one and febrile convulsion with tonic clinic seizures, may represent a new expression of merosine-positive congenital muscular disease (PCMD) in which the deficiency of an undiscovered muscular protein with a cerebral isoform may be the cause of epileptic events in this group of patients.

Self-reported incidence and age of onset of chronic comorbid medical conditions in adults aging with long-term physical disability

BACKGROUND

Adults with long-term disability are living longer and may experience accelerated aging. More information is needed to understand the incidence of chronic comorbid medical conditions in this population.

OBJECTIVE

To examine the incidence, prevalence, age of onset and predictors of five chronic conditions in a sample of adults with long-term physical disability.

METHODS

Longitudinal self-report surveys were mailed to 1594 adults with multiple sclerosis, muscular dystrophy, post-polio syndrome or spinal cord injury twice, 3.5 years apart. Survey questions assessed demographics (date of birth, sex, income, disability type, height/weight), self-reported diagnosis of coronary heart disease, hypertension, arthritis, diabetes and cancer, and health behaviors (alcohol use, smoking, physical activity).

RESULTS

Over the course of the study, the most commonly reported new onset chronic comorbid medical condition was arthritis (percent incidence = 14%), followed by hypertension (9%) and cancer (7%). Report of a new condition was greatest in adults aged between 56 and 65 years, and risk factors included greater BMI, waist circumference, and the presence of another chronic comorbid medical condition at baseline.

CONCLUSIONS

Chronic comorbid medical conditions are prevalent in persons with long-term physical disability. Midlife appears to be the period of greatest risk for onset of a new condition, and risk for incidence increases in the presence of other chronic comorbid medical conditions. Modifiable risk factors include BMI and waist circumference. Future research should explore whether changes in modifiable factors at midlife or earlier (e.g., diet, exercise) would help prevent or delay onset of comorbid conditions in this population.

[Anesthetic Management for Endoscopic Sinus Surgery in a Patient with Transplanted Heart--A Case Report]

A 19-year-old male patient with transplanted heart received endoscopic sinus surgery. He was with X-linked dilated cardiomyopathy, and was one year after the transplantation. Preanesthetic study showed lactate dehydrogenase elevation estimated to have derived from striated muscle. Heart function was normal, and other abnormal findings were not revealed. Total intravenous anesthesia was performed with propofol target controlled infusion and remifentanil. Rocuronium was administered only for oro-tracheal ntubation. After the operation, train-of-four ratio was 95%, and he awoke from anesthesia smoothly. We did not use atropine, neostigmine or sugammadex to reverse neuromuscular blockade. No inotropic agent was administered. He was discharged from the hospital 5 days after the operation without any complications. We used usual anesthetic management but we had to be careful about both denervated heart and myopathy.

Teaching mindfulness meditation to adults with severe speech and physical impairments: An exploratory study

People with severe speech and physical impairments may benefit from mindfulness meditation training because it has the potential to enhance their ability to cope with anxiety, depression and pain and improve their attentional capacity to use brain-computer interface systems. Seven adults with severe speech and physical impairments (SSPI) - defined as speech that is understood less than 25% of the time and/or severely reduced hand function for writing/typing - participated in this exploratory, uncontrolled intervention study. The objectives were to describe the development and implementation of a six-week mindfulness meditation intervention and to identify feasible outcome measures in this population. The weekly intervention was delivered by an instructor in the participant's home, and participants were encouraged to practise daily using audio recordings. The objective adherence to home practice was 10.2 minutes per day. Exploratory outcome measures were an n-back working memory task, the Attention Process Training-II Attention Questionnaire, the Pittsburgh Sleep Quality Index, the Perceived Stress Scale, the Positive and Negative Affect Schedule, and a qualitative feedback survey. There were no statistically significant pre-post results in this small sample, yet administration of the measures proved feasible, and qualitative reports were overall positive. Obstacles to teaching mindfulness meditation to persons with SSPI are reported, and solutions are proposed.

