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Respiratory pattern in an adult population of dystrophic patients. J Neurol Sci 2011; 306:54-61. [DOI: 10.1016/j.jns.2011.03.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 03/11/2011] [Accepted: 03/29/2011] [Indexed: 11/23/2022]
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Redding GJ, Praud JP, Mayer OH. Pulmonary Function Testing in Children with Restrictive Chest Wall Disorders. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2011; 24:89-94. [DOI: 10.1089/ped.2011.0080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Gregory J. Redding
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jean-Paul Praud
- Department of Pediatrics, Université de Sherbrooke, Québec, Canada
| | - Oscar Henry Mayer
- Department of Pediatrics, University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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53
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Ravenscroft G, Jackaman C, Bringans S, Papadimitriou JM, Griffiths LM, McNamara E, Bakker AJ, Davies KE, Laing NG, Nowak KJ. Mouse models of dominant ACTA1 disease recapitulate human disease and provide insight into therapies. ACTA ACUST UNITED AC 2011; 134:1101-15. [PMID: 21303860 DOI: 10.1093/brain/awr004] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mutations in the skeletal muscle α-actin gene (ACTA1) cause a range of pathologically defined congenital myopathies. Most patients have dominant mutations and experience severe skeletal muscle weakness, dying within one year of birth. To determine mutant ACTA1 pathobiology, transgenic mice expressing ACTA1(D286G) were created. These Tg(ACTA1)(D286G) mice were less active than wild-type individuals. Their skeletal muscles were significantly weaker by in vitro analyses and showed various pathological lesions reminiscent of human patients, however they had a normal lifespan. Mass spectrometry revealed skeletal muscles from Tg(ACTA1)(D286G) mice contained ∼25% ACTA1(D286G) protein. Tg(ACTA1)(D286G) mice were crossed with hemizygous Acta1(+/-) knock-out mice to generate Tg(ACTA1)(D286G)(+/+).Acta1(+/-) offspring that were homozygous for the transgene and hemizygous for the endogenous skeletal muscle α-actin gene. Akin to most human patients, skeletal muscles from these offspring contained approximately equal proportions of ACTA1(D286G) and wild-type actin. Strikingly, the majority of these mice presented with severe immobility between postnatal Days 8 and 17, requiring euthanasia. Their skeletal muscles contained extensive structural abnormalities as identified in severely affected human patients, including nemaline bodies, actin accumulations and widespread sarcomeric disarray. Therefore we have created valuable mouse models, one of mild dominant ACTA1 disease [Tg(ACTA1)(D286G)], and the other of severe disease, with a dramatically shortened lifespan [Tg(ACTA1)(D286G)(+/+).Acta1(+/-)]. The correlation between mutant ACTA1 protein load and disease severity parallels effects in ACTA1 families and suggests altering this ratio in patient muscle may be a therapy for patients with dominant ACTA1 disease. Furthermore, ringbinden fibres were observed in these mouse models. The presence of such features suggests that perhaps patients with ringbinden of unknown genetic origin should be considered for ACTA1 mutation screening. This is the first experimental, as opposed to observational, evidence that mutant protein load determines the severity of ACTA1 disease.
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Affiliation(s)
- Gianina Ravenscroft
- Centre for Medical Research, The University of Western Australia, Western Australian Institute for Medical Research, Nedlands, Australia.
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54
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Bönnemann CG. The collagen VI-related myopathies Ullrich congenital muscular dystrophy and Bethlem myopathy. HANDBOOK OF CLINICAL NEUROLOGY 2011; 101:81-96. [PMID: 21496625 DOI: 10.1016/b978-0-08-045031-5.00005-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Mutations in the genes COL6A1, COL6A2, and COL6A3, coding for three α chains of collagen type VI, underlie a spectrum of myopathies, ranging from the severe congenital muscular dystrophy-type Ullrich (UCMD) to the milder Bethlem myopathy (BM), with disease manifestations of intermediate severity in between. UCMD is characterized by early-onset weakness, associated with pronounced distal joint hyperlaxity and the early onset or early progression of more proximal contractures. In the most severe cases ambulation is not achieved, or it may be achieved only for a limited period of time. BM may be of early or later onset, but is milder in its manifestations, typically allowing for ambulation well into adulthood, whereas typical joint contractures are frequently prominent. A genetic spectrum is emerging, with BM being caused mostly by dominantly acting mutations, although rarely recessive inheritance of BM is also possible, whereas both dominantly as well as recessively acting mutations underlie UCMD.
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Affiliation(s)
- Carsten G Bönnemann
- Neuromuscular and Neurogenetic Disorders of Childhood Section, Neurogenetics Branch, National Institute of Neurological Disorders and Stroke/NIH, Bethesda, MD 20892-3705, USA.
