Self-reported quality of life has no correlation with functional status in children and adolescents with spinal muscular atrophy

Correlation between general quality of life and oral health related quality in the mixed dentition

The aim of this study was to evaluate the convergence between the domains of the Autoquestionnaire Qualité de Vie Enfant image (AUQUEI) and the Child Perceptions Questionnaire (CPQ8-10) in the mixed dentition. A sample of 676 children aged 8 to 10 years responded to the health-related quality of life (HRQoL) and oral health-related quality of life (OHRQoL) questionnaires using the AUQUEI and the CPQ8-10, respectively. Clinical (dental caries and malocclusion) and socioeconomic variables were assessed. The validity of convergence between scores (total and per domain) of the two instruments was assessed by Spearman correlation analysis, considering that non-zero coefficient values represented a correlation between scores. The median was calculated to compare the scores of each questionnaire relative to the variables, and the nonparametric Mann-Whitney test was applied to determine statistically significant differences between the categories. A weak significant correlation (between 0.30 and 0.50) was observed between the domains and the total scores of instruments (p < 0.05), except for the leisure domain (p > 0.05). Participants with a lower family income had worse HRQoL (p < 0.05), and those with caries and malocclusion experience had worse OHRQoL (p < 0.05). In conclusion, the AUQUEI and CPQ8-10 instruments showed a weak correlation. Income and clinical variables had a negative impact on the AUQUEI and CPQ8-10, respectively.

Impact of nusinersen on the health-related quality of life and caregiver burden of patients with spinal muscular atrophy with symptom onset after age 6 months

INTRODUCTION/AIMS

Novel disease-modifying approaches for spinal muscular atrophy (SMA) have highlighted the patient's perspective on functional changes over time. In this study, we evaluated the impact of nusinersen on the health-related quality of life (HRQoL) of patients with later-onset SMA and the caregiver burden.

METHODS

We assessed the changes in HRQoL using the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL GCS) and the Pediatric Quality of Life Inventory 3.0 Neuromuscular Module (PedsQL NMM) during 26 months of treatment. Caregiver burden was assessed using the Assessment of Caregiver Experience with Neuromuscular Disease. We also assessed motor function using the Hammersmith Functional Motor Scale-Expanded (HFMSE) and the Revised Upper Limb Module score.

RESULTS

Twenty-four patients and their caregivers were included. The median age of patients at treatment onset was 148.8 (6.8 to 269.4) months. A significant improvement was observed in psychosocial health in proxy-reported PedsQL (P = .023). However, the physical health scores of the PedsQL GCS and About my neuromuscular disorder subscores of the PedsQL NMM did not change, although there was a significant increase in HFMSE scores. Regarding the caregiver burden, the financial burden was reduced, whereas time burden increased. A higher HFMSE score was associated with better self-reported PedsQL GCS total scores (P < .001).

DISCUSSION

Our results provide insights into the multifaceted implications of disease-modifying therapies for SMA through patient-reported outcome measures (PROMs). PROMs should be taken into consideration to assess the clinical significance of the functional changes identified by clinician-reported scales.

Caregivers' Expectations on Possible Functional Changes following Disease-Modifying Treatment in Type II and III Spinal Muscular Atrophy: A Comparative Study

Background: The primary aim of this study was to explore current caregivers' expectations on possible functional changes following treatment in comparison to data obtained in the pre-pharmacological era. Methods: A questionnaire, previously used in 2016, was administered to caregivers of type II and III SMA patients of age between 3 and 71 years, and to patients over the age of 13 years. The questionnaire focuses on (1) caregivers and patients expectations, (2) meaningfulness of the changes observed on the functional motor scales, and (3) their willingness to be enrolled in a clinical trial. A comparative study was performed with data obtained using the same questionnaire soon before the advent of disease-modifying therapies. Results: We administered the questionnaire to 150 caregivers. When comparing current caregiver data to those obtained in 2016, the most obvious differences were related to disease perception over the last year (stability: 16.5% in 2016 vs. 43.6% in 2022; deterioration 70.5% vs. 12.8%, and improvement: 12.9% vs. 43.6%) and expectations from clinical trials with higher expectations in 2022 compared to 2016 (p < 0.001). Forty-five of the 150 in the current study were caregivers of patients above the age of 13. In these 45 the questionnaire was also administered to the patient. No difference was found in responses between patients and their caregivers. Conclusions: Both carers and patients reported that even small changes on functional scales, similar to those reported by clinical studies and real-world data, are perceived as meaningful. Comparing the recent responses to those obtained in 2016, before pharmacological treatment was available, we found significant changes in caregivers' perception with increased expectations. These findings will provide a better understanding of the patients' expectations and facilitate discussion with regulators.

