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Urushitani M, Warita H, Atsuta N, Izumi Y, Kano O, Shimizu T, Nakayama Y, Narita Y, Nodera H, Fujita T, Mizoguchi K, Morita M, Aoki M. The clinical practice guideline for the management of amyotrophic lateral sclerosis in Japan-update 2023. Rinsho Shinkeigaku 2024; 64:252-271. [PMID: 38522911 DOI: 10.5692/clinicalneurol.cn-001946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
Amyotrophic lateral sclerosis (ALS) is an adult-onset intractable motor neuron disease characterized by selective degeneration of cortical neurons in the frontotemporal lobe and motor neurons in the brainstem and spinal cord. Impairment of these neural networks causes progressive muscle atrophy and weakness that spreads throughout the body, resulting in life-threatening bulbar palsy and respiratory muscle paralysis. However, no therapeutic strategy has yet been established to halt ALS progression. Although evidence for clinical practice in ALS remains insufficient, novel research findings have steadily accumulated in recent years. To provide updated evidence-based or expert consensus recommendations for the diagnosis and management of ALS, the ALS Clinical Practice Guideline Development Committee, approved by the Japanese Society of Neurology, revised and published the Japanese clinical practice guidelines for the management of ALS in 2023. In this guideline, disease-modifying therapies that have accumulated evidence from randomized controlled trials were defined as "Clinical Questions," in which the level of evidence was determined by systematic reviews. In contrast, "Questions and Answers" were defined as issues of clinically important but insufficient evidence, according to reports of a small number of cases, observational studies, and expert opinions. Based on a literature search performed in February 2022, recommendations were reached by consensus, determined by an independent panel, reviewed by external reviewers, and submitted for public comments by Japanese Society of Neurology members before publication. In this article, we summarize the revised Japanese guidelines for ALS, highlighting the regional and cultural diversity of care processes and decision-making. The guidelines cover a broad range of essential topics such as etiology, diagnostic criteria, disease monitoring and treatments, management of symptoms, respiration, rehabilitation, nutrition, metabolism, patient instructions, and various types of care support. We believe that this summary will help improve the daily clinical practice for individuals living with ALS and their caregivers.
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Affiliation(s)
| | - Hitoshi Warita
- Department of Neurology, Tohoku University Graduate School of Medicine
| | - Naoki Atsuta
- Department of Neurology, Aichi Medical University School of Medicine
| | - Yuishin Izumi
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences
| | - Osamu Kano
- Department of Neurology, Toho University Faculty of Medicine
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Yuki Nakayama
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science
| | - Yugo Narita
- Department of Neurology, Mie University Graduate School of Medicine
| | | | | | | | - Mitsuya Morita
- Division of Neurology, Department of Internal Medicine, Jichi Medical University
| | - Masashi Aoki
- Department of Neurology, Tohoku University Graduate School of Medicine
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Morishima R, Shimizu T, Kimura H, Bokuda K, Saotome T, Nakayama Y, Takahashi K. High doses of opioids usage for amyotrophic lateral sclerosis patients with non-invasive ventilation. Acta Neurol Belg 2024; 124:101-107. [PMID: 37543533 DOI: 10.1007/s13760-023-02344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/19/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION While opioids have been found to be useful in relieving suffering in amyotrophic lateral sclerosis (ALS), there is a lack of evidence concerning how and how much to use them in practice. This study was conducted to clarify how opioids were used for patients with ALS. METHODS We performed a retrospective case-based analysis at a single tertiary neurology center in Tokyo from 2010 to 2018. We enrolled patients with ALS who had died before the end of 2018. We examined the opioid dosage equivalent of morphine hydrochloride and patients' clinical backgrounds, focusing on ventilatory support. RESULTS Morphine was administered in 110 patients with ALS, and 84 were followed up until their death. Of these 84 patients, 57 (69.9%) did not use mechanical ventilation until death (no-MV group), and 21 (22.9%) utilized only non-invasive ventilation (NIV group). Final morphine dosage in the NIV group was significantly higher (mean 65.7 mg [SD 54.6], range 10-200 mg) than in the no-MV group (mean 31.7 mg [SD 26.9], range 0-120 mg; p = 0.015, Welch's t-test). The NIV group needed psychotropic drugs more frequently than the no-MV group (62% [n = 13] vs. 35% [n = 20]). CONCLUSION Patients in the NIV group used opioids for a statistically significantly longer time and at a higher dose than those in the no-MV group. Symptom control with opioids alone may be difficult, and the development of multifaceted evaluation and care is desirable.
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Affiliation(s)
- Ryo Morishima
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan.
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hideki Kimura
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kota Bokuda
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takako Saotome
- Department of Rehabilitation Medicine, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Yuki Nakayama
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
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Kredentser MS, Mackenzie CS, McClement SE, Enns MW, Hiebert-Murphy D, Murphy DJ, Chochinov HM. Neuroticism as a moderator of symptom-related distress and depression in 4 noncancer end-of-life populations. Palliat Support Care 2023:1-9. [PMID: 37734916 DOI: 10.1017/s147895152300127x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
OBJECTIVES Neuroticism is a significant predictor of adverse psychological outcomes in patients with cancer. Less is known about how this relationship manifests in those with noncancer illness at the end-of-life (EOL). The objective of this study was to examine the impact of neuroticism as a moderator of physical symptoms and development of depression in patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and frailty in the last 6 months of life. METHODS We met this objective using secondary data collected in the Dignity and Distress across End-of-Life Populations study. The data included N = 404 patients with ALS (N = 101), COPD (N = 100), ESRD (N = 101), and frailty (N = 102) in the estimated last 6 months of life, with a range of illness-related symptoms, assessed longitudinally at 2 time points. We examined neuroticism as a moderator of illness-related symptoms at Time 1 (∼6 months before death) and depression at Time 2 (∼3 months before death) using ordinary least squares regression. RESULTS Results revealed that neuroticism significantly moderated the relationship between the following symptoms and depression measured 3 months later: drowsiness, fatigue, shortness of breath, wellbeing (ALS); drowsiness, trouble sleeping, will to live, activity (COPD); constipation (ESRD); and weakness and will to live (frailty). SIGNIFICANCE OF RESULTS These findings suggest that neuroticism represents a vulnerability factor that either attenuates or amplifies the relationship of specific illness and depressive symptoms in these noncancer illness groups at the EOL. Identifying those high in neuroticism may provide insight into patient populations that require special care at the EOL.