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Wang CH, Bonnemann CG, Rutkowski A, Sejersen T, Bellini J, Battista V, Florence JM, Schara U, Schuler PM, Wahbi K, Aloysius A, Bash RO, Béroud C, Bertini E, Bushby K, Cohn RD, Connolly AM, Deconinck N, Desguerre I, Eagle M, Estournet-Mathiaud B, Ferreiro A, Fujak A, Goemans N, Iannaccone ST, Jouinot P, Main M, Melacini P, Mueller-Felber W, Muntoni F, Nelson LL, Rahbek J, Quijano-Roy S, Sewry C, Storhaug K, Simonds A, Tseng B, Vajsar J, Vianello A, Zeller R. Consensus statement on standard of care for congenital muscular dystrophies. J Child Neurol 2010; 25:1559-81. [PMID: 21078917 PMCID: PMC5207780 DOI: 10.1177/0883073810381924] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Congenital muscular dystrophies are a group of rare neuromuscular disorders with a wide spectrum of clinical phenotypes. Recent advances in understanding the molecular pathogenesis of congenital muscular dystrophy have enabled better diagnosis. However, medical care for patients with congenital muscular dystrophy remains very diverse. Advances in many areas of medical technology have not been adopted in clinical practice. The International Standard of Care Committee for Congenital Muscular Dystrophy was established to identify current care issues, review literature for evidence-based practice, and achieve consensus on care recommendations in 7 areas: diagnosis, neurology, pulmonology, orthopedics/rehabilitation, gastroenterology/ nutrition/speech/oral care, cardiology, and palliative care. To achieve consensus on the care recommendations, 2 separate online surveys were conducted to poll opinions from experts in the field and from congenital muscular dystrophy families. The final consensus was achieved in a 3-day workshop conducted in Brussels, Belgium, in November 2009. This consensus statement describes the care recommendations from this committee.
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Affiliation(s)
- Ching H. Wang
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | - Robert O. Bash
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christophe Béroud
- INSERM U827, Laboratoire de Génétique Moleculaire, Montpellier, France
| | | | - Kate Bushby
- Institute of Human Genetics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ronald D. Cohn
- John Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Michelle Eagle
- Institute of Human Genetics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Ana Ferreiro
- UMR 787 Groupe Myologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Albert Fujak
- Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | | | | | | | | | | | | | | | | | - Jes Rahbek
- Rehabiliterings Center for Muskelsvind, Aarhus, Denmark
| | | | | | - Kari Storhaug
- National Resource Centre for Oral Health in Rare Medical Conditions, Oslo, Norway
| | | | - Brian Tseng
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jiri Vajsar
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Reinhard Zeller
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Rocha CT, Hoffman EP. Limb-girdle and congenital muscular dystrophies: current diagnostics, management, and emerging technologies. Curr Neurol Neurosci Rep 2010; 10:267-76. [PMID: 20467841 DOI: 10.1007/s11910-010-0119-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The muscular dystrophies show muscle degeneration and regeneration (necrotizing myopathy) on muscle biopsy, typically associated with elevated serum creatine kinase, and muscle weakness. In 1986, the first causative gene was identified for the most prevalent and best-characterized form of muscular dystrophy, Duchenne muscular dystrophy. Over the past 25 years, the number of other genes determined to cause different subtypes has grown rapidly. This review gives a synopsis of the 45 genetically defined types of muscular dystrophies and describes the clinical, pathologic, and molecular aspects of each disease. DNA diagnosis remains the most sensitive and specific method for differential diagnosis, but molecular diagnostics can be expensive and complex (because of multiple genes at multiple testing facilities) and reimbursement may be challenging to obtain. However, emerging DNA sequencing technologies (eg, single-molecule third-generation sequencing units) promise to dramatically reduce the complexity and costs of DNA diagnostics. Treatment for nearly all forms remains supportive and is aimed at preventing complications. However, several promising approaches have entered clinical trials, providing tangible hope that quality of life will improve for many patients in the near future.
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Affiliation(s)
- Carolina Tesi Rocha
- Research Center for Genetic Medicine, Division of Neurology, Department of Pediatrics, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010, USA.
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58
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Yang ML, Finkel RS. Overview of paediatric neuromuscular disorders and related pulmonary issues: diagnostic and therapeutic considerations. Paediatr Respir Rev 2010; 11:9-17. [PMID: 20113986 DOI: 10.1016/j.prrv.2009.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pulmonary compromise is common in neuromuscular disease. Respiratory failure may be a presenting feature of neuromuscular disease and remains a major cause of morbidity and mortality. This article will review the current understanding of the more commonly encountered neuromuscular disorders in childhood and emphasize related pulmonary issues.
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Affiliation(s)
- M L Yang
- Children's Hospital Denver, Aurora, CO 80045-7106, USA
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59
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Schara U, Barisic N, Deschauer M, Lindberg C, Straub V, Strigl-Pill N, Wendt M, Abicht A, Müller J, Lochmüller H. Ephedrine therapy in eight patients with congenital myasthenic syndrome due to DOK7 mutations. Neuromuscul Disord 2009; 19:828-32. [DOI: 10.1016/j.nmd.2009.09.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 09/21/2009] [Indexed: 10/20/2022]
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Laing NG, Dye DE, Wallgren-Pettersson C, Richard G, Monnier N, Lillis S, Winder TL, Lochmüller H, Graziano C, Mitrani-Rosenbaum S, Twomey D, Sparrow JC, Beggs AH, Nowak KJ. Mutations and polymorphisms of the skeletal muscle alpha-actin gene (ACTA1). Hum Mutat 2009; 30:1267-77. [PMID: 19562689 PMCID: PMC2784950 DOI: 10.1002/humu.21059] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The ACTA1 gene encodes skeletal muscle alpha-actin, which is the predominant actin isoform in the sarcomeric thin filaments of adult skeletal muscle, and essential, along with myosin, for muscle contraction. ACTA1 disease-causing mutations were first described in 1999, when a total of 15 mutations were known. In this article we describe 177 different disease-causing ACTA1 mutations, including 85 that have not been described before. ACTA1 mutations result in five overlapping congenital myopathies: nemaline myopathy; intranuclear rod myopathy; actin filament aggregate myopathy; congenital fiber type disproportion; and myopathy with core-like areas. Mixtures of these histopathological phenotypes may be seen in a single biopsy from one patient. Irrespective of the histopathology, the disease is frequently clinically severe, with many patients dying within the first year of life. Most mutations are dominant and most patients have de novo mutations not present in the peripheral blood DNA of either parent. Only 10% of mutations are recessive and they are genetic or functional null mutations. To aid molecular diagnosis and establishing genotype-phenotype correlations, we have developed a locus-specific database for ACTA1 variations (http://waimr.uwa.edu.au).