Subjective wellbeing of preschool children

Objective

The aim of the present study was to evaluate the psychometric properties of the Autoquestionnaire Qualité de Vie Enfant Imagé (AUQEI) in pre-school children and estimate the influence of demographic characteristics on their subjective wellbeing.

Methods

Construct validity was estimated using confirmatory analysis and the chi-square per degrees of freedom ratio (χ²/df), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA). Reliability was assessed by the ordinal alpha (α) and omega (ω) coefficients and the factorial invariance by the difference in CFI (ΔCFI). Mean scores for each AUQEI item and the general score were calculated.

Results

A total of 443 Preschool children enrolled in public education institutions participated. The original 4-factor AUQEI model showed collinearity between factors and a high correlation between two items. A single factor model was tested, presenting adequate fit to the data (χ²/df = 4.47; CFI = 0.98; TLI = 0.98; RMSEA = 0.08; α = 0.98; ω = 0.93; UniCo > 0.95, EVC > 0.85, and MIREAL < 0.30) and strict model invariance (ΔCFI < 0.01). The AUQEI model proved to be valid in relation to the external variables. Most children (76.7%) had positive subjective wellbeing. Higher scores were observed for items concerning recreation, holidays, and birthdays, and lower scores for those referring to hospitalization, medication, medical consultation, and being away from the family. The relationship between the demographic characteristics of the child or his/her mother and subjective wellbeing was not significant (p > 0.05).

Conclusions

The assessment of subjective wellbeing with the single-factor AUQEI model provided valid, reliable, and invariant. Thus, being a relevant and interesting instrument to assess wellbeing in young children.

The quality of life in children with spinal muscular atrophy: a case-control study

OBJECTIVES

This study aimed to analyze the health-related quality of life (HRQoL) of patients with spinal muscular atrophy (SMA) based on the type of SMA, demographic and clinical features and compare HRQoL of these patients with a matched healthy control group.  METHODS: This was a case-control study of Patients with SMA in Iran. Sixty-six patients with SMA type II and III aged 8-18 years and also 264 healthy age, sex, and socio-economic matched individuals were enrolled. To assess the quality of life, we used the Persian version of the KIDSCREEN-27.

RESULTS

The health-related quality of life between children with type II and type III SMA was not significant in all 5 subscales. However, HRQoL in healthy children was significantly higher than in SMA children in all 5 subscales.

CONCLUSION

The quality of life in children with SMA was lower than the healthy control group in all subscales, and physical well-being and psychosocial aspects are the main domains of life impaired by SMA disease. However, no significant difference between the quality of life in children with SMA type II and type III was observed.

Spinal muscular atrophy

Spinal muscular atrophy (SMA) is a neurodegenerative disorder caused by mutations in SMN1 (encoding survival motor neuron protein (SMN)). Reduced expression of SMN leads to loss of α-motor neurons, severe muscle weakness and often early death. Standard-of-care recommendations for multidisciplinary supportive care of SMA were established in the past few decades. However, improved understanding of the pathogenetic mechanisms of SMA has led to the development of different therapeutic approaches. Three treatments that increase SMN expression by distinct molecular mechanisms, administration routes and tissue biodistributions have received regulatory approval with others in clinical development. The advent of the new therapies is redefining standards of care as in many countries most patients are treated with one of the new therapies, leading to the identification of emerging new phenotypes of SMA and a renewed characterization of demographics owing to improved patient survival.