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Affiliation(s)
- Maia S Kredentser
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Corey S Mackenzie
- Department of Psychology, and Adjunct Professor, Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada
| | - Susan E McClement
- Research, College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Murray W Enns
- Department of Psychiatry, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Diane Hiebert-Murphy
- Faculty of Social Work and the Psychological Service Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Dallas J Murphy
- Department of Psychology, University of Manitoba, Winnipeg, MB, Canada
| | - Harvey M Chochinov
- Department of Psychiatry, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Fidelix EC, Santana GC, Barros DMDS, Dourado Junior MET. Telehealth for amyotrophic lateral sclerosis in a multidisciplinary service in a Brazilian reference center. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:469-474. [PMID: 37257467 DOI: 10.1055/s-0043-1768161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Telehealth has been used in the treatment of different diseases, and it has been shown to provide benefits for patients with amyotrophic lateral sclerosis (ALS). Due to the social distancing measures put into effect during the coronavirus disease 2019 (COVID-19) pandemic, there was an urgent need for telehealth to ensure the provision of healthcare. OBJECTIVE To evaluate the feasibility of telehealth for the provision of multidisciplinary ALS care, and to assess its acceptability among patients and caregivers. METHODS We conducted a retrospective cohort study in which multidisciplinary evaluations were performed using the Teleconsulta platform. The patients included had ALS and at least one in-person clinical evaluation. The patients and the caregivers answered satisfaction questionnaires. RESULTS The sample was composed of 46 patients, 32 male and 14 female subjects. The average distance from their residences to the reference services was of 115 km. Respiratory adjustment was the most addressed topic. CONCLUSION The strategy is viable and well accepted in terms of satisfaction. It was even more positive for patients in advanced stages of the disease or for those living far from the referral center.
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Affiliation(s)
- Emanuela Coriolano Fidelix
- Universidade Federal do Rio Grande do Norte, Departamento de Medicina Integrada, Natal RN, Brazil
- Universidade Federal do Rio Grande do Norte, Laboratório de Inovação Tecnológica em Saúde, Natal RN, Brazil
| | - Glauciane Costa Santana
- Universidade Federal do Rio Grande do Norte, Departamento de Medicina Integrada, Natal RN, Brazil
- Universidade Federal do Rio Grande do Norte, Laboratório de Inovação Tecnológica em Saúde, Natal RN, Brazil
| | | | - Mário Emílio Teixeira Dourado Junior
- Universidade Federal do Rio Grande do Norte, Departamento de Medicina Integrada, Natal RN, Brazil
- Universidade Federal do Rio Grande do Norte, Laboratório de Inovação Tecnológica em Saúde, Natal RN, Brazil
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Ketabforoush AHME, Chegini R, Barati S, Tahmasebi F, Moghisseh B, Joghataei MT, Faghihi F, Azedi F. Masitinib: The promising actor in the next season of the Amyotrophic Lateral Sclerosis treatment series. Biomed Pharmacother 2023; 160:114378. [PMID: 36774721 DOI: 10.1016/j.biopha.2023.114378] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/25/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease with high mortality and morbidity rate affecting both upper and lower motor neurons (MN). Muscle force reduction, behavioral change, pseudobulbar affect, and cognitive impairments are the most common clinical manifestations of ALS. The main physiopathology of ALS is still unclear, though several studies have identified that oxidative stress, proteinopathies, glutamate-related excitotoxicity, microglial activation, and neuroinflammation may be involved in the pathogenesis of ALS. From 1995 until October 2022, only Riluzole, Dextromethorphan Hydrobromide (DH) with Quinidine sulfate (Q), Edaravone, and Sodium phenylbutyrate with Taurursodiol (PB/TUDCO) have achieved FDA approval for ALS treatment. Despite the use of these four approved agents, the survival rate and quality of life of ALS patients are still low. Thus, finding novel treatments for ALS patients is an urgent requirement. Masitinib, a tyrosine kinase inhibitor, emphasizes the neuro-inflammatory activity of ALS by targeting macrophages, mast cells, and microglia cells. Masitinib downregulates the proinflammatory cytokines, indirectly reduces inflammation, and induces neuroprotection. Also, it was effective in phase 2/3 and 3 clinical trials (CTs) by increasing overall survival and delaying motor, bulbar, and respiratory function deterioration. This review describes the pathophysiology of ALS, focusing on Masitinib's mechanism of action and explaining why Masitinib could be a promising actor in the treatment of ALS patients. In addition, Masitinib CTs and other competitor drugs in phase 3 CTs have been discussed.
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Affiliation(s)
| | - Rojin Chegini
- Metabolic Liver Disease Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shirin Barati
- Department of Anatomy, Saveh University of Medical Sciences, Saveh, Iran
| | - Fatemeh Tahmasebi
- Department of Anatomy, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bardia Moghisseh
- Student Research Committee, Arak University of Medical Sciences, Arak, Iran
| | - Mohammad Taghi Joghataei
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran; Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Faezeh Faghihi
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Fereshteh Azedi
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran; Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Panyarath P, Adam V, Kimoff RJ, Kaminska M. Alveolar Ventilation-Targeted Versus Spontaneous/Timed Mode for Home Noninvasive Ventilation in Amyotrophic Lateral Sclerosis. Respir Care 2022; 67:1109-1120. [PMID: 35246497 PMCID: PMC9994340 DOI: 10.4187/respcare.09580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Home noninvasive ventilation (NIV) is increasingly used in amyotrophic lateral sclerosis (ALS) to improve symptoms and survival. Our primary objective was to compare intelligent volume-assured pressure support (iVAPS) versus spontaneous/timed (S/T) modes regarding time to first change in ventilator parameters and the number of interventions over 6 months in subjects with ALS in a respiratory therapist (RT)-led program. METHODS In this study, 30 subjects with ALS meeting criteria for NIV initiation were randomized to iVAPS or S/T. NIV was initiated using standardized protocols targeting optimal tidal volume and comfort in a daytime session. Download data were recorded at 1 week and 1 and 6 months. Any changes in ventilator parameters were recorded. RESULTS Of the 30 subjects, 56.7% had bulbar onset ALS, 8 died, and 11 in each group completed the study. Median time to first parameter change was 33.5 (interquartile range [IQR] 7.7-96.0) d versus 41.0 (IQR 12.5-216.5) d for iVAPS versus S/T groups, respectively, (P = .48). The average number of RT interventions was similar between groups (1.1 ± 1.1 vs 0.9 ± 0.9 at 1 month, P = .72; 2.4 ± 2.1 vs 2.4 ± 2.3 at 6 months, P = .95, for iVAPS vs S/T, respectively). Adherence was significantly lower with iVAPS than S/T at 1 week but not at 1 or 6 months. Download parameters were similar between groups at 1 week and 6 months except for higher residual apnea-hypopnea index (AHI) and less spontaneously triggered breaths with iVAPS at 6 months. CONCLUSIONS The time to first change of parameters and the number of interventions at 6 months from NIV initiation were similar for the iVAPS and S/T modes in subjects with ALS. With iVAPS, adherence was lower transiently at NIV initiation, and the residual AHI was higher at 6 months. Alveolar ventilation-targeted NIV may require a longer adaptation period and result in greater upper-airway instability predominantly in patients with bulbar ALS.