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Affiliation(s)
- Nigel G Laing
- Centre for Medical Research, University of Western Australia, Western Australian Institute for Medical Research, QEII Medical Centre, Western Australia, Australia.
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61
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Leroy PLJM, Knoester H, Cobben NAM. Screening en follow-up van kinderen die voor thuisbeademing in aanmerking komen. ACTA ACUST UNITED AC 2009. [DOI: 10.1007/bf03086371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Clinical commentary: obstetric and respiratory management of pregnancy with severe spinal muscular atrophy. Obstet Gynecol Int 2009; 2009:942301. [PMID: 19960049 PMCID: PMC2778181 DOI: 10.1155/2009/942301] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/15/2008] [Accepted: 03/09/2009] [Indexed: 11/17/2022] Open
Abstract
We present a combined obstetric and respiratory perspective on two pregnancies for a woman with severe Type 2 Spinal Muscular Atrophy (SMA). Our patient had the lowest prepregnancy weight (20 kg) and vital capacity of 0.34 L (VC 11% predicted) yet to be reported in the sparse literature on pregnancy with SMA. She delivered two live healthy infants via planned caesarean section without pregnancy or neonatal complication. We describe the respiratory and obstetric management techniques used for a pregnancy with this degree of respiratory compromise.
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63
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Reed UC. Congenital muscular dystrophy. Part I: a review of phenotypical and diagnostic aspects. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:144-68. [DOI: 10.1590/s0004-282x2009000100038] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Accepted: 12/17/2008] [Indexed: 12/30/2022]
Abstract
The congenital muscular dystrophies (CMDs) are a group of genetically and clinically heterogeneous hereditary myopathies with preferentially autosomal recessive inheritance, that are characterized by congenital hypotonia, delayed motor development and early onset of progressive muscle weakness associated with dystrophic pattern on muscle biopsy. The clinical course is broadly variable and can comprise the involvement of the brain and eyes. From 1994, a great development in the knowledge of the molecular basis has occurred and the classification of CMDs has to be continuously up dated. We initially present the main clinical and diagnostic data concerning the CMDs related to changes in the complex dystrophin-associated glycoproteins-extracellular matrix: CMD with merosin deficiency (CMD1A), collagen VI related CMDs (Ullrich CMD and Bethlem myopathy), CMDs with abnormal glycosylation of alpha-dystroglycan (Fukuyama CMD, Muscle-eye-brain disease, Walker-Warburg syndrome, CMD1C, CMD1D), and the much rarer CMD with integrin deficiency. Finally, we present other forms of CMDs not related with the dystrophin/glycoproteins/extracellular matrix complex (rigid spine syndrome, CMD1B, CMD with lamin A/C deficiency), and some apparently specific clinical forms not yet associated with a known molecular mechanism. The second part of this review concerning the pathogenesis and therapeutic perspectives of the different subtypes of CMD will be described in a next number.
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Abstract
The outlook for children with respiratory complications of neuromuscular disease has improved significantly in the past 15 years. This has been the result of many advances in clinical care, including improved monitoring of lung function and hypoventilation during sleep; coordinated respiratory care by experienced physicians with access to specialized respiratory services, especially physiotherapy; and, most importantly, the widespread introduction of noninvasive ventilation.
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Affiliation(s)
- J Declan Kennedy
- Discipline of Paediatrics, Faculty of Health Sciences, Medical School, University of Adelaide, South Australia 5005, Australia.
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65
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Paiva R, Krivec U, Aubertin G, Cohen E, Clément A, Fauroux B. Carbon dioxide monitoring during long-term noninvasive respiratory support in children. Intensive Care Med 2009; 35:1068-74. [PMID: 19172246 DOI: 10.1007/s00134-009-1408-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 01/06/2009] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Routine monitoring of noninvasive respiratory support relies on nocturnal pulse oximetry and daytime arterial blood gases, without systematic nocturnal carbon dioxide recording. The aim of the study was to assess if overnight pulse oximetry and daytime blood gases are sufficiently accurate to detect nocturnal hypoventilation in children receiving long-term noninvasive respiratory support. MATERIALS AND METHODS Pulse oximetry and carbon dioxide pressure measured by capillary arterialized blood gases and a combined transcutaneous carbon dioxide and pulse oximetry (PtcCO(2)/SpO(2)) monitor were compared in 65 patients (asthma, n = 16, recurrent bronchitis, n = 8, lung infection, n = 8, cystic fibrosis, n = 15, interstitial lung disease, n = 6, neuromuscular disease, n = 12). Daytime capillary arterialized blood gases and nocturnal recording of pulse oximetry and carbon dioxide by means of a combined PtcCO(2)/SpO(2) monitor were performed in 50 other patients receiving nocturnal noninvasive respiratory support at home. RESULTS A correlation was observed between pulse oximetry (r = 0.832, P < 0.0001) and carbon dioxide pressure (r = 0.644, P < 0.0001) measured by capillary arterialized blood gases and the combined PtcCO(2)/SpO(2) monitor. Twenty-one of the 50 patients (42%) on long-term noninvasive respiratory support presented nocturnal hypercapnia, defined by a PtcCO(2) value >50 mmHg, without nocturnal hypoxemia. Daytime capillary arterialized carbon dioxide levels were normal in 18 of these 21 patients. CONCLUSIONS Nocturnal hypercapnia may occur in children receiving nocturnal noninvasive respiratory support at home. Nocturnal pulse oximetry and daytime arterial blood gases are not sufficiently accurate to diagnose nocturnal hypercapnia, underlying the importance of a systematic carbon dioxide monitoring in children receiving noninvasive respiratory support.