Systematic Review of Motor Function Scales and Patient-Reported Outcomes in Spinal Muscular Atrophy

ABSTRACT

Spinal muscular atrophy is a heterogeneous disease that results in loss of motor function. In an evolving treatment landscape, establishing the suitability and limitations of existing motor function scales and patient-reported outcomes used to monitor patients with this disease is important. A systematic review was conducted to examine utility of motor function scales and patient-reported outcomes in evaluating patients with spinal muscular atrophy. Published literature was reviewed up to June 2021 with no start date restriction. Of the reports screened, 122 were deemed appropriate for inclusion and are discussed in this review (including 24 validation studies for motor function scales or patient-reported outcomes). Fifteen motor function scales and patient-reported outcomes were identified to be commonly used (≥5 studies), of which 11 had available validation assessments. Each instrument has its strengths and limitations. It is imperative that the patient population (e.g., age, mobility), goals of treatment, and outcomes or endpoints of interest be considered when selecting the appropriate motor function scales and patient-reported outcomes for clinical studies.

Understanding Symptoms in RYR1-Related Myopathies: A Mixed-Methods Analysis Based on Participants' Experience

BACKGROUND

In rare diseases such as ryanodine receptor 1-related myopathies (RYR1-RM), health-related quality of life (HRQoL) measures are critically important so clinicians and researchers can better understand what symptoms are most important to participants, with the ultimate goal of finding tangible solutions for them.

OBJECTIVES

The main objective of this study was to characterize symptoms in individuals with RYR1-RM to inform future research. A secondary objective of this study was to analyze positive and negative sentiments regarding symptoms and treatment effects post N-acetylcysteine (NAC) administration in individuals with RYR1-RM.

METHODS

The study used a mixed-methods design applying methodological triangulation. Qualitative data were collected via semi-structured interviews at three visits to characterize symptoms in individuals with RYR1-RM and to analyze treatment effects. Qualitative data were then transformed into quantitative results to measure the frequency with which each symptom was mentioned by participants.

RESULTS

A total of 12 symptoms were identified as areas of interest to participants with RYR1-RM, highlighting fatigue and weakness as key symptoms. Data transformation categorized more than 1000 citations, reporting a greater number of positive comments for postintervention interviews than for baseline and preintervention visits and that NAC group participants stated more positive comments regarding treatment effect than did the placebo group.

CONCLUSIONS

We present a comprehensive characterization of symptoms in RYR1-RM and how those symptoms influence HRQoL. Furthermore, the introduction of mixed methods may be a valuable way to better understand patient-centered data in rare diseases to support affected individuals in coping with their symptoms.

Quality of Life in SMA Patients Under Treatment With Nusinersen

Background: Spinal Muscular Atrophy (SMA) is a severe neurodegenerative disease, characterized by progressive muscle weakness and atrophy. The approval of the antisense oligonucleotide (ASO) nusinersen now provides an effective pharmacological approach with the potential to slow down or stop disease progression with a potentially major impact on patients' well-being.

Objective: This study evaluates quality of life (QoL) in pediatric and adult patients over the course of therapy with nusinersen.

Methods: Twenty-six SMA patients treated with nusinersen were evaluated regarding global QoL (gQoL), health-related QoL (HRQoL) and depressiveness. Assessments were conducted three times over the first 6 months of treatment. Applied were different questionnaires: the Anamnestic Comparative Self-Assessment (ACSA) for gQoL, the Short Form-36 Health Survey (SF-36) for HRQoL in adult patients and the ALS Depression Inventory 12 Items (ADI-12) for depressiveness. The sample was matched with 22 healthy controls.

Results: Despite severe physical restrictions, patients reported high levels of QoL and low levels of depressiveness at study entry. Early disease onset and low levels of physical functioning were associated with better gQoL and lower levels of depressiveness. A significant decrease of gQoL in patients was evident over the course of the study. Still, adult patients reported a significant increase in perceived health.