Left ventricular non-compaction cardiomyopathy associated with epidermolysis bullosa simplex with muscular dystrophy and PLEC1 mutation

Plectin mutations have been reported in epidermolysis bullosa simplex with muscular dystrophy. We report the first case of left ventricular non-compaction in an 18-year-old male with epidermolysis bullosa simplex with muscular dystrophy. The patient was diagnosed with epidermolysis bullosa simplex after blistering was noted at birth. Motor function difficulties were first recognized at age 11, however the patient was lost to follow up. He was re-evaluated at age 17 and demonstrated significant ptosis, ophthalmoparesis, and pharyngeal muscle weakness. He had predominant proximal muscle weakness with the inability to raise arms against gravity. He was ambulatory for short distances but lost the ability to rise from the floor at 14 years. He was subsequently diagnosed with epidermyolysis bullosa simplex with muscular dystrophy and a PLEC1 mutation. Screening cardiovascular imaging revealed a diagnosis of isolated left ventricular non-compaction. This case highlights the potential for delayed onset muscular dystrophy in patients with epidermolysis bullosa simplex. Furthermore, this case also underscores the importance of long term, routine cardiac evaluation, including imaging and electrophysiologic evaluation, in patients with epidermolysis bullosa simplex with muscular dystrophy as the cardiac phenotype appears to parallel the variable severity and age of onset that characterize the neuromuscular phenotype.

Dystroglycanopathy with two novel POMT1 mutations in a Chinese boy with developmental delay and muscular dystrophy

Alpha-dystroglycanopathies are a group of diseases due to reduced glycosylation of alpha-dystroglycan, which commonly result from mutations in POMT1, POMT2, and POMGnT1. Patients with alpha-dystroglycanopathies present with muscular, cerebral, and ocular involvements with differing severities. We reported a boy who presented with muscular dystrophy, developmental delay, and non-specific white matter lesions. Mutation analysis of POMT1 was performed and revealed two novel mutations, a substitution mutation (c.176T>G) and a duplication mutation (c.2059dupC) which results in premature termination of translation. In-silico prediction in five different platforms concurred that the substitution is damaging, and functional studies by immunofluorescence revealed lack of staining in the carbohydrate moiety of alpha-dystroglycan, confirming the molecular findings in a functional manner. In conclusion, we reported the first case of genetically confirmed alpha-dystroglycanopathy due to mutations in POMT1 in Chinese.

Risk of fracture in patients with muscular dystrophies

The aim of the study was to determine fracture risk in incident muscular dystrophy (MD) patients. Patients with MD are at a 1.4-fold increased risk of fracture as compared with population-based control patients. Risk further increased among elderly and female patients and among patients exposed to oral glucocorticoids.

INTRODUCTION

Muscular dystrophies (MDs) are inherited diseases causing muscle weakness and thereby increase the risk of falling and detrimental effects on bone. Both are recognised risk factors for fracture. Therefore, the aim of this study was to determine the hazard ratio of fracture in patients with MD.

METHODS

We conducted a retrospective cohort study using the UK General Practice Research Database (1987-2012). Each patient with MD was matched by year of birth, sex and practice to up to six patients without a history of MD. Outcome measure was all fractures.

RESULTS

As compared with control patients, risk of any fracture was statistically significantly increased in MD patients (adjusted hazard ratio [AHR], 1.40; 95 % confidence interval [CI], 1.14-1.71). An increased risk of fracture was observed among MD patients with female gender (AHR, 1.78; 95 % CI, 1.33-2.40) and an increasing age as compared with control patients. Stratification to Duchenne MD showed no association with fracture, whereas risk of fracture was increased twofold among patients with myotonic dystrophy (AHR, 2.34; 95 % CI, 1.56-3.51). MD patients had an almost tripled risk of fracture when they used oral glucocorticoids in the previous 6 months as compared to non-users with MD.

CONCLUSION

Patients with MD are at a 1.4-fold increased risk of fracture as compared with population-based control patients. Especially in older age groups and female gender, the fracture risk of MD versus non-MD patients is increased, whereas exposure to glucocorticoids further increased fracture risk among MD patients.