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Affiliation(s)
- Rebeca Paiva
- Pediatric Pulmonary Department, Exequiel Gonzalez Cortes Hospital, Santiago, Chili
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66
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Abstract
The collagen VI-related myopathies comprise two major forms, Bethlem myopathy (BM) and Ullrich congenital muscular dystrophy (UCMD), which show a variable combination of muscle wasting and weakness, joint contractures, distal laxity, and respiratory compromise. Specific diagnosis requires molecular genetic testing showing mutation in one of the three genes involved. This review summarizes current treatments, in particular indication for physiotherapy, orthopedic treatment for correction of foot deformity, scoliosis, and flexion contractures of elbows, and treatment of respiratory failure. The turning point in basic research on collagen VI myopathies was the discovery of an unexpected mitochondrial dysfunction as a pathogenetic mechanism underlying the myopathic syndrome seen in Col6a1 null mice. Treatment of Col6a1(-/-) mice with cyclosporin A (CsA) rescued the mitochondrial dysfunction and decreased apoptosis. Similar mitochondrial defects were revealed in cultures of UCMD patients. The results of an open pilot trial with CsA in five patients with collagen VI-related myopathies are summarized and discussed. With the availability of new potential effective treatments, several challenges must be addressed in conducting trials in orphan diseases and in neuromuscular disorders in particular. Outcome measures are discussed in the context of the expected effect of the cure. Randomized clinical trials often are not feasible for rare diseases, and sometimes would be ethically inappropriate. The need to develop alternative outcome measures or biomarkers using platforms such as genomics and proteomics is stressed in this context.
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Affiliation(s)
- Luciano Merlini
- Laboratory of Myology, Department of Medical Genetics, University of Ferrara, Ferrara, Italy.
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67
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Jungbluth H, Wallgren-Pettersson C, Laporte J. Centronuclear (myotubular) myopathy. Orphanet J Rare Dis 2008; 3:26. [PMID: 18817572 PMCID: PMC2572588 DOI: 10.1186/1750-1172-3-26] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 09/25/2008] [Indexed: 01/23/2023] Open
Abstract
Centronuclear myopathy (CNM) is an inherited neuromuscular disorder characterised by clinical features of a congenital myopathy and centrally placed nuclei on muscle biopsy. The incidence of X-linked myotubular myopathy is estimated at 2/100000 male births but epidemiological data for other forms are not currently available. The clinical picture is highly variable. The X-linked form usually gives rise to a severe phenotype in males presenting at birth with marked weakness and hypotonia, external ophthalmoplegia and respiratory failure. Signs of antenatal onset comprise reduced foetal movements, polyhydramnios and thinning of the ribs on chest radiographs; birth asphyxia may be the present. Affected infants are often macrosomic, with length above the 90th centile and large head circumference. Testes are frequently undescended. Both autosomal-recessive (AR) and autosomal-dominant (AD) forms differ from the X-linked form regarding age at onset, severity, clinical characteristics and prognosis. In general, AD forms have a later onset and milder course than the X-linked form, and the AR form is intermediate in both respects. Mutations in the myotubularin (MTM1) gene on chromosome Xq28 have been identified in the majority of patients with the X-linked recessive form, whilst AD and AR forms have been associated with mutations in the dynamin 2 (DNM2) gene on chromosome 19p13.2 and the amphiphysin 2 (BIN1) gene on chromosome 2q14, respectively. Single cases with features of CNM have been associated with mutations in the skeletal muscle ryanodine receptor (RYR1) and the hJUMPY (MTMR14) genes. Diagnosis is based on typical histopathological findings on muscle biopsy in combination with suggestive clinical features; muscle magnetic resonance imaging may complement clinical assessment and inform genetic testing in cases with equivocal features. Genetic counselling should be offered to all patients and families in whom a diagnosis of CNM has been made. The main differential diagnoses include congenital myotonic dystrophy and other conditions with severe neonatal hypotonia. Management of CNM is mainly supportive, based on a multidisciplinary approach. Whereas the X-linked form due to MTM1 mutations is often fatal in infancy, dominant forms due to DNM2 mutations and some cases of the recessive BIN1-related form appear to be associated with an overall more favourable prognosis.
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Affiliation(s)
- Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, St Thomas' Hospital, London, UK.