Conclusions: Our study provides first insight that SMA patients experience a gQoL superior to healthy controls at start of therapy. This might indicate patients' high hopes and expectations toward treatment. gQoL returns to a level similar to that of healthy controls over the course of therapy.

Mixed methods analysis of Health-Related Quality of Life in ambulant individuals affected with RYR1-related myopathies pre-post-N-acetylcysteine therapy

PURPOSE

To characterize Health-Related Quality of Life (HRQoL) in ambulant individuals with RYR1-RM and to determine if a qualitative PRO tool (subjective self-assessment) complements PROMIS and Neuro-QoL scales to detect changes in HRQoL in ambulant individuals with RYR1-RM post N-acetylcysteine (NAC) treatment.

METHODS

The study used a mixed methods research (MMR) design applying methodological triangulation. Qualitative data were collected via semi-structured interviews using open-ended questions. Quantitative data were gathered through PROMIS and Neuro-QoL instruments. Additionally, qualitative data were transformed into quantitative data for subjective self-assessment and frequency analyses.

RESULTS

Qualitative results identified five domains and 33 subdomains as areas of interest. The most valuable were the importance of social impacts, the development of several coping strategies, both physical and psychological, and the identification of fatigue and weakness as key symptoms. Data transformation then categorized more than 3100 citations on frequency analyses, globally and by domain, visit, and participant. Regarding quantitative results, there was no clear evidence that any of the three PRO tools captured positive changes as a result of NAC treatment.

CONCLUSION

Qualitative results showed a comprehensive characterization of HRQoL in this population based on a symptom/patient-centered approach. These findings will inform future studies. Furthermore, given the similar findings across our multiple methods and endpoints, the introduction of MMR may be a valuable, complementary approach to clinical trials. MMR may be especially useful to incorporate in order to address and follow the FDA's guidance and prioritization on the inclusion of affected individuals' perspectives in clinical trials.

Longitudinal changes in clinical outcome measures in COL6-related dystrophies and LAMA2-related dystrophies

OBJECTIVE

To identify the rate of change of clinical outcome measures in children with 2 types of congenital muscular dystrophy (CMD), COL6-related dystrophies (COL6-RDs) and LAMA2-related dystrophies (LAMA2-RDs).

METHODS

Over the course of 4 years, 47 individuals (23 with COL6-RD and 24 with LAMA2-RD) 4 to 22 years of age were evaluated. Assessments included the Motor Function Measure 32 (MFM32), myometry (knee flexors and extensors, elbow flexors and extensors), goniometry (knee and elbow extension), pulmonary function tests, and quality-of-life measures. Separate linear mixed-effects models were fitted for each outcome measurement, with subject-specific random intercepts.

RESULTS

Total MFM32 scores for COL6-RDs and LAMA2-RDs decreased at a rate of 4.01 and 2.60 points, respectively, each year (p < 0.01). All muscle groups except elbow flexors for individuals with COL6-RDs decreased in strength between 1.70% (p < 0.05) and 2.55% (p < 0.01). Range-of-motion measurements decreased by 3.21° (p < 0.05) at the left elbow each year in individuals with LAMA2-RDs and 2.35° (p < 0.01) in right knee extension each year in individuals with COL6-RDs. Pulmonary function demonstrated a yearly decline in sitting forced vital capacity percent predicted of 3.03% (p < 0.01) in individuals with COL6-RDs. There was no significant change in quality-of-life measures analyzed.

CONCLUSION

Results of this study describe the rate of change of motor function as measured by the MFM32, muscle strength, range of motion, and pulmonary function in individuals with COL6-RDs and LAMA2-RDs.

Quality of life of patients with spinal muscular atrophy: A systematic review

OBJECTIVES

To systematically review the literature of quality of life (QoL) of patients with spinal muscular atrophy (SMA), a rare, autosomal-recessive neuromuscular disease associated with extensive morbidity and elevated mortality.