Patients with neuromuscular disorder

This article describes the preoperative preparation of patients with neuromuscular disorders. These entities are a relatively rare and diverse group of diseases that can affect various organ systems in addition to the central nervous system. The anesthetic implications for the various comorbidities are varied and can be profound. These patients should be optimized before surgery, with the involvement of a multidisciplinary team of specialists.

Magnetic resonance of the heart in a muscular dystrophy patient with an MR conditional ICD: assessment of safety, diagnostic value and technical limitations

Cardiovascular magnetic resonance (CMR) studies in patients with pacemakers or implantable cardioverter/defibrillators (ICD) are increasingly required in daily clinical practice. Therefore, in the last years the manufacturers developed not only MR-conditional pacemakers, but also MR-conditional ICDs. However, the clinical experience regarding the feasibility and limitations of MR studies of the heart in patients with ICDs is still limited. In particular, there are hardly any CMR studies in the same patients performed prior to and post ICD implantation allowing a one-to-one comparison of the obtained CMR images. This is the first presentation of a CMR study in a patient with the world's first and so far only MR-conditional ICD. In our case, a major problem related to the presence of the MR conditional ICD was an image artifact caused by the device's generator which hampered the visualization of the midventricular and apical anterior and antero-lateral segments in all sequences performed. Considering previous studies, right chest implantation of the ICD could probably have helped in this setting and may be preferred in future ICD implantations. Our case report nicely illustrates the real clinical need for specially designed implantable devices that ensure safe and high-quality imaging in patients in whom serial CMR is required.

Prevention and management of limb contractures in neuromuscular diseases

Limb contractures are a common impairment in neuromuscular diseases. They contribute to increased disability from decreased motor performance, mobility limitations, reduced functional range of motion, loss of function for activities of daily living, and increased pain. The pathogenesis of contractures is multifactorial. Myopathic conditions are associated with more severe limb contractures compared with neuropathic disorders. Although the evidence supporting the efficacy of multiple interventions to improve range of motion in neuromuscular diseases in a sustained manner is lacking, there are generally accepted principles with regard to splinting, bracing, stretching, and surgery that help minimize the impact or disability from contractures.

Congenital generalized lipodystrophy type 4 with muscular dystrophy: clinical and pathological manifestations in early childhood

A boy with congenital generalized lipodystrophy type 4 with muscular dystrophy presented in infancy with delay in motor milestones and a persistent elevation of CK. There was no associated mental retardation. He was followed up to 3 years and 11 months; he had a homozygous c.696_697insC mutation in polymerase I and transcript release factor (PTRF). He started to walk at 2 years and 6 months although he did not have mental retardation. Insulin resistance appeared at 3 years and 11 months of age. PTRF immunostaining positivity was absent in the muscle but caveolin-3 was preserved in the sarcolemma at 16 months of age. Secondary deficiency of caveolins may be closely associated with disease progression.

Quality-of-life measures in children with neurological conditions: pediatric Neuro-QOL

BACKGROUND

A comprehensive, reliable, and valid measurement system is needed to monitor changes in children with neurological conditions who experience lifelong functional limitations.

OBJECTIVE

This article describes the development and psychometric properties of the pediatric version of the Quality of Life in Neurological Disorders (Neuro-QOL) measurement system.

METHODS

The pediatric Neuro-QOL consists of generic and targeted measures. Literature review, focus groups, individual interviews, cognitive interviews of children and consensus meetings were used to identify and finalize relevant domains and item content. Testing was conducted on 1018 children aged 10 to 17 years drawn from the US general population for generic measures and 171 similarly aged children with muscular dystrophy or epilepsy for targeted measures. Dimensionality was evaluated using factor analytic methods. For unidimensional domains, item parameters were estimated using item response theory models. Measures with acceptable fit indices were calibrated as item banks; those without acceptable fit indices were treated as summary scales.

RESULTS

Ten measures were developed: 8 generic or targeted banks (anxiety, depression, anger, interaction with peers, fatigue, pain, applied cognition, and stigma) and 2 generic scales (upper and lower extremity function). The banks reliably (r > 0.90) measured 63.2% to 100% of the children tested.