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Affiliation(s)
- Pattaraporn Panyarath
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; and Division of Respiratory and Respiratory Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Veronique Adam
- Quebec National Program for Home Ventilatory Assistance, McGill University Health Centre, Montreal, Quebec, Canada
| | - R John Kimoff
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; and Center for Research Outcomes Evaluation, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marta Kaminska
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada; Center for Research Outcomes Evaluation, McGill University Health Centre, Montreal, Quebec, Canada; and Quebec National Program for Home Ventilatory Assistance, McGill University Health Centre, Montreal, Quebec, Canada
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Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review. Anaesth Intensive Care 2022; 50:345-360. [DOI: 10.1177/0310057x211065042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Amyotrophic lateral sclerosis, or motor neuron disease, is an uncommon progressive neurological disorder. Professionals working in the perioperative field may encounter patients with amyotrophic lateral sclerosis only rarely. The relevant published literature on amyotrophic lateral sclerosis is broad in scope, but a contemporary review focused on the perioperative period is absent. This structured narrative review seeks to provide a summary of the contemporary management of patients and then focuses on eliciting if there are perioperative management considerations specific to amyotrophic lateral sclerosis that can be optimised. A comprehensive structured narrative literature review, including grey literature searching, indicated worsening ventilatory failure is of prime concern but that patients may present with a broad range of neurological symptoms, and that cardiovascular and cognitive dysfunction specific to amyotrophic lateral sclerosis may exist and be occult. Exacerbation of neuromuscular weakness during the perioperative period is multifaceted and requires the application of a high standard of the core principles of surgical and anaesthetic management of neuromuscular disease. Standard perioperative approaches require rigorous attention and potential exists for significant alteration. There is a potential high risk of postoperative increased morbidity from neurological decline and mortality from pulmonary complications. A meticulous approach to planning preoperative assessment, shared decision-making, intraoperative and postoperative care is required.
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Wang Y, Yang X, Han Q, Liu M, Zhou C. Prevalence of Sialorrhea Among Amyotrophic Lateral Sclerosis Patients: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2022; 63:e387-e396. [PMID: 34920148 DOI: 10.1016/j.jpainsymman.2021.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative motor neuron disease (MND), and sialorrhea is a known symptom in patients with ALS, which may cause a social embarrassment and discomfort. However, people do not pay attention to sialorrhea up to now. This study is aimed at conducting a systematic review and meta-analysis of the pooled prevalence of sialorrhea in ALS patients all around the world and raising awareness of salivation. METHODS We searched PubMed and EMBASE databases to obtain the comprehensive literatures which reported the prevalence of sialorrhea. We used AHRQ and NOS to evaluate the literature quality. Subgroup analyses were performed based on screening instruments and severity of sialorrhea. At the meantime, sensitivity analyses was also conducted to identify the source of heterogeneity. RESULTS A total of 17 eligible studies which included 21 groups of data reported prevalence of sialorrhea. The pooled prevalence of sialorrhea among ALS patients was 30.8% (95% CI: 20.0%-44.2%). For studies using ALSFRS-R, direct questioning, postal survey, and ALSSoL average and ALSFRS-R, the pooled prevalence of sialorrhea was 22.7%, 25.8%, 29.8% and 52.0% respectively. According to the severity of sialorrhea, the prevalence of mild, moderate, and severe sialorrhea were 25.1%, 11.2%, and 10.5%, respectively. And none of the studies alone had a significant effect on the overall prevalence of sialorrhea after we eliminated each study separately in sensitivity analyses. CONCLUSIONS Sialorrhea is a relatively common symptom in ALS patients with a comparatively high prevalence. In our study, we found that the prevalence of sialorrhea in ALS patients is relatively higher than the results based on direct questioning or postal survey. Therefore, we deduced that sialorrhea should be evaluated by more complex professional assessment scales to improve the quality of life and improve early prognosis of disease.
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Affiliation(s)
- Yao Wang
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
| | - Xiaoyu Yang
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Qun Han
- Department of Orthopedics, (Q.H.) Xianggong Central Health Center, Linyi, Shandong Province, China
| | - Min Liu
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Chang Zhou
- Department of Neurology, (Y.W., X.Y., M.L.) The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China.
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Su XW, Simmons Z. Laryngospasm: A Frequently Underrecognized Symptom in Amyotrophic Lateral Sclerosis. Muscle Nerve 2022; 65:367-368. [PMID: 35092060 DOI: 10.1002/mus.27510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Xiaowei W Su
- Department of Neurology, Penn State Health M.S. Hershey Medical Center, Hershey, Pennsylvania
| | - Zachary Simmons
- Department of Neurology, Penn State Health M.S. Hershey Medical Center, Hershey, Pennsylvania
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Oskarsson B, Maragakis N, Bedlack RS, Goyal N, Meyer JA, Genge A, Bodkin C, Maiser S, Staff N, Zinman L, Olney N, Turnbull J, Brooks BR, Klonowski E, Makhay M, Yasui S, Matsuda K. MN-166 (ibudilast) in amyotrophic lateral sclerosis in a Phase IIb/III study: COMBAT-ALS study design. Neurodegener Dis Manag 2021; 11:431-443. [PMID: 34816762 DOI: 10.2217/nmt-2021-0042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with motor neuron loss as a defining feature. Despite significant effort, therapeutic breakthroughs have been modest. MN-166 (ibudilast) has demonstrated neuroprotective action by various mechanisms: inhibition of proinflammatory cytokines and macrophage migration inhibitory factor, phosphodiesterase inhibition, and attenuation of glial cell activation in models of ALS. Early-phase studies suggest that MN-166 may improve survival outcomes and slow disease progression in patients with ALS. This article describes the rationale and design of COMBAT-ALS, an ongoing randomized, double-blind, placebo-controlled, multicenter Phase IIb/III study in ALS. This study is designed to evaluate the pharmacokinetics, safety and tolerability and assess the efficacy of MN-166 on function, muscle strength, quality of life and survival in ALS.