METHODS

We searched Embase, Web of Science, and PubMed for full-text, English-language articles (published between January 1, 2000 and July 31, 2018) reporting results from studies of QoL of patients with SMA. We excluded review and editorial articles, studies reporting results for samples comprising <5 patients (to allow for meaningful inference), and case reports/qualitative assessments.

RESULTS

Of 824 identified articles, 15 met study criteria. Included publications contained data derived from samples from a total of 11 countries and three continents (Europe, North America, and South America). Estimates of the latent trait, primarily derived using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and the PedsQL 3.0 Neuromuscular Module, indicated impairment in patient QoL, in particular physical functioning. However, both patient self- and caregiver proxy-assessments varied markedly across studies and subgroups. Among adult individuals, the mean self-assessed EuroQol-5D-3L utility has been estimated at 0.16 for a pooled sample of patients with SMA type I, II, and III, and -0.01 for SMA type II. Little is known of the impact of available treatments, including nusinersen, on patient QoL.

CONCLUSIONS

Our review show that QoL is impaired in SMA, mainly due to compromised physical health, but also reveal that little is known of the impact of the disease across different phenotypes and clinical interventions.

Psychological well-being in adults with spinal muscular atrophy: the contribution of participation and psychological needs

Purpose: Patients with spinal muscular atrophy (SMA) suffer from slowly progressive weakness of axial, respiratory and proximal muscles, leading to restrictions in activity and participation. This study aims to investigate patients' level of psychological well-being, using the International Classification of Functioning model and self-determination theory as theoretical frameworks.Materials and methods: In this cross-sectional study, adults with SMA were invited to complete a questionnaire. Instruments to assess psychological well-being included the Satisfaction with Life Scale, the Rosenberg Self-Esteem Scale and the Positive and Negative Affect Scale. Hierarchical lineal regression analyses were performed to investigate the contribution of participation (International Classification of Functioning model) and satisfaction of the need for autonomy, competence and relatedness (self-determination theory) to well-being.Results: Ninety-two respondents (67%) returned the questionnaire. Levels of psychological well-being were comparable to that of healthy reference samples. Well-being was unrelated to sociodemographic variables or illness characteristics. By contrast, well-being was closely related to respondents' satisfaction with participation, and their sense of autonomy, competence and relatedness.Conclusions: This study illustrates the relevance of psychological needs for understanding well-being of individuals with SMA. Supporting patients in meeting their psychological needs should become an objective of person-centred care for this population.Implications for rehabilitationSpinal muscular atrophy is a rare inherited disease, characterized by slowly progressive muscle weakness.Psychological well-being, including satisfaction with life, self-esteem and emotional functioning of adults with spinal muscular atrophy appears very comparable with that of healthy reference samples.In line with the International Classification of Functioning framework, well-being in adults with spinal muscular atrophy may be improved by increasing their (satisfaction with) participation.Moreover, clinical assessment and management should focus on optimizing patients' satisfaction with their basic psychological needs (autonomy, competence, relatedness), as this is strongly related to indices of psychological well-being.

What Matters Most: A Perspective From Adult Spinal Muscular Atrophy Patients

There are multiple symptoms that affect adults with spinal muscular atrophy (SMA). The extent of these symptoms and their impact on individuals' lives is not fully known. We interviewed 15 adults with genetically confirmed SMA. Participants were asked to identify issues that have significant impact on their lives. Interviews were recorded, transcribed, coded, and analyzed. Participants provided 1045 direct quotes. 177 potential symptoms of importance were identified. Symptoms were grouped by like topics into fourteen symptomatic themes. The symptoms and issues identified by SMA patients alter their physical, mental, and social health and may be amendable to therapeutic intervention.

Measuring Participation After Stroke in Africa: Development of the Participation Measurement Scale

OBJECTIVE

To develop a valid stroke-specific tool, named the Participation Measurement Scale (PM-Scale), for the measurement of participation after stroke.

DESIGN

Observational study and questionnaire development.

SETTING

Outpatient rehabilitation centers.