CONCLUSIONS

The pediatric Neuro-QOL is a comprehensive measurement system with acceptable psychometric properties that could be used in computerized adaptive testing. The next step is to validate these measures in various clinical populations.

[Respiratory management in muscular dystrophies]

Respiratory failure is a major contributor to immobility and mortality in progressive muscular dystrophies. The severity of pulmonary impairment and the stage at which it develops differ according to the type of muscular dystrophy. Appropriate respiratory management for each type should be considered. In Duchenne muscular dystrophy (DMD), respiratory impairment manifests in the late teens, and assisted mechanical ventilation is administered. Noninvasive positive-pressure ventilation (NIPPV) has increased the median survival of patients with DMD by 10 year and improved quality of life. In myotonic dystrophy (MyD), the causes of respiratory failure can involve both the central and the peripheral nervous systems in addition to respiratory muscles. Nocturnal desaturation is more severe in MyD than in other muscular dystrophies with similar degrees of respiratory muscle weakness. Cognitive impairment should be taken into account in the management of MyD patients. NIPPV does not appear to improve survival of MyD. Guidelines for DMD have been published. Respiratory function should be assessed serially by measuring forced vital capacity, oxyhemoglobin saturation, peak cough flow, and end-tidal CO₂ level. A respiratory action plan should be enacted with increasing disease severity. Therapeutic measures comprise airway clearance, respiratory muscle training, noninvasive nocturnal ventilation, daytime noninvasive ventilation, and continuous invasive ventilation. At the advanced stage of respiratory failure, attention should be paid to complications related to long-term mechanical ventilation, such as pneumothorax and tracheal hemorrhage. Discussing about end-of-life care among the patient, family, and physician is important before mechanical ventilatory support is required.

[Successful use of sugammadex in a muscular dystrophy patient]

Muscular dystrophy requires cautious administration of muscle relaxants due to variable sensitivity and prolonged effects. A 43-year-old man with muscular dystrophy was scheduled for open reduction and internal fixation under general anesthesia. Following patient's TOF ratio with the muscle relaxation monitor, 80 minutes after rocuronium bromide (Rb) administration, we found that TOF ratio was over 0.9. We used sugammadex 4 mg x kg(-1) to reverse Rb-induced neuromuscular block, and then extubated. There was no clinical adverse effect on his muscular function and no respiratory distress after the use of sugammadex in the postoperative phase. Reversal of Rb-induced neuromuscular block by sugammadex in a patient with muscular dystrophy is efficient and safe.

[Anesthesia preoperative preparation of muscular dystrophy]

The muscular dystrophies are inherited myogenic disorders characterized by progressive muscle wasting and weakness of variable distribution and severity. They can be subdivided into several groups, including congenital forms, in accordance with the distribution of predominant muscle weakness: Duchenne/Becker; limb-girdle; Fukuyama type congenital muscular dystrophy; Emery-Dreifus; facioscapulohumeral; oculopharyngeal; myotonic dystrophy, et al. Muscular dystrophies are susceptible to perioperative respiratory, cardiac and other complications, such as rhabdomyolysis. Halogenated inhalational anesthetic agents have been implicated as a cause of acute rhabdomyolysis that resembles malignant hyperthermia. Depolarizing neuromuscular blocking drugs that cause rhabdomyolysis are contraindicated in these patients. Recommendations are proposed for the safe anesthetic management of these patients.

Severe respiratory and skeletal muscles involvement in a carrier of dysferlinopathy with chronic obstructive pulmonary disease

The natural course of progressive neuromuscular diseases can be complicated by respiratory muscle involvement. In muscular dystrophies such as Duchenne muscular dystrophy and myotonic dystrophy, respiratory muscle involvement is common. In others such as Becker, limb-girdle, and facioscapulo-humeral dystrophies, respiratory muscle involvement is infrequent and generally occurs in the more severe cases. Recently, it was reported that a mutation in the dysferlin gene and/or dysferlin deficiency causes proximal and distal forms of muscular dystrophy, which are known by the term dysferlinopathy. We describe a case of severe weakness of both limb-girdle and respiratory muscles in a patient who was carrier of the dysferlin gene mutation and who also had COPD. We suggest that the systemic inflammatory response of COPD and the dysferlin deficit interact and are responsible for both the skeletal and respiratory muscle impairment.