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Affiliation(s)
| | | | | | - Namita Goyal
- Department of Neurology, University California Irvine, Irvine, CA, USA
| | - Jenny A Meyer
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Angela Genge
- Montreal Neurological Institute, Montreal, Quebec, Canada
| | - Cynthia Bodkin
- Department of Neurology, University of Indiana, Indianapolis, IN, USA
| | - Samuel Maiser
- Department of Neurology, Hennepin County Hospital, Minneapolis, MN, USA
| | - Nathan Staff
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Lorne Zinman
- Department of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - John Turnbull
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | - Seiichi Yasui
- Faculty of Science and Technology, Department of Industrial Administration, University of Tokyo, Japan
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A Multi-Center Cohort Study on Characteristics of Pain, Its Impact and Pharmacotherapeutic Management in Patients with ALS. J Clin Med 2021; 10:jcm10194552. [PMID: 34640573 PMCID: PMC8509485 DOI: 10.3390/jcm10194552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/20/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Although pain is common in amyotrophic lateral sclerosis (ALS) and an effectively treatable symptom, it is widely under-recognized and undertreated. This study investigates epidemiological and clinical characteristics of pain, its impact and pharmacological treatment in ALS patients. In addition, opportunities for further optimization of pain therapy need to be identified. Methods: Patients from three German ALS outpatient clinics were asked to complete the Brief Pain Inventory and the ALS Functional Rating Scale—Extension and to participate in semi-structured telephone interviews. Results: Of the 150 study participants, 84 patients reported pain. Pain occurred across all disease stages, predominantly in the neck, back and lower extremities. It was described with a broad spectrum of pain descriptors and mostly interfered with activity-related functions. Of the 84 pain patients, 53.8% reported an average pain intensity ≥4 on the numerical rating scale (NRS), indicating pain of at least moderate intensity, and 64.3% used pain medication. Irrespective of the medication type, 20.4% of them had no sufficient pain relief. Thirteen out of 30 patients without pain medication reported an average NRS value ≥4. Eleven of them—mainly in the context of high pain interference with daily functions—were supposed to benefit from adequate pain therapy. However, many patients had relevant concerns and misconceptions about pain therapy. Conclusion: Given the frequency, extent and multi-faceted impact of pain, it is necessary to systematically assess pain throughout the disease course. Potentials to optimize pain therapy were seen in the subset of patients with insufficient pain relief despite medication and in those patients without pain medication but high pain interference. However, there is a need to respond to patients’ barriers to pain therapy.
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Chowdhury A, Mukherjee A, Sinharoy U, Pandit A, Biswas A. Non-Motor Features of Amyotrophic Lateral Sclerosis: A Clinic-based Study. Ann Indian Acad Neurol 2021; 24:745-753. [PMID: 35002134 PMCID: PMC8680868 DOI: 10.4103/aian.aian_51_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/31/2021] [Accepted: 03/08/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of motor neurons. Spread of pathology to other brain areas leads to development of non-motor symptoms (NMSs). These usually remain undiagnosed because of overwhelming motor problem and are responsible for significant distress to the patient. Our objective was to explore the burden of various NMSs of patients with ALS, compare between limb-onset and bulbar-onset patients, and to correlate with severity and duration of disease. Methods: Fifty patients with ALS diagnosed according to revised El Escorial Criteria and 50 healthy controls were included in this study. They were assessed with NMS Questionnaire, Beck's Depression Inventory, Center for Neurologic Study-Lability Scale, Drooling Frequency and Severity Scale, Epworth Sleepiness scale, Bengali Mental State Examination, and Frontal Assessment Battery and relevant statistical analyses were carried out. Results: The patients with ALS had significantly increased prevalence of almost all NMSs compared to controls. There was also significant increase in depression, suicidal ideation, pseudobulbar affect, and daytime sleepiness in patients with ALS. The bulbar onset subgroup had significantly increased daytime drooling, dysphagia, nausea and vomiting, whereas the limb onset subgroup reported increased frequency of leg swelling. Executive dysfunction was detected in 24% of patients with ALS and 9.8% had mild cognitive impairment. Weight loss, frequency of falling, insomnia, unpleasant nocturnal leg sensations, difficulty having sex, depression, and cognitive impairment increased significantly with an increase in severity of the disease. Conclusion: NMSs were significantly more prevalent in patients with ALS. Some NMSs worsened with advancement of the disease.
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Affiliation(s)
- Abhishek Chowdhury
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Adreesh Mukherjee
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Uma Sinharoy
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Atanu Biswas
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGME&R) and Bangur Institute of Neurosciences, Kolkata, West Bengal, India
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13
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Alam M, Yadav RK, Minj E, Tiwari A, Mehan S. Exploring Molecular Approaches in Amyotrophic Lateral Sclerosis: Drug Targets from Clinical and Pre-Clinical Findings. Curr Mol Pharmacol 2021; 14:263-280. [PMID: 32342825 DOI: 10.2174/1566524020666200427214356] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/24/2019] [Accepted: 12/26/2019] [Indexed: 11/22/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease (MND) characterized by the death of upper and lower motor neurons (corticospinal tract) in the motor cortex, basal ganglia, brain stem, and spinal cord. The patient experiences the sign and symptoms between 55 to 75 years of age, which include impaired motor movement, difficulty in speaking and swallowing, grip loss, muscle atrophy, spasticity, and sometimes associated with memory and cognitive impairments. Median survival is 3 to 5 years after diagnosis and 5 to 10% of the patients live for more than 10 years. The limited intervention of pharmacologically active compounds, that are used clinically, is majorly associated with the narrow therapeutic index. Pre-clinically established experimental models, where neurotoxin methyl mercury mimics the ALS like behavioural and neurochemical alterations in rodents associated with neuronal mitochondrial dysfunctions and downregulation of adenyl cyclase mediated cAMP/CREB, is the main pathological hallmark for the progression of ALS in central as well in the peripheral nervous system. Despite the considerable investigation into neuroprotection, it still constrains treatment choices to strong care and organization of ALS complications. Therefore, this current review specially targeted the investigation of clinical and pre-clinical features available for ALS to understand the pathogenic mechanisms and to explore the pharmacological interventions associated with the up-regulation of intracellular adenyl cyclase/cAMP/ CREB and activation of mitochondrial-ETC coenzyme-Q10 as a future drug target in the amelioration of ALS mediated motor neuronal dysfunctions.