PARTICIPANTS

Patients with stroke (N=276; mean age, 58.5±11.1y; 57% men).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed a 100-item experimental questionnaire of the PM-Scale. Items were scored as "not at all," "weakly," or "strongly." The Hospital Anxiety and Depression Scale was used to evaluate depression, and the modified Rankin Scale was used to categorize the severity of disability on the basis of observation.

RESULTS

After successive Rasch analyses using unrestricted partial credit parameterization, a valid, unidimensional, and linear 22-item scale for the measurement of participation was constructed. All 22 items fulfilled the measurement requirements of overall and individual item and person fits, category discrimination, invariance, and local response independence. The PM-Scale showed good internal consistency (person separation index, .93). The test-retest reliability of item difficulty hierarchy (r=.96; P<.001) and patient location (r=.99; P<.001) were excellent. This patient-based scale covers all 9 International Classification of Functioning, Disability and Health domains of participation.

CONCLUSIONS

The PM-Scale has good psychometric qualities and provides accurate measures of participation in patients with stroke in Africa.

Physician driven variation in the care of children with spinal muscular atrophy type 1

BACKGROUND

Increasing numbers of families are requesting active supportive management for their child with spinal muscular atrophy type 1 (SMA1), leading to longer survival and greater prevalence of affected children. Strong opinions exist among physicians for and against the provision of care measures prolonging life.

OBJECTIVE

To describe current practice in the care of SMA1 in Canada, and explore the factors underlying inter-physician variability.

METHODS

A cross-sectional survey of Canadian hospital-based pediatric neurologists and pediatric respirologists was performed in 2015. Odds ratios and 95% confidence intervals were calculated to compare proportions between groups.

RESULTS

There was a 54% completion rate (99 physicians). Over half of participants believed that a disease modifying therapy was likely within 10 years. Quebec respirologists were 50 times less likely to offer long-term non-invasive ventilation (NIV) than respirologists in other provinces (OR 50.6, 95% CI 2.4-1075.3), and 20 times less likely to discuss tracheostomy with families (OR 20.4, 95% CI 2.0-211.8). High raters of perceived happiness of affected children were more likely to find NIV an acceptable measure for acute (OR 6.7, 95% CI 1.7-26.0) and chronic (OR 13.7, 95% CI 4.0-46.4) respiratory failure and prophylactic use (OR 5.8, 95% CI 2.2-15.6).

CONCLUSION

Physician knowledge, opinions, subjective perception of child happiness, and regional factors, all influence physicians' practices and the shared decision-making process. Parents may not be informed or offered all the services available to their child. Knowledge translation initiatives are needed to enhance SMA1 care. Pediatr Pulmonol. 2017;52:662-668. © 2016 Wiley Periodicals, Inc.

Disease burden of spinal muscular atrophy in Germany

BACKGROUND

This study aimed at analyzing the economic burden and disease-specific health-related quality of life (HRQOL) of patients with spinal muscular atrophy (SMA) in Germany. SMA is a so far non-curable neuromuscular disease of the anterior nerve cells that causes high rates of morbidity and mortality.

METHODS

In a cross-sectional study we analyzed the cost of illness (COI) and factors that influence the direct, indirect and informal care costs of affected patients and their families by using standardized, self-developed questionnaires. We used the PedsQL™(©) Measurement Model to analyze the disease-specific HRQOL of patients.

RESULTS

One hundred eighty nine patients with SMA types I to III aged <1 to 73 years were enrolled. The average annual COI was estimated at €70,566 per patient in 2013. The highest cost resulted in SMA I with significant lower costs for the milder phenotypes. Inversely, the self-estimated HRQOL increased from SMA I to SMA III. Major cost drivers were informal care cost and indirect cost incurred by patients and their caregivers.

CONCLUSIONS

Although SMA requires high standards of care, there has been a distinct lack of health services research on SMA. Accordingly, our results significantly contribute to a more comprehensive insight into the current burden of SMA and quality of life status as related to SMA health services in Germany. In the light of innovative therapeutic interventions, our results suggest a notable potential for a reduction in overall COI and improvement of HRQOL if the therapeutic intervention leads to a less severe course of the disease.