Cardiac manifestations of neuromuscular disorders in children

Cardiac abnormalities occur in association with many of the neuromuscular disorders that present in childhood. Genetic defects involving the cytoskeleton, nuclear membrane, and mitochondrial function have all been described in patients with skeletal myopathy and cardiac involvement. The most common classes of neuromuscular disorders with cardiac manifestations are the muscular dystrophies- Duchenne, Becker, limb-girdle and Emery Dreifuss. Friedreich Ataxia and myotonic dystrophy also have important cardiac involvement. The type and extent of cardiac manifestations are specific to the type of neuromuscular disorder. The most common cardiac findings include dilated or hypertrophic cardiomyopathy, atrioventricular conduction defects, atrial fibrillation and ventricular arrhythmias. Screening for cardiac involvement should be performed in all children with neuromuscular disorders that have the potential for cardiac involvement. This review discusses the cardiac findings associated with specific neuromuscular disorders and outlines the indications for evaluation and treatment.

Anesthesia and perioperative management for a patient with Ullrich syndrome undergoing surgery for scoliosis

Ullrich syndrome is a rare congenital hypotonic-sclerotic muscular disorder in which affected children develop a slowly progressive scoliosis and contractures and limpness of joints. The disease causes increasingly invalidating contractures and hardening of the muscles of the neck and trunk. While this neuromuscular type of scoliosis is progressive, patients rarely attain the point of surgery due to their compromised general medical condition. This may explain the current lack of outcome data and the paucity of information on perioperative management for patients with Ullrich syndrome undergoing major surgery. The purpose of this report was therefore to describe our first experience with the perioperative and anesthetic management of a 15-year-old boy presenting with Ullrich syndrome and a secondary invalidating scoliosis. The specific challenges of this condition characterized by severe restrictive lung disease and a challenging airway abnormality are discussed.

The environmental barriers of children with Muscular Dystrophies and its effect on mother's low back pain

PURPOSE

The aim of this study is to determine the architectural barriers of children with Muscular Dystrophy at home according to their diminished functional capacity and its effect on their mother's back problem.

METHOD

Twenty children with Muscular Dystrophy (11.1 +/- 4.14 years) were evaluated with Brooke Scale and WeeFIM. Quebec and Oswestry Disability Scales were used for determining physical disability of their mothers (38.65 +/- 5.91 years). The architectural barriers have been detected with attention to standard criterias of International Organizations for all countries around the world.

RESULTS

The heights of thresholds, switches of wall plugs, shelves, cupboards, mirrors, hangers, arm of windows and siphons were found to be higher than standard values. The relation between back disability questionnaire results of mothers and dependency level of children on Activity of Daily Living has showed negative correlation (p < 0.05).

CONCLUSIONS

The protective back health programmes and home arrangements that are suitable for disabled children must be added to the neuromuscular rehabilitation programmes.

Perioperative care of a child with Ullrich congenital muscular dystrophy

Ullrich congential muscular dystrophy (UCMD) is a severe form of congenital muscular dystrophy manifesting axial muscle contractures and distal joint hyperlaxity. Severe hypotonia and associated respiratory failure may occur early in the disease process. Given the various associated orthopedic conditions, anesthetic management may be required during surgical interventions to correct skeletal deformities or these patients may present with surgical conditions unrelated to their primary illness. We present a 4-year-old with UCMD who required operative intervention for a ruptured appendix. Anesthetic care implications included the need for a rapid airway control to limit the risks of aspiration due to the intra-abdominal process, choice of neuromuscular blocking agent for rapid sequence intubation, associated airway issues related to micrognathia and limited mouth opening, and the potential for involvement of the cardiovascular and respiratory systems. The perioperative management of patients with UCMD is discussed including the use of propofol and remifentanil for rapid sequence intubation to avoid the need for neuromuscular blocking agents.