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Ishizaki M, Kobayashi M, Hashimoto H, Nakamura A, Maeda Y, Ueyama H, Matsumura T. Caregiver Burden with Duchenne and Becker Muscular Dystrophy in Japan: A Clinical Observation Study. Intern Med 2024; 63:365-372. [PMID: 37344421 PMCID: PMC10901721 DOI: 10.2169/internalmedicine.9372-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/14/2023] [Indexed: 06/23/2023] Open
Abstract
Objective Skeletal muscle weakness and cardiomyopathy can be seen in carriers of dystrophinopathy. Therefore, the health management of caregivers of Duchenne/Becker muscular dystrophy (DMD/BMD) patients who are themselves carriers is an important issue. However, few studies have focused on caregivers who have dystrophin mutations. Methods In this cross-sectional study conducted at five hospitals, the daily living, situation medical treatment status, genetic testing, physical assessment, care burden, and quality of life of caregivers of DMD/BMD patients were surveyed. Results The subjects were 36 main caregivers (mean age 55.7±8.4 years old), of whom 52.8% were diagnosed as carriers, 8.3% were noncarriers, and 38.9% were not confirmed. In addition, half of the caregivers were not examined regularly at medical institutions. Of all caregivers, 54.3% had muscle or cardiac symptoms, and 75% had elevated serum creatine kinase levels. The mean Zarit Caregiver Burden Interview (ZBI) total score of current caregivers was 20.9±13.1. The frequency of a ZBI total score ≥25 was significantly higher in caregivers diagnosed as carriers than in caregivers unexamined as carriers (p=0.04). The health-related quality of life score (Short Form 36; SF-36) in caregivers was slightly lower than the Japanese standard scores in the sections of physical functioning, role limitations-physical, bodily pain, and social functioning. Conclusion Some caregivers of DMD/BMD patients can themselves have muscular or cardiac symptoms and a heavy care burden. It is therefore necessary for carrier caregivers, especially women, to undergo regular health checkups and receive appropriate health management.
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Affiliation(s)
- Masatoshi Ishizaki
- Department of Neurology, National Hospital Organization Kumamoto Saishun Medical Center, Japan
| | - Michio Kobayashi
- Department of Neurology, National Hospital Organization Akita National Hospital, Japan
| | - Hiroya Hashimoto
- Clinical Research Management Center, Nagoya City University Hospital, Japan
| | - Akinori Nakamura
- Department of Neurology, National Hospital Organization Matsumoto Medical Center, Japan
| | - Yasushi Maeda
- Department of Neurology, National Hospital Organization Kumamoto Saishun Medical Center, Japan
| | - Hidetsugu Ueyama
- Department of Neurology, National Hospital Organization Kumamoto Saishun Medical Center, Japan
| | - Tsuyoshi Matsumura
- Department of Neurology, National Hospital Organization Osaka Toneyama Medical Center, Japan
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2
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Jesus A, Bennett C, Masterson C, Brenner L, Scharf R. Self- and Caregiver-Reported Participation, Quality of Life, and Related Mood and Behavior Challenges in People Living With Dystrophinopathies. Pediatr Neurol 2024; 151:37-44. [PMID: 38101306 DOI: 10.1016/j.pediatrneurol.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Previous studies of quality of life (QOL), mood, and behavior in muscular dystrophy focus on caregiver perceptions. This cross-sectional study aims to determine the prevalence of clinically significant mood and behavior problems by both patient and caregiver report and assess relationship between mood/behavior and QOL. METHODS Forty-one patients with dystrophinopathies (Duchenne muscular dystrophy [DMD] and Becker muscular dystrophy [BMD]) were recruited through the University of Virginia Neuromuscular Clinic. Each patient and caregiver dyad completed questionnaires, including the Behavior Assessment System for Children, 2nd Edition (BASC-2); the Pediatric Quality of Life Inventory for DMD (PedsQL-DMD); Children's Depression Inventory, 2nd Edition; and Screen for Child Anxiety Related Disorders. RESULTS Persons with dystrophinopathies rated most of their behavior and adaptive skills similarly to the general population. Sixty-four percent of parent assessments rated clinically significant problems on the BASC-2. Worse BASC-2 scores for self- and parent assessments correlated with lower (worse) scores in the Worry and Communication PedsQL domains. Patient-reported QOL scores were higher than parent-reported scores in each domain except Worry. CONCLUSIONS Individuals with DMD/BMD rate their adaptive skills, behavioral symptoms, externalizing and internalizing problems, and school problems more positively than parents/caregivers. Obtaining self-report data is a worthwhile endeavor that can add value to intervention planning, with the ultimate goal of optimizing QOL.