Understanding the experiences and needs of individuals with Spinal Muscular Atrophy and their parents: a qualitative study

BACKGROUND

The clinical features of SMA, which range along a spectrum of severity, are relatively well described. In contrast, the literature on how individuals with SMA and their families experience this condition is limited. To address this gap, we undertook a qualitative study with individuals affected by SMA Types I, II and III, parents of those affected, and clinicians.

METHODS

We completed 16 focus group sessions and 37 interviews in the US with 96 participants including: 21 with individuals with SMA; 64 parents of individuals affected by SMA; and 11 clinicians who specialize in the care of SMA patients.

RESULTS

The Diagnostic Journey: Families reported substantial diagnostic delays owing to: 1) lack of awareness and knowledge about SMA; 2) the difficulty of distinguishing normal from abnormal development; and 3) the challenge of differential diagnosis. Lack of sensitivity in how clinicians communicated this potentially devastating diagnosis compounded parents' negative impressions. Newborn Screening: Parents generally held positive views about adding SMA to newborn screening panels. For example, it would: 1) enable earlier access to care; 2) shorten the diagnostic journey; and 3) give families more time to prepare to care for a disabled child. Some noted negative outcomes such as prematurely affecting a parent's relationship with a child before symptoms are evident. The Psychosocial Impact of Living with SMA: Ten thematic areas characterized the impact: 1) confronting premature death; 2) making difficult treatment choices; 3) fearing the loss of functional ability; 4) coming to terms with lost expectations; 5) loss of sleep and stress; 6) stigma; 7) limitations on social activities; 8) independence; 9) uncertainty and helplessness; and 10) family finances.

CONCLUSIONS

The results of this study suggest high levels of burden experienced by individuals with SMA and their families. The difficulties of living with SMA begin with the long and often arduous process of finding a diagnosis for their child. Newborn screening for SMA is seen as an important step toward shortening this journey. The psychosocial effects of coping with SMA are substantial and wide ranging both for the individual living with this condition and family members of affected individuals.

Oral health, socio-economic and home environmental factors associated with general and oral-health related quality of life and convergent validity of two instruments

Background

The objective of this study was to evaluate the convergent validity between the domains of the Autoquestionnaire Qualité de Vie Enfant image (AUQUEI) and the Child Perceptions Questionnaire instrument (CPQ_11–14) among schoolchildren and to assess the difference between socio-economic and clinical variables associated with their scores.

Methods

An analytical cross-sectional study was conducted in Juiz de Fora, Minas Gerais, Brazil, with 515 schoolchildren aged 12 years from 22 public and private schools, selected with the use of a random multistage sampling design. They were clinically examined for dental caries experience (DMFT and dmft index) and orthodontic treatments needs (DAI index) and were asked to complete the Brazilian versions of Child Perception Questionnaire (CPQ_11–14) and Autoquestionnaire Qualité de Vie Enfant image (AUQUEI). In addition, a questionnaire was sent to their parents inquiring about their socio-economic status and home characteristics. The convergent validity of the Brazilian versions of CPQ_11–14 and AUQUEI instruments was analyzed by Spearman’s correlation coefficients. For comparison between the summarized scores of each questionnaire with regard to the schoolchildren’s socio-environmental and clinical aspects the nonparametric Mann–Whitney was used at level of significance of 5%.

Results

The mean DMFT index was 1.09 and 125 (24.3%) children had orthodontic treatment needs (DAI ≥ 31). There was a similarity and a weak correlation between the scores of the domains of CPQ_11–14 and AUQUEI (r ranged between −0.006 and 0.0296). In addition, a significant difference was found between the scores of the two instruments according to the socio-economic variables (p < 0.05) and presence of teeth with carious lesions (p < 0.05).

Conclusions

The general and oral health-related quality of life instruments AUQUEI and CPQ_11–14 were both found to be useful, and significant influence of socio-economic and clinical variables were detected with both instruments.