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Affiliation(s)
- Mamtaj Alam
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Rajeshwar K Yadav
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Elizabeth Minj
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Aarti Tiwari
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Sidharth Mehan
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
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14
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Mori T, Miyagaki T, Kishi A, Takeuchi S, Kobayashi M, Araki Y, Nakamura N, Koike J, Kadono T. Stewart-Treves syndrome associated with disuse edema in amyotrophic lateral sclerosis. J Dermatol 2021; 48:e443-e444. [PMID: 34058020 DOI: 10.1111/1346-8138.16004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/30/2021] [Accepted: 05/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Toko Mori
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Tomomitsu Miyagaki
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Arisa Kishi
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Sora Takeuchi
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | | | | | - Naoki Nakamura
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Junki Koike
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takafumi Kadono
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
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15
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Forbes J, Humbert I. Impact of the Chin-Down Posture on Temporal Measures of Patients With Dysphagia: A Pilot Study. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:1049-1060. [PMID: 33945295 PMCID: PMC8702847 DOI: 10.1044/2021_ajslp-19-00223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/11/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Purpose The chin-down position is a commonly prescribed posture by health care professionals to alleviate the symptoms of dysphagia. Yet, how the technique influences swallowing physiology lacks clarity. Our goal was to examine the impact of the postural technique on patients with various medical conditions and swallowing impairments. Method Temporal and functional measures were examined with videofluoroscopy in the chin-down and neutral head position on 15 patients. Also, timing differences between head positions were examined to determine the presence of improvement during the chin-down posture. Results The primary finding was chin-down posture swallows prolonged the elapsed time between when the prematurely spilled bolus entered the pharynx relative to swallow onset compared to the neutral head position (p = .006). Also, no improvement in airway protection was found when performing the postural technique. Conclusions The chin-down posture may benefit patients with specific swallowing impairments. However, the general use of the technique for all patients who experience swallowing difficulty might be negligent and could potentially have adverse or no effect on patient outcomes. Future studies examining patients with the same pathophysiology are needed to understand the benefit of the chin-down posture based on swallowing impairment.
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Affiliation(s)
- Jessica Forbes
- Department of Communication Sciences and Disorders, Howard University, Washington, DC
| | - Ianessa Humbert
- Department of Communication Sciences and Disorders, The University of Iowa, Iowa City
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16
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Eljas Ahlberg E, Axelsson B. End-of-life care in amyotrophic lateral sclerosis: A comparative registry study. Acta Neurol Scand 2021; 143:481-488. [PMID: 33141927 DOI: 10.1111/ane.13370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/25/2020] [Accepted: 10/24/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a fatal disease requiring palliative care. End-of-life care has been well studied in patients with incurable cancer, but less is known about the quality of such care for patients with ALS. AIM To study whether the quality of end-of-life care the last week in life for patients dying from ALS differed compared to patients with cancer in terms of registered symptoms, symptom management, and communication. DESIGN This retrospective comparative registry study used data from the Swedish Registry of Palliative Care for 2012-2016. Each patient with ALS (n = 825) was matched to 4 patients with cancer (n = 3,300). RESULTS Between-group differences in assessments for pain and other symptoms were significant (p < 0.01), and patients with ALS had fewer as-needed injection drugs prescribed than patients with cancer. Patients with ALS also had dyspnea and anxiety significantly more often than patients with cancer. There was no significant difference in communication about transition to end-of-life care between the two groups. Patients dying from ALS received artificial nutrition on their last day of life significantly more often than patients with cancer. CONCLUSIONS The results indicate that patients with ALS receive poorer end-of-life care than patients dying from cancer in terms of validated symptom assessments, prescription of as-needed drugs, and timely cessation of artificial nutrition. Educational efforts seem needed to facilitate equal care of dying patients, regardless of diagnosis.
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Affiliation(s)
| | - Bertil Axelsson
- Unit of Clinical Research Centre Östersund Umeå University Umeå Sweden
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17
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Abstract
Amyotrophic lateral sclerosis is a progressive neurodegenerative disease involving upper and lower motor neurons and has limited treatment options. The weakness progresses to involve the diaphragms, resulting in respiratory failure and death. Home noninvasive ventilation has been shown to improve survival and quality of life, especially in those with intact bulbar function. Once initiated, close monitoring with nocturnal oximetry, remote downloads from the home noninvasive ventilation machine, and measurement of serum bicarbonate should be conducted. Additionally, transcutaneous CO2 monitoring can be considered if available. This article discusses the indications, timing, initiation, and management of noninvasive ventilation in amyotrophic lateral sclerosis.
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Affiliation(s)
- Jessica A Cooksey
- Northwestern University, 1475 East Belvidere Road, Suite 185, Grayslake, IL 60030, USA
| | - Amen Sergew
- Division of Pulmonary, Critical Care and Sleep Medicine, Section of Critical Care Medicine, Department of Medicine, National Jewish Health, 1400 Jackson Street, B140, Denver, CO 80207, USA.
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18
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Boddy SL, Giovannelli I, Sassani M, Cooper-Knock J, Snyder MP, Segal E, Elinav E, Barker LA, Shaw PJ, McDermott CJ. The gut microbiome: a key player in the complexity of amyotrophic lateral sclerosis (ALS). BMC Med 2021; 19:13. [PMID: 33468103 PMCID: PMC7816375 DOI: 10.1186/s12916-020-01885-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Much progress has been made in mapping genetic abnormalities linked to amyotrophic lateral sclerosis (ALS), but the majority of cases still present with no known underlying cause. Furthermore, even in families with a shared genetic abnormality there is significant phenotypic variability, suggesting that non-genetic elements may modify pathogenesis. Identification of such disease-modifiers is important as they might represent new therapeutic targets. A growing body of research has begun to shed light on the role played by the gut microbiome in health and disease with a number of studies linking abnormalities to ALS. MAIN BODY The microbiome refers to the genes belonging to the myriad different microorganisms that live within and upon us, collectively known as the microbiota. Most of these microbes are found in the intestines, where they play important roles in digestion and the generation of key metabolites including neurotransmitters. The gut microbiota is an important aspect of the environment in which our bodies operate and inter-individual differences may be key to explaining the different disease outcomes seen in ALS. Work has begun to investigate animal models of the disease, and the gut microbiomes of people living with ALS, revealing changes in the microbial communities of these groups. The current body of knowledge will be summarised in this review. Advances in microbiome sequencing methods will be highlighted, as their improved resolution now enables researchers to further explore differences at a functional level. Proposed mechanisms connecting the gut microbiome to neurodegeneration will also be considered, including direct effects via metabolites released into the host circulation and indirect effects on bioavailability of nutrients and even medications. CONCLUSION Profiling of the gut microbiome has the potential to add an environmental component to rapidly advancing studies of ALS genetics and move research a step further towards personalised medicine for this disease. Moreover, should compelling evidence of upstream neurotoxicity or neuroprotection initiated by gut microbiota emerge, modification of the microbiome will represent a potential new avenue for disease modifying therapies. For an intractable condition with few current therapeutic options, further research into the ALS microbiome is of crucial importance.