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Affiliation(s)
- Anna Jesus
- Neurodevelopmental Pediatrics, University of Virginia, Charlottesville, Virginia.
| | - Carolyn Bennett
- Neurodevelopmental Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Chelsea Masterson
- Neurodevelopmental Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Laurie Brenner
- Neurology, University of Virginia, Charlottesville, Virginia
| | - Rebecca Scharf
- Neurodevelopmental Pediatrics, University of Virginia, Charlottesville, Virginia
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3
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Matias-Valiente L, Sanchez-Fernandez C, Rodriguez-Outeiriño L, Ramos MC, Díaz C, Crespo G, González-Menéndez V, Genilloud O, Reyes F, Montolio M, Hernandez-Torres F, Aranega AE. Evaluation of pro-regenerative and anti-inflammatory effects of isolecanoric acid in the muscle: Potential treatment of Duchenne Muscular Dystrophy. Biomed Pharmacother 2024; 170:116056. [PMID: 38159372 DOI: 10.1016/j.biopha.2023.116056] [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: 11/15/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024] Open
Abstract
Duchenne muscular dystrophy (DMD) is a devastating degenerative disease of skeletal muscles caused by loss of dystrophin, a key protein that maintains muscle integrity, which leads to progressive muscle degeneration aggravated by chronic inflammation, muscle stem cells' (MuSCs) reduced regenerative capacity and replacement of muscle with fibroadipose tissue. Previous research has shown that pharmacological GSK-3β inhibition favors myogenic differentiation and plays an important role in modulating inflammatory processes. Isolecanoric acid (ILA) is a natural product isolated from a fungal culture displaying GSK-3β inhibitory properties. The present study aimed to investigate the proregenerative and anti-inflammatory properties of this natural compound in the DMD context. Our results showed that ILA markedly promotes myogenic differentiation of myoblasts by increasing β-Catenin signaling and boosting the myogenic potential of mouse and human stem cells. One important finding was that the GSK-3β/β-Catenin pathway is altered in dystrophic mice muscle and ILA enhances the myofiber formation of dystrophic MuSCs. Treatment with this natural compound improves muscle regeneration of dystrophic mice by, in turn, improving functional performance. Moreover, ILA ameliorates the inflammatory response in both muscle explants and the macrophages isolated from dystrophic mice to, thus, mitigate fibrosis after muscle damage. Overall, we show that ILA modulates both inflammation and muscle regeneration to, thus, contribute to improve the dystrophic phenotype.
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Affiliation(s)
- Lidia Matias-Valiente
- Cardiovascular Development Group, Department of Experimental Biology, Faculty of Experimental Sciences, University of Jaen, Jaen, Spain; Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Cristina Sanchez-Fernandez
- Cardiovascular Development Group, Department of Experimental Biology, Faculty of Experimental Sciences, University of Jaen, Jaen, Spain; Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Lara Rodriguez-Outeiriño
- Cardiovascular Development Group, Department of Experimental Biology, Faculty of Experimental Sciences, University of Jaen, Jaen, Spain; Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Maria C Ramos
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Caridad Díaz
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Gloria Crespo
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | | | - Olga Genilloud
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Fernando Reyes
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain
| | - Marisol Montolio
- Department of Cell Biology, Physiology and Immunology, Faculty of Biology, University of Barcelona, Spain; Duchenne Parent Project Spain Madrid, Spain
| | - Francisco Hernandez-Torres
- Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain; Department of Biochemistry and Molecular Biology III and Immunology, Faculty of Medicine, University of Granada, Granada, Spain.
| | - Amelia Eva Aranega
- Cardiovascular Development Group, Department of Experimental Biology, Faculty of Experimental Sciences, University of Jaen, Jaen, Spain; Fundación MEDINA, Technology Park of Health Sciences, Granada, Spain.
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4
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Ramicone I, Whitford B, Mosley L, Thienprayoon R. Polysymptomatology and Polypharmacy at End of Life in Patients with Duchenne Muscular Dystrophy. J Pediatr 2023; 261:113598. [PMID: 37402439 DOI: 10.1016/j.jpeds.2023.113598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE To characterize symptom frequency and symptom-directed treatment approaches in patients who died with advanced Duchenne muscular dystrophy (DMD). STUDY DESIGN This was a retrospective cohort study of patients in a multidisciplinary DMD program who died between January 1, 2013, and June 30, 2021. Inclusion criteria were patients who died with advanced DMD in the time period studied; exclusion criteria were low exposure to palliative care (<2 encounters). Demographic, symptom, and end-of-life data, as well as medications used for symptom management, were abstracted from the electronic medical record. RESULTS In total, 15 patients were eligible for analysis. The median age of death was 23 years (range 15-30 years). One (6.7%) experienced a full code at death, 8 (53.3%) had do-not-resuscitate orders, and 4 (26.7%) had limited do-not-resuscitate orders. Mean palliative care exposure was 1280 days. All 15 (100%) had pain and dyspnea; 14 (93.3%) anorexia, constipation, and sleep difficulty; 13 (86.7%) wounds; and 12 (80%) anxiety and nausea/vomiting. Multiple medications and drug classes were used to target symptoms. CONCLUSIONS We found significant polysymptomatology and polypharmacy in patients who died with advanced DMD. Clinicians who care for patients with advanced DMD should clarify goals of care and document advance care planning. Given the complexity of multisystem disease progression, palliative care should provide subspecialty pain management and assist with psychosocial burdens.
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Affiliation(s)
- Isabella Ramicone
- Division of Palliative Care, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brittney Whitford
- Division of Palliative Care, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Luke Mosley
- Division of Palliative Care, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rachel Thienprayoon
- Division of Palliative Care, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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5
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Chrastina J, Haroková M. End of Life in Boys and Young Men With Duchenne Muscular Dystrophy - The Perspective of Dying Men and Their Families: A Systematic Review and Thematic Synthesis of Qualitative Evidence. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231186358. [PMID: 37408104 DOI: 10.1177/00302228231186358] [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: 07/07/2023]
Abstract
Understanding the perceptions and experiences related to the end of life (EoL) of boys and men with Duchenne muscular dystrophy from their own and/or family perspective is limited based on the available qualitative empirical studies. This systematic review was done with a thematic synthesis of qualitative evidence according to the PRISMA Statement Guidelines and the SPIDER search tool. The review included empirical, qualitative, and relevant full-text studies published in 2000-2023 in the EBSCO Discovery Service, ISI Web of Science, Scopus, PubMed, and ProQuest databases. From o total of eight included qualitative studies, four main key themes were identified: "Being a parent/caregiver" - psychosocial aspects, needs, and experiences; "Communication about EoL with healthcare and other professionals" - positive experiences and personal shortcomings; "Discussions about…" - the issue of EoL, dying and death; and "End of life" - end-of-life care, planning and the need for palliative care.
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Affiliation(s)
- Jan Chrastina
- Institute of Special Education Studies, Faculty of Education, Palacký University Olomouc, Olomouc, Czech Republic
| | - Martina Haroková
- Institute of Special Education Studies, Faculty of Education, Palacký University Olomouc, Olomouc, Czech Republic
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6
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Lupu M, Ioghen M, Perjoc RȘ, Scarlat AM, Vladâcenco OA, Roza E, Epure DAM, Teleanu RI, Severin EM. The Importance of Implementing a Transition Strategy for Patients with Muscular Dystrophy: From Child to Adult-Insights from a Tertiary Centre for Rare Neurological Diseases. CHILDREN (BASEL, SWITZERLAND) 2023; 10:959. [PMID: 37371191 DOI: 10.3390/children10060959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Progress in the field of muscular dystrophy (MD) using a multidisciplinary approach based on international standards of care has led to a significant increase in the life expectancy of patients. The challenge of transitioning from pediatric to adult healthcare has been acknowledged for over a decade, yet it continues to be a last-minute concern. Currently, there is no established consensus on how to evaluate the effectiveness of the transition process. Our study aimed to identify how well patients are prepared for the transition and to determine their needs. We conducted a descriptive, cross-sectional study on 15 patients aged 14 to 21 years. The patients completed a sociodemographic and a Transition Readiness Assessment Questionnaire (TRAQ). We also analyzed the comorbidities of these patients. Our study revealed that only 46.7% of the patients had engaged in a conversation with a medical professional, namely, a child neurologist, about transitioning. A total of 60% of the participants expressed having confidence in their self-care ability. However, the median TRAQ score of 3.6 shows that these patients overestimate themselves. We emphasize the necessity for a slow, personalized transition led by a multidisciplinary team to ensure the continuity of state-of-the-art care from pediatric to adult healthcare services and the achievement of the highest possible quality of life for these patients.
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Affiliation(s)
- Maria Lupu
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaela Ioghen
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Radu-Ștefan Perjoc
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andra-Maria Scarlat
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Oana Aurelia Vladâcenco
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Eugenia Roza
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Diana Ana-Maria Epure
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Raluca Ioana Teleanu
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Emilia Maria Severin
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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7
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Braz JKFDS, Gomes VA, Siman VA, da Matta SLP, Clebis NK, de Oliveira MF, Assis AC, Morais DB, de Moura CEB. Intertubular morphometric and ultrastructural testes analyses in mdx mice. Anim Reprod 2022; 19:e20210124. [PMID: 36313597 PMCID: PMC9613355 DOI: 10.1590/1984-3143-ar2021-0124] [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: 01/14/2022] [Accepted: 09/28/2022] [Indexed: 11/21/2022] Open
Abstract
Duchenne Muscular Dystrophy (DMD) reproductive alterations and the influence of antioxidant treatments may aid in understanding morphometry testicular quantification. In this context, the aim of the present study was to characterize the intertubular compartment (ITC) morphometry of animal testes in mdx mice supplemented with ascorbic acid (AA). Sixteen mice were used, namely the C57BL/10 (non-dystrophic) and C57BL/10Mdx (dystrophic) lineages, distributed into the following groups: Control (C60), Dystrophic (D60), Control supplemented with AA (CS60), Dystrophic supplemented with AA (DS60). A total of 200 mg/kg of AA were administered to mice for 30 days. Subsequently, the testicles were collected, weighed, and fragmented. The obtained fragments were fixed in Karnovsky's solution (pH 7.2) and embedded in historesin for morphometric and transmission electron microscopy assessments. Leydig cells were hypertrophic in the D60 group, but was reverted by AA supplementation in the DS60 group. The DS60 group also exhibited increased intertubular volume compared to the CS60 group. The ultrastructural images identified multilamellar bodies in dystrophic animals (lipid storage) and telocyte cells (transport substances) in both control and dystrophic animals. Morphometric alterations were, therefore, noted in the intertubular compartment due to Duchenne muscular dystrophy (DMD), with AA administration capable of altering Leydig cells in this condition.
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Affiliation(s)
| | - Vilessa Araújo Gomes
- Departamento de Ciências da Saúde, Universidade Federal de Campina Grande, Campina Grande, PB, Brasil
| | | | | | - Naianne Kelly Clebis
- Departamento de Morfologia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brasil
| | | | - Antônio Chaves Assis
- Departamento de Cirurgia, Faculdade de Medicina Veterinária e Ciência Animal, Universidade de São Paulo, São Paulo, SP, Brasil
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8
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Groh WJ, Bhakta D, Tomaselli GF, Aleong RG, Teixeira RA, Amato A, Asirvatham SJ, Cha YM, Corrado D, Duboc D, Goldberger ZD, Horie M, Hornyak JE, Jefferies JL, Kääb S, Kalman JM, Kertesz NJ, Lakdawala NK, Lambiase PD, Lubitz SA, McMillan HJ, McNally EM, Milone M