Anesthesia and spinal muscle atrophy

Spinal muscle atrophy (SMA) is autosomal recessive and one of the most common inherited lethal diseases in childhood. The spectrum of symptoms of SMA is continuous and varies from neonatal death to progressive symmetrical muscle weakness first appearing in adulthood. The disease is produced by degeneration of spinal motor neurons and can be described in three or more categories: SMA I with onset of symptoms before 6 months of age; SMAII with onset between 6 and 18 months and SMA III, which presents later in childhood. Genetics: The disease is in more than 95% of cases caused by a homozygous deletion in survival motor neuron gene 1 (SMN1).

PATHOPHYSIOLOGY

The loss of full-length functioning SMN protein leads to a degeneration of anterior spinal motor neurons which causes muscle weakness. Anesthetic risks: Airway: Tracheal intubation can be difficult. Respiration: Infants with SMA I almost always need postoperative respiratory support. Patients with SMA II sometimes need support, while SMA III patients seldom need support. Circulation: Circulatory problems during anesthesia are rare. Anesthetic drugs: Neuromuscular blockers: Patients with SMA may display increased sensitivity to and prolonged effect of nondepolarizing neuromuscular blockers. Intubation without muscle relaxation should be considered. Succinylcholine should be avoided. Opioids: These should be titrated carefully. Anesthetic techniques: All types of anesthetic technique have been used. Although none is absolutely contraindicated, none is perfect: anesthesia must be individualized.

CONCLUSION

The perioperative risks can be considerable and are mainly related to the respiratory system, from respiratory failure to difficult/impossible intubation.

Health outcomes measurement: concepts, guidelines and opportunities

In this chapter we argue that modern thinking about chronic neurological and developmental conditions requires that we recognize all aspects of functioning and quality of life in addition to the biomedical dimensions of these disorders. We find the International Classification of Functioning, Disability, and Health (ICF) a useful framework by which to think about and understand the many dimensions of health; and we appreciate its heuristic value as a stimulus to consider a range of outcomes of these individuals. Quality of Life (QOL) and Health-Related Quality of Life (HRQL) cover the additional perceived dimensions that are so important to patients' personal valuations, aspirations, and satisfaction about health throughout their lifespan, of which we see QOL being the broader construct. In order to measure outcomes at either the individual clinical or research level it is essential to ask clear and specific questions as a prelude to selecting measures that are appropriate in terms of both their content and their measurement properties. We provide some brief guidelines that we hope will be helpful to readers who wish to expand their activities in measuring clinical outcomes.

Palliation of Dyspnea in pediatrics

Dyspnea is a complex physiologic and psychosocial symptom that is difficult to characterize and measure, but essential to treat, as it has a significant effect on quality of life. Although palliation of dyspnea in the child with chronic illness is an under-researched area, children and their families cannot wait for the research to catch up with their current needs. This article addresses several aspects of dyspnea in pediatrics palliative care, with an eye toward practical suggestions for evaluation and management.

Outcomes in pediatric neurology: a review of conceptual issues and recommendationsThe 2010 Ronnie Mac Keith Lecture

This paper discusses how to evaluate whether, and in what ways, treatments affect the lives of children with neurological conditions and their families. We argue that professionals should incorporate perspectives from patients and families to help them make decisions about what 'outcomes' are important, and we discuss how those outcomes might be assessed. A case vignette illustrates the differences and complementarity between the perspectives of clinicians and those of children and their parents. We recommend methods for expanding the range of relevant health outcomes in child neurology to include those that reflect the ways patients and families view their conditions and our interventions. We explore the added value of a 'non-categorical' approach to the choice of outcomes. The International Classification of Functioning, Disability and Health is a useful biopsychosocial framework to 'rule in' relevant aspects of child and family issues to create a dynamic system of possible influences on outcomes. We examine the meaning of 'health', 'health-related quality of life', and 'quality of life' as related but conceptually distinct outcomes. Specific issues are discussed about the construction, validation, and appraisal of outcome measures, as well as practical recommendations on how to select outcome measures in the clinical setting and research.