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Affiliation(s)
- Sarah L Boddy
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Ilaria Giovannelli
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Matilde Sassani
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Johnathan Cooper-Knock
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Michael P Snyder
- Stanford Center for Genomics and Personalized Medicine, Stanford University School of Medicine, Stanford, USA
| | - Eran Segal
- Department of Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel
| | - Eran Elinav
- Department of Immunology, Weizmann Institute of Science, Rehovot, Israel
- Division of Cancer-Microbiome Research, DKFZ, Heidelberg, Germany
| | - Lynne A Barker
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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19
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Gotkine M, Kviatcovsky D, Elinav E. Amyotrophic lateral sclerosis and intestinal microbiota-toward establishing cause and effect. Gut Microbes 2020; 11:1833-1841. [PMID: 32501768 PMCID: PMC7524331 DOI: 10.1080/19490976.2020.1767464] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The intestinal microbiota may be involved, through metabolic gut-brain interactions, in a variety of neurological conditions. In this addendum, we summarize the findings of our recent study investigating the potentially modulatory influence of the microbiome in a transgenic ALS mouse model, and the possible application to human disease. We found that transgenic mice show evidence of dysbiosis, even at the pre-symptomatic stage, and have a more severe disease course under germ-free conditions or after receiving broad-spectrum antibiotics. We demonstrated that Akkermansia muciniphila ameliorated the disease in mice and that this may be due to the production of nicotinamide. We then conducted a preliminary study in human ALS and identified functionally similar alterations within the metagenome. Furthermore, we found that patients with ALS had lower systemic and CSF levels of nicotinamide, suggesting that the changes observed in the mouse model may be relevant to human disease.
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Affiliation(s)
- Marc Gotkine
- Neuromuscular/EMG Service and ALS/Motor Neuron Disease Clinic, Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel,CONTACT Marc Gotkine Neuromuscular/EMG Service and ALS/Motor Neuron Disease Clinic, Hadassah - Hebrew University Medical Center, Jerusalem9112001, Israel
| | | | - Eran Elinav
- Immunology Department, Weizmann Institute of Science, Rehovot, Israel,Division of Cancer-Microbiome Research, DKFZ, Heidelberg, Germany
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20
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Brown J. Tracheostomy to Noninvasive Ventilation: From Acute Care to Home. Sleep Med Clin 2020; 15:593-598. [PMID: 33131668 DOI: 10.1016/j.jsmc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The number of patients experiencing prolonged mechanical ventilation is increasing over time. Patients who have a tracheostomy placed in a critical care setting have been described as having an average of 4 separate transitions between the acute care setting, long-term acute care (LTAC), and home. Transition points can be problematic if not addressed adequately; however, proactive planning can optimize patient care. Individual patient factors will determine if the patient will require long-term tracheostomy, transitioned to noninvasive positive pressure ventilation, or able to be decannulated. Patients and caregivers should be included in transition planning to optimize outcomes.
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Affiliation(s)
- Jeanette Brown
- Division of Pulmonary Medicine, University of Utah, 26 North 1900 East, Salt Lake City, UT 84132, USA.
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21
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Zhao C, Lange DJ, Wymer JP. Management of Primary Lateral Sclerosis. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal disease with no cure; however, symptomatic management has an impact on quality of life and survival. Symptom management is best performed in a multidisciplinary care setting, where patients are evaluated by multiple health care professionals. Respiratory failure is a significant cause of morbidity and mortality in patients with ALS. Early initiation of noninvasive ventilation can prolong survival, and adequate use of airway clearance techniques can prevent respiratory infections. Preventing and treating weight loss caused by dysphagia may slow down disease progression, and expert management of spasticity from upper motor neuron dysfunction enhances patient well-being.
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Affiliation(s)
- Jonathan R Brent
- Department of Neurology, Feinberg School of Medicine, Northwestern University, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Colin K Franz
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Neurology, Shirley Ryan AbilityLab, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John M Coleman
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Senda Ajroud-Driss
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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23
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Darbà J. Current status and direct medical cost of amyotrophic lateral sclerosis in the region of Catalonia: A population-based analysis. PLoS One 2019; 14:e0223772. [PMID: 31603947 PMCID: PMC6788732 DOI: 10.1371/journal.pone.0223772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/27/2019] [Indexed: 12/14/2022] Open
Abstract
Introduction Amyotrophic lateral sclerosis is a neurodegenerative disease that leads to motor weakness. There is no cure, and treatment focuses on slowing down progression, which is achieved by a multidisciplinary approach. Hence, it is vital to understand the population needs for an optimal management of the disease. Objectives To evaluate the current status of amyotrophic lateral sclerosis in the region of Catalonia, how the disease is managed and its direct medical costs. Methods Records corresponding to 841 patients diagnosed between the year 2007 and 2017 were analysed in a retrospective population-based study, including data from primary care centres, hospitals (inpatient and outpatient care), extended care facilities and mental health centres. Results Mean diagnosis age was 66.11 years (SD = 12.61) and 52.79% of admitted patients were males. On average, 14.91 months elapsed between diagnosis and death, and the mean age of death was 72.64 years (SD = 12.00). Patients were admitted 10.70 times per year, mostly into primary care (86.50%), although most expenses were concentrated in hospital inpatient care. The mean cost per patient per year was €1,168. The 83.24% of patients had more than 4 systems affected by chronic conditions. Conclusions Primary care is of utmost importance in ALS attention in Catalonia, which may have a direct impact in reducing hospitalisation costs. Nonetheless, the expenses linked to inpatient care represent the biggest portion of total costs. Patients’ healthcare usage patterns and the high proportion of patients with multiple chronic conditions should be taken into account in order to adapt and improve guidelines and healthcare systems.
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Affiliation(s)
- Josep Darbà
- Universitat de Barcelona, Barcelona, Spain
- * E-mail:
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24
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Gajewski BJ, Statland J, Barohn R. Using Adaptive Designs to Avoid Selecting the Wrong Arms in Multiarm Comparative Effectiveness Trials. Stat Biopharm Res 2019; 11:375-386. [PMID: 31839873 DOI: 10.1080/19466315.2019.1610044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Limited resources are a challenge when planning comparative effectiveness studies of multiple promising treatments, often prompting study planners to reduce the sample size to meet the financial constraints. The practical solution is often to increase the efficiency of this sample size by selecting a pair of treatments among the pool of promising treatments before the clinical trial begins. The problem with this approach is that the investigator may inadvertently leave out the most beneficial treatment. This paper demonstrates a possible solution to this problem by using Bayesian adaptive designs. We use a planned comparative effectiveness clinical trial of treatments for sialorrhea in amyotrophic lateral sclerosis as an example of the approach. Rather than having to guess at the two best treatments to compare based on limited data, we suggest putting more arms in the trial and letting response adaptive randomization (RAR) determine better arms. To ground this study relative to previous literature we first compare RAR, adaptive equal randomization (ER), arm(s) dropping, and a fixed design. Given the goals of this trial we demonstrate that we may avoid 'type III errors' - inadvertently leaving out the best treatment - with little loss in power compared to a two-arm design, even when choosing the correct two arms for the two-armed design. There are appreciable gains in power when the two arms are prescreened at random.
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Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Mail Stop 2012, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| | - Richard Barohn
- Department of Neurology, University of Kansas Medical Center, Mail Stop 2012, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
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25
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Theme 14 Palliative care and decision making. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:375-388. [DOI: 10.1080/21678421.2018.1510584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Fiorentino G, Annunziata A, Gaeta AM, Lanza M, Esquinas A. Continuous noninvasive ventilation for respiratory failure in patients with amyotrophic lateral sclerosis: current perspectives. Degener Neurol Neuromuscul Dis 2018; 8:55-61. [PMID: 30233272 PMCID: PMC6130289 DOI: 10.2147/dnnd.s170771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Respiratory failure is a recognized late complication of amyotrophic lateral sclerosis. It is related to the neurological progression of the diseases with the impairment of the respiratory musculature. Survival and quality of life of amyotrophic lateral sclerosis patients is improved by using noninvasive mechanical ventilation. The rate of long-term mechanical ventilation is different within and between countries. Cultural factors, socioeconomic conditions, and physician attitude often influence the decision to start noninvasive ventilation. Technical elements, like the choice of the correct interface, solid caregivers support, and the communication between the patient and the physician are essential for achieving therapeutic goals, especially in the case of continuous treatment.
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Affiliation(s)
| | - Anna Annunziata
- Division of Respiratory Physiopathology, Monaldi Hospital, Naples, Italy,
| | - Anna Michela Gaeta
- Respiratory Department, Arnau de Vilanova and Santa Maria Universitary Hospital, IRBLleida, Lleida, Spain
| | - Maurizia Lanza
- Division of Respiratory Physiopathology, Monaldi Hospital, Naples, Italy,
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Abstract
PURPOSE OF REVIEW Although there is no cure for motor neurone disease (MND), the advent of multidisciplinary care and neuroprotective agents has improved treatment interventions and enhanced quality of life for MND patients and their carers. RECENT FINDINGS Evidence-based multidisciplinary care, respiratory management and disease-modifying therapy have improved the outcomes of patients diagnosed with MND. Supportive approaches to nutritional maintenance and optimization of symptomatic treatments, including management of communication and neuropsychiatric issues, improve the quality of life for MND patients. SUMMARY Recent progress in the understanding of the clinical, pathophysiological and genetic heterogeneity of MND has improved the approach of clinicians to treatment. Notwithstanding improvement to care and quality of life, survival benefit has become evident with the advent of a multidisciplinary care framework, early treatment with riluzole and noninvasive ventilation. Weight maintenance remains critical, with weight loss associated with more rapid disease progression. The end-of-life phase is poorly defined and treatment is challenging, but effective symptom control through palliative care is achievable and essential. Encouragingly, current progress of clinical trials continues to close the gap towards the successful development of curative treatment in MND.
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Dieplinger A, Kundt FS, Lorenzl S. Palliative care nursing for patients with neurological diseases: what makes the difference? ACTA ACUST UNITED AC 2017; 26:356-359. [PMID: 28345980 DOI: 10.12968/bjon.2017.26.6.356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neurodegenerative diseases progress slowly, creating increasing physical disability with unpredictable disease trajectories. The disease's life-threatening nature often places these patients in palliative care. There are several factors that complicate the care of patients with neurodegenerative diseases in palliative care units. Owing to physical impairments, there are many communication barriers between patients and staff. Nurses are not able to duplicate the patient's meticulous daily routine leading to caregiver mistrust in the nurse's competencies. Even if the patient is hospitalised, caregivers may not take the much-needed time off to recuperate. The placement of patients with neurodegenerative diseases in palliative care is confusing, since they rarely die during in-hospital treatment but might even get better due to multidisciplinary treatment. Finally, patients and caregivers lack adequate knowledge about disease progression and available help and support programmes. Patients with neurodegenerative diseases urgently need palliative care and nurses and caregivers need better preparation to appropriately deal with these diseases.
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Affiliation(s)
- Anna Dieplinger
- Research Associate, Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Firuzan Sari Kundt
- Research Associate, Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Stefan Lorenzl
- Professor for Palliative Care and Professor for Neurology, Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
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29
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Hogden A, Foley G, Henderson RD, James N, Aoun SM. Amyotrophic lateral sclerosis: improving care with a multidisciplinary approach. J Multidiscip Healthc 2017; 10:205-215. [PMID: 28579792 PMCID: PMC5446964 DOI: 10.2147/jmdh.s134992] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease, leading to death within an average of 2–3 years. A cure is yet to be found, and a single disease-modifying treatment has had a modest effect in slowing disease progression. Specialized multidisciplinary ALS care has been shown to extend survival and improve patients’ quality of life, by providing coordinated interprofessional care that seeks to address the complex needs of this patient group. This review examines the nature of specialized multidisciplinary care in ALS and draws on a broad range of evidence that has shaped current practice. The authors explain how multidisciplinary ALS care is delivered. The existing models of care, the role of palliative care within multidisciplinary ALS care, and the costs of formal and informal care are examined. Critical issues of ALS care are then discussed in the context of the support rendered by multidisciplinary-based care. The authors situate the patient and family as key stakeholders and decision makers in the multidisciplinary care network. Finally, the current challenges to the delivery of coordinated interprofessional care in ALS are explored, and the future of coordinated interprofessional care for people with ALS and their family caregivers is considered.
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Affiliation(s)
- Anne Hogden
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Geraldine Foley
- Discipline of Occupational Therapy, School of Medicine, Trinity College Dublin, the University of Dublin, Republic of Ireland
| | | | - Natalie James
- Motor Neurone Disease (MND) Service, Communication and Assistive Technology (CAT) Clinic, St Joseph's Hospital, St Vincent's Health Network, Sydney, NSW
| | - Samar M Aoun
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
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30
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Petrov D, Mansfield C, Moussy A, Hermine O. ALS Clinical Trials Review: 20 Years of Failure. Are We Any Closer to Registering a New Treatment? Front Aging Neurosci 2017; 9:68. [PMID: 28382000 PMCID: PMC5360725 DOI: 10.3389/fnagi.2017.00068] [Citation(s) in RCA: 286] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 03/06/2017] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating condition with an estimated mortality of 30,000 patients a year worldwide. The median reported survival time since onset ranges from 24 to 48 months. Riluzole is the only currently approved mildly efficacious treatment. Riluzole received marketing authorization in 1995 in the USA and in 1996 in Europe. In the years that followed, over 60 molecules have been investigated as a possible treatment for ALS. Despite significant research efforts, the overwhelming majority of human clinical trials (CTs) have failed to demonstrate clinical efficacy. In the past year, oral masitinib and intravenous edaravone have emerged as promising new therapeutics with claimed efficacy in CTs in ALS patients. Given their advanced phase of clinical development one may consider these drugs as the most likely near-term additions to the therapeutic arsenal available for patients with ALS. In terms of patient inclusion, CT with masitinib recruited a wider, more representative, less restrictive patient population in comparison to the only successful edaravone CT (edaravone eligibility criteria represents only 18% of masitinib study patients). The present manuscript reviews >50 CTs conducted in the last 20 years since riluzole was first approved. A special emphasis is put on the analysis of existing evidence in support of the clinical efficacy of edaravone and masitinib and the possible implications of an eventual marketing authorisation in the treatment of ALS.
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Affiliation(s)
| | | | | | - Olivier Hermine
- AB ScienceParis, France
- Imagine Institute, Necker HospitalParis, France
- INSERM, Laboratory of Cellular and Molecular Mechanisms of Hematological Disorders and Therapeutic Implications, UMR 1163Paris, France
- Imagine Institute, Paris Descartes–Sorbonne Paris Cité UniversityParis, France
- CNRS, ERL 8254Paris, France
- Laboratory of Excellence GR-ExParis, France
- Equipe Labélisée par la Ligue Nationale Contre le CancerParis, France
- Department of Hematology, Necker HospitalParis, France
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31
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Kim GH. Edematous Hyponatremia Treated with Tolvaptan in a Patient with Amyotrophic Lateral Sclerosis. Electrolyte Blood Press 2017; 15:37-41. [PMID: 29399022 PMCID: PMC5788813 DOI: 10.5049/ebp.2017.15.2.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/13/2017] [Indexed: 11/24/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) patients rarely present with either syndrome of inappropriate antidiuretic hormone secretion or generalized edema. Tolvaptan is a selective vasopressin V2 receptor antagonist that produces effective aquaresis, and its use in ALS patients has not been previously reported. A 50-year-old male ALS patient was admitted because of both generalized edema and dilutional hyponatremia. These manifestations were refractory to conventional diuretics and fluid therapy, but a very brisk diuresis was induced by tolvaptan administration. Edema and hyponatremia were also improved, and the patient was able to be discharged without tolvaptan. In this case report, we postulate how edema and dilutional hyponatremia developed in the patient, and discuss the mechanism of tolvaptan in treating hypervolemic hyponatremia. Further experience is necessary to evaluate the usefulness of tolvaptan in patients with neurological disorders.
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Affiliation(s)
- Gheun-Ho Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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32
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Orsini M, Nascimento OJ, Matta AP, Reis CHM, de Souza OG, Bastos VH, Moreira R, Ribeiro P, Fiorelli S, Novellino P, Pessoa B, Cunha M, Pupe C, Morales PS, Filho PFM, Trajano EL, Oliveira AB. Revisiting the Term Neuroprotection in Chronic and Degenerative Diseases. Neurol Int 2016; 8:6311. [PMID: 27127599 PMCID: PMC4830365 DOI: 10.4081/ni.2016.6311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/01/2016] [Indexed: 11/25/2022] Open
Abstract
Thanks to the development of several new researches, the lifetime presented a significant increase, even so, we still have many obstacles to overcome - among them, manage and get responses regarding neurodegenerative diseases. Where we are in the understanding of neuroprotection? Do we really have protective therapies for diseases considered degeneratives such as amyotrophic lateral sclerosis and its variants, Parkinson's disease, Alzheimer's disease and many others? Neuroprotection is defined by many researches as interactions and interventions that can slow down or even inhibit the progression of neuronal degeneration process. We make some considerations on this neuroprotective effect.
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Affiliation(s)
- Marco Orsini
- Department of Neurosurgery, Universidade Federal Fluminense, 95 Tavares de Macedo street, 902 Niterói, RJ, ZIP 24220-211, Brazil.
| | - Osvaldo J.M. Nascimento
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Andre P.C. Matta
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | | | - Olivia Gameiro de Souza
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Victor Hugo Bastos
- Brain Mapping Laboratory and Electroencephalogram, Federal University of Rio de Janeiro
- Brain Mapping and Functionality Laboratory, Federal University of Piauí
| | - Rayele Moreira
- Brain Mapping Laboratory and Electroencephalogram, Federal University of Rio de Janeiro
- Brain Mapping and Functionality Laboratory, Federal University of Piauí
| | - Pedro Ribeiro
- Brain Mapping Laboratory and Electroencephalogram, Federal University of Rio de Janeiro
- Brain Mapping and Functionality Laboratory, Federal University of Piauí
| | - Stenio Fiorelli
- Severino Sombra University Center, School of Medicine, Vassouras
| | - Pietro Novellino
- Severino Sombra University Center, School of Medicine, Vassouras
| | - Bruno Pessoa
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Mariana Cunha
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Camila Pupe
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Pedro S. Morales
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
| | - Pedro F. Moreira Filho
- Department of Neurology, Antonio Pedro University Hospital, Fluminense Federal University, Niterói
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