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68
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Abstract
OBJECTIVE We describe the distribution of cough peak flows (CPFs) in a random population of healthy children and adolescents. DESIGN Spirometric and peak expiratory flows including CPF data were collected on 649 (341 females, 308 males) healthy children ages 4-18 yrs, using a portable spirometer and a peak flow meter. CPFs were related to anthropometric characteristics, age, and gender by linear multiple regression analysis. Reference values for CPF were estimated through regression models and calculation of empirical percentiles of data distribution. RESULTS Other than peak expiratory flow rate, which was normally distributed, all other variables required logarithmic transformation to attain normal distribution. Significant relationships were found between CPF and gender, height, and body mass surface (P < 0.001) in both males and females. Age, even if correlated with CPF, does not add predictive value to the model. Fiftieth percentiles were from 147 to 488 liters/min and from 162 to 728 liters/min in females and males, respectively, through an age range of 4-18 yrs, with levels in males being generally higher than those in females at any particular age. CPF values also significantly correlated with other respiratory variables. CONCLUSIONS The availability of reference levels for CPF in the pediatric population, as provided by this study, could be useful for establishing the risk of acute respiratory complications for young patients with weak coughs, particularly those with neuromuscular disease and restrictive pulmonary syndromes.
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Pelin K, Wallgren-Pettersson C. Nebulin—A Giant Chameleon. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2008. [DOI: 10.1007/978-0-387-84847-1_3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Wang CH, Finkel RS, Bertini ES, Schroth M, Simonds A, Wong B, Aloysius A, Morrison L, Main M, Crawford TO, Trela A. Consensus statement for standard of care in spinal muscular atrophy. J Child Neurol 2007; 22:1027-49. [PMID: 17761659 DOI: 10.1177/0883073807305788] [Citation(s) in RCA: 535] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spinal muscular atrophy is a neurodegenerative disease that requires multidisciplinary medical care. Recent progress in the understanding of molecular pathogenesis of spinal muscular atrophy and advances in medical technology have not been matched by similar developments in the care for spinal muscular atrophy patients. Variations in medical practice coupled with differences in family resources and values have resulted in variable clinical outcomes that are likely to compromise valid measure of treatment effects during clinical trials. The International Standard of Care Committee for Spinal Muscular Atrophy was formed in 2005, with a goal of establishing practice guidelines for clinical care of these patients. The 12 core committee members worked with more than 60 spinal muscular atrophy experts in the field through conference calls, e-mail communications, a Delphi survey, and 2 in-person meetings to achieve consensus on 5 care areas: diagnostic/new interventions, pulmonary, gastrointestinal/nutrition, orthopedics/rehabilitation, and palliative care. Consensus was achieved on several topics related to common medical problems in spinal muscular atrophy, diagnostic strategies, recommendations for assessment and monitoring, and therapeutic interventions in each care area. A consensus statement was drafted to address the 5 care areas according to 3 functional levels of the patients: nonsitter, sitter, and walker. The committee also identified several medical practices lacking consensus and warranting further investigation. It is the authors' intention that this document be used as a guideline, not as a practice standard for their care. A practice standard for spinal muscular atrophy is urgently needed to help with the multidisciplinary care of these patients.
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Affiliation(s)
- Ching H Wang
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, California 94305-5235, USA.
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71
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Abstract
Multi-minicore Disease (MmD) is a recessively inherited neuromuscular disorder characterized by multiple cores on muscle biopsy and clinical features of a congenital myopathy. Prevalence is unknown. Marked clinical variability corresponds to genetic heterogeneity: the most instantly recognizable classic phenotype characterized by spinal rigidity, early scoliosis and respiratory impairment is due to recessive mutations in the selenoprotein N (SEPN1) gene, whereas recessive mutations in the skeletal muscle ryanodine receptor (RYR1) gene have been associated with a wider range of clinical features comprising external ophthalmoplegia, distal weakness and wasting or predominant hip girdle involvement resembling central core disease (CCD). In the latter forms, there may also be a histopathologic continuum with CCD due to dominant RYR1 mutations, reflecting the common genetic background. Pathogenetic mechanisms of RYR1-related MmD are currently not well understood, but likely to involve altered excitability and/or changes in calcium homeoestasis; calcium-binding motifs within the selenoprotein N protein also suggest a possible role in calcium handling. The diagnosis of MmD is based on the presence of suggestive clinical features and multiple cores on muscle biopsy; muscle MRI may aid genetic testing as patterns of selective muscle involvement are distinct depending on the genetic background. Mutational analysis of the RYR1 or the SEPN1 gene may provide genetic confirmation of the diagnosis. Management is mainly supportive and has to address the risk of marked respiratory impairment in SEPN1-related MmD and the possibility of malignant hyperthermia susceptibility in RYR1-related forms. In the majority of patients, weakness is static or only slowly progressive, with the degree of respiratory impairment being the most important prognostic factor.
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Affiliation(s)
- Heinz Jungbluth
- Department of Paediatric Neurology, Evelina Children's Hospital, St. Thomas' Hospital, London, UK.
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Lehtokari VL, Ceuterick-de Groote C, de Jonghe P, Marttila M, Laing NG, Pelin K, Wallgren-Pettersson C. Cap disease caused by heterozygous deletion of the β-tropomyosin gene TPM2. Neuromuscul Disord 2007; 17:433-42. [PMID: 17434307 DOI: 10.1016/j.nmd.2007.02.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 02/14/2007] [Accepted: 02/22/2007] [Indexed: 01/14/2023]
Abstract
"Cap myopathy" or "cap disease" is a congenital myopathy characterised by cap-like structures at the periphery of muscle fibres, consisting of disarranged thin filaments with enlarged Z discs. Here we report a deletion in the beta-tropomyosin (TPM2) gene causing cap disease in a 36-year-old male patient with congenital muscle weakness, myopathic facies and respiratory insufficiency. The mutation identified in this patient is an in-frame deletion (c.415_417delGAG) of one codon in exon 4 of TPM2 removing a single glutamate residue (p.Glu139del) from the beta-tropomyosin protein. This is expected to disrupt the seven-amino acid repeat essential for making a coiled coil, and thus to impair tropomyosin-actin interaction. Missense mutations in TPM2 have previously been found to cause rare cases of nemaline myopathy and distal arthrogryposis. This mutation is one not previously described and the first genetic cause identified for cap disease.
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Affiliation(s)
- Vilma-Lotta Lehtokari
- The Folkhälsan Institute of Genetics and the Department of Medical Genetics, University of Helsinki, Helsinki, Finland, and Division of Neurology, University Hospital of Antwerp, Antwerpen, Belgium
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73
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Abstract
Central core disease (CCD) is an inherited neuromuscular disorder characterised by central cores on muscle biopsy and clinical features of a congenital myopathy. Prevalence is unknown but the condition is probably more common than other congenital myopathies. CCD typically presents in infancy with hypotonia and motor developmental delay and is characterized by predominantly proximal weakness pronounced in the hip girdle; orthopaedic complications are common and malignant hyperthermia susceptibility (MHS) is a frequent complication. CCD and MHS are allelic conditions both due to (predominantly dominant) mutations in the skeletal muscle ryanodine receptor (RYR1) gene, encoding the principal skeletal muscle sarcoplasmic reticulum calcium release channel (RyR1). Altered excitability and/or changes in calcium homeostasis within muscle cells due to mutation-induced conformational changes of the RyR protein are considered the main pathogenetic mechanism(s). The diagnosis of CCD is based on the presence of suggestive clinical features and central cores on muscle biopsy; muscle MRI may show a characteristic pattern of selective muscle involvement and aid the diagnosis in cases with equivocal histopathological findings. Mutational analysis of the RYR1 gene may provide genetic confirmation of the diagnosis. Management is mainly supportive and has to anticipate susceptibility to potentially life-threatening reactions to general anaesthesia. Further evaluation of the underlying molecular mechanisms may provide the basis for future rational pharmacological treatment. In the majority of patients, weakness is static or only slowly progressive, with a favourable long-term outcome.
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Affiliation(s)
- Heinz Jungbluth
- Evelina Children's Hospital, Department of Paediatric Neurology, St. Thomas' Hospital, London, UK.
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74
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de Visser M. Myopathies with early contractures. HANDBOOK OF CLINICAL NEUROLOGY 2007; 86:35-59. [PMID: 18808994 DOI: 10.1016/s0072-9752(07)86002-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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75
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Affiliation(s)
- Nigel G Laing
- Centre for Medical Research, University of Western Australia, West Australian Institute for Medical Research, Nedlands, Western Australia, Australia
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76
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Bushby K, Norwood F, Straub V. The limb-girdle muscular dystrophies--diagnostic strategies. Biochim Biophys Acta Mol Basis Dis 2006; 1772:238-42. [PMID: 17123791 DOI: 10.1016/j.bbadis.2006.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 09/27/2006] [Accepted: 09/27/2006] [Indexed: 11/26/2022]
Abstract
The limb-girdle muscular dystrophies are a group of disorders where our understanding of their underlying molecular basis has made huge strides over the past years, revealing great heterogeneity at the clinical and molecular level. The availability of direct protein and/ or gene based approaches to diagnosis means that these disorders can now be precisely defined, and such definition of a precise diagnosis is increasingly allowing directed management for these diseases by the ability to predict specific complications such as those of the cardiac or respiratory systems. An algorithm combining clinical, biochemical and molecular testing is described which will aid precision of diagnosis and direct specific testing towards the cases most likely to benefit. This brings advantages for the patients of today in recognising the specific risks of their disorders, and in the future will be the starting point for specific gene and protein based therapies.
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Affiliation(s)
- Kate Bushby
- Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK.
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77
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Shahrizaila N, Kinnear WJM, Wills AJ. Respiratory involvement in inherited primary muscle conditions. J Neurol Neurosurg Psychiatry 2006; 77:1108-15. [PMID: 16980655 PMCID: PMC2077539 DOI: 10.1136/jnnp.2005.078881] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Patients with inherited muscle disorders can develop respiratory muscle weakness leading to ventilatory failure. Predicting the extent of respiratory involvement in the different types of inherited muscle disorders is important, as it allows clinicians to impart prognostic information and offers an opportunity for early interventional management strategies. The approach to respiratory assessment in patients with muscle disorders, the current knowledge of respiratory impairment in different muscle disorders and advice on the management of respiratory complications are summarised.
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Affiliation(s)
- N Shahrizaila
- Department of Neurology, Queen's Medical Centre, Nottingham NG7 2UH, UK
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78
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Abstract
Mutations in the genes encoding collagen VI (COL6A1, COL6A2, and COL6A3) cause Bethlem myopathy (BM) and Ullrich congenital muscular dystrophy (UCMD), two conditions which were previously believed to be completely separate entities. BM is a relatively mild dominantly inherited disorder characterised by proximal weakness and distal joint contractures. UCMD was originally described as an autosomal recessive condition causing severe muscle weakness with proximal joint contractures and distal hyperlaxity. Here we review the clinical phenotypes of BM and UCMD and their diagnosis and management, and provide an overview of the current knowledge of the pathogenesis of collagen VI related disorders.
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Affiliation(s)
- A K Lampe
- Institute of Human Genetics, University of Newcastle upon Tyne, International Centre for Life, Central Parkway, Newcastle upon Tyne, NE1 3BZ.
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79
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Dohna-Schwake C, Ragette R, Teschler H, Voit T, Mellies U. IPPB-assisted coughing in neuromuscular disorders. Pediatr Pulmonol 2006; 41:551-7. [PMID: 16617451 DOI: 10.1002/ppul.20406] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In neuromuscular disorders, reduced peak cough flows (PCFs) are considered to increase the risk of respiratory complications such as pneumonia or chronic atelectasis. Different methods were described to improve PCF. However, these studies were primarily carried out in adults, and there is limited information regarding the use and efficacy of these methods in children with respiratory muscle weakness. The aim of this study was to investigate whether hyperinsufflation with an intermittent positive-pressure breathing (IPPB) device is effective in cough augmentation in pediatric patients. Spirometry (forced inspiratory vital capacity, FIVC; forced expiratory volume in 1 sec, FEV1), respiratory muscle pressures (peak inspiratory pressure, PIP; peak expiratory pressure, PEP), and PCF were measured in 29 schoolchildren with various neuromuscular disorders. IPPB-assisted hyperinsufflation was taught individually to increase lung volumes (maximum insufflation capacity, MIC) above FIVC. The impact of hyperinsufflation on peak cough flow was documented. In 28/29 patients, IPPB-assisted hyperinsufflation enhanced FIVC from 0.68 +/- 0.40 l to an MIC of 1.05 +/- 0.47 l (P < 0.001). Unassisted PCF was 119.0 +/- 57.7 l/min, and increased to 194.5 +/- 74.9 l/min (P < 0.001) in 27/29 patients. This effect was similar in young patients (ages 6-10 years) and older patients (aged >10 years). Augmentation of lung volumes from FIVC to MIC correlated with an increase of PCF (R = 0.42, P < 0.05). IPPB-assisted hyperinsufflation improves PCF in pediatric neuromuscular disorders. The results suggest that this technique can be used to improve clearance of airway secretions and therefore reduce respiratory morbidity in children with NMD.
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Affiliation(s)
- Christian Dohna-Schwake
- Department of Pediatrics and Pediatric Neurology, University Hospital of Essen, Essen, Germany.
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80
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Abstract
The heterogeneous childhood limb-girdle muscular dystrophies have originally been defined as a group of autosomal recessive and dominant diseases with progressive weakness and wasting of shoulder and pelvic-girdle muscles. Over the last 12 years, the underlying genetic defects for many of the diseases have been identified and insight into pathomechanisms of disease has been gained. At the same time, improved diagnostic techniques have allowed to extend the phenotypic spectrum for many of these devastating conditions, which showed that clinical symptoms and pathological findings are not restricted to skeletal muscles. Childhood limb-girdle muscular dystrophies are systemic diseases that often affect the musculoskeletal, respiratory, and cardiovascular system and that can go along with central nervous system involvement and gastrointestinal symptoms. The systemic nature of the diseases requires adequate management strategies that improve symptoms, longevity, and quality of life of the patients. As we are entering an era of translational research the need for precise molecular diagnoses, a thorough understanding of the natural history of the diseases and guidelines for standardized assessments of the patients become even more relevant. In this review, the best characterized childhood limb-girdle muscular dystrophies are discussed and their management aspects highlighted.
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Affiliation(s)
- Volker Straub
- Institute of Human Genetics, University of Newcastle upon Tyne, International Centre for Life, Newcastle upon Tyne, United Kingdom.
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81
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Abstract
PURPOSE OF REVIEW This review highlights emerging evidence on the management of patients with muscular dystrophies. RECENT FINDINGS New diagnostic modalities based on muscle biopsy and DNA analysis mean that diagnoses within the heterogeneous group of muscular dystrophies can be much more precise; also, as the phenotypes associated with these different disorders are clarified, new management implications can be recognized. At the same time, the spread of evidence based medicine into this area has led to an increase in clinical trial activity and the development of evidence based guidelines. Because many if not all muscular dystrophies are multisystem disorders, these guidelines relate not only to the limited number of interventions aimed at improving strength but also to the management of potentially life threatening complications. SUMMARY Because specific diagnoses carry specific management implications in many areas for these hitherto rather neglected disorders, a more proactive approach to patients with muscular dystrophies is needed. Complications involving, for example, the cardiovascular, respiratory and gastrointestinal systems may need to be sought and actively managed, whereas caution for complications of anaesthesia and other interventions may also be necessary. However, areas remain where there is little evidence from which practice guidelines can be developed and these will need to be addressed with well planned clinical trials.
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Affiliation(s)
- Kate Bushby
- Newcastle upon Tyne Muscle Centre, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle upon Tyne, UK.
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82
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Mellies U, Dohna-Schwake C, Voit T. Respiratory function assessment and intervention in neuromuscular disorders. Curr Opin Neurol 2006; 18:543-7. [PMID: 16155437 DOI: 10.1097/01.wco.0000180662.03544.5f] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Published research on neuromuscular respiratory failure has increased rapidly over the past decade. Progress in the management of respiratory complications and preventive care have improved outcomes and quality of life for many. In particular, noninvasive positive pressure ventilation (NIPPV) is effective in resolving respiratory failure and has dramatically changed the management of these patients. In this review we discuss recent studies assessing the course of respiratory failure, with a focus on non-Duchenne muscular dystrophy; investigating the impact NIPPV has when it is introduced before diurnal respiratory failure develops; and evaluating a device to treat insufficient cough--the mechanical insufflator--exsufflator (MI-E). RECENT FINDINGS Studies in children with congenital muscular dystrophies and spinal muscular atrophies detected a high prevalence of respiratory complications and confirmed that respiratory failure can be predicted by measurement of vital capacity. NIPPV is an established treatment that is effective in the long-term management of end-stage diurnal respiratory failure. Additionally, recent studies showed improvement in symptoms, quality of life and prevention of respiratory complications when it is introduced for nocturnal hypoventilation before the development of diurnal respiratory failure. However, data on the efficiency of the MI-E are limited, and studies comparing it with other techniques of assisted coughing are needed. SUMMARY Recent findings stress the importance of regular respiratory assessment in neuromuscular disease, including sleep studies; strongly support the introduction of NIPPV for management of symptomatic nocturnal hypoventilation; and suggest that prospective randomized trials are required to verify the usefulness of the MI-E.
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Affiliation(s)
- Uwe Mellies
- University of Essen, Children's Hospital, Department of General Pediatrics and Neuropediatrics, Essen, Germany.
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83
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Ward S, Chatwin M, Heather S, Simonds AK. Randomised controlled trial of non-invasive ventilation (NIV) for nocturnal hypoventilation in neuromuscular and chest wall disease patients with daytime normocapnia. Thorax 2005; 60:1019-24. [PMID: 16299118 PMCID: PMC1747266 DOI: 10.1136/thx.2004.037424] [Citation(s) in RCA: 230] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Long term non-invasive ventilation (NIV) reduces morbidity and mortality in patients with neuromuscular and chest wall disease with hypercapnic ventilatory failure, but preventive use has not produced benefit in normocapnic patients with Duchenne muscular dystrophy. Individuals with nocturnal hypercapnia but daytime normocapnia were randomised to a control group or nocturnal NIV to examine whether nocturnal hypoventilation is a valid indication for NIV. METHODS Forty eight patients with congenital neuromuscular or chest wall disease aged 7-51 years and vital capacity<50% predicted underwent overnight respiratory monitoring. Twenty six with daytime normocapnia and nocturnal hypercapnia were randomised to either nocturnal NIV or to a control group without ventilatory support. NIV was started in the control group if patients fulfilled preset safety criteria. RESULTS Peak nocturnal transcutaneous carbon dioxide tension (Tcco2) did not differ between the groups, but the mean (SD) percentage of the night during which Tcco2 was >6.5 kPa decreased in the NIV group (-57.7 (26.1)%) but not in controls (-11.75 (46.1)%; p=0.049, 95% CI -91.5 to -0.35). Mean (SD) arterial oxygen saturation increased in the NIV group (+2.97 (2.57)%) but not in controls (-1.12 (2.02)%; p=0.024, 95% CI 0.69 to 7.5). Nine of the 10 controls failed non-intervention by fulfilling criteria to initiate NIV after a mean (SD) of 8.3 (7.3) months. CONCLUSION Patients with neuromuscular disease with nocturnal hypoventilation are likely to deteriorate with the development of daytime hypercapnia and/or progressive symptoms within 2 years and may benefit from the introduction of nocturnal NIV before daytime hypercapnia ensues.
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Affiliation(s)
- S Ward
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton & Harefield NHS Trust, Sydney Street, London SW3 6NP, UK
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84
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Mellies U, Dohna-Schwake C, Stehling F, Voit T. Sleep disordered breathing in spinal muscular atrophy. Neuromuscul Disord 2004; 14:797-803. [PMID: 15564035 DOI: 10.1016/j.nmd.2004.09.004] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2004] [Revised: 08/03/2004] [Accepted: 09/08/2004] [Indexed: 11/21/2022]
Abstract
Sleep disordered breathing is a common but under-diagnosed complication causing sleep disturbance and daytime symptoms in children with spinal muscular atrophy. Non-invasive (positive pressure) ventilation is an established treatment of respiratory failure; its role in treatment of sleep disordered breathing though remains controversial. Aim of this study was to verify the hypothesis that nocturnal non-invasive ventilation has beneficial impact on breathing during sleep, sleep quality and daytime complaints in children with spinal muscular atrophy. Twelve children with spinal muscular atrophy type I or II (7.8+/-1.9 years) underwent polysomnography and were asked to fill out a symptom questionnaire. Seven patients (six with spinal muscular atrophy I and one with spinal muscular atrophy II) had sleep disordered breathing and received non-invasive ventilation during sleep. Five less severely affected patients (one with spinal muscular atrophy I and four with spinal muscular atrophy II) had no sleep disordered breathing and served as reference group. Patients were restudied after 6-12 months. In patients with sleep disordered breathing both sleep architecture and disease related symptoms were significantly worse than in the reference-group. Non-invasive ventilation during sleep completely eliminated disordered breathing, normalized sleep architecture and improved symptoms (P<0.05 for all). In children with spinal muscular atrophy sleep disordered breathing may cause relevant impairment of sleep and well-being. Both can be highly improved by nocturnal non-invasive ventilation.
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Affiliation(s)
- Uwe Mellies
- Department of General Pediatrics and Neuropediatrics, University of Essen, Children's Hospital, Hufelandstr. 55 D-45122 Essen, Germany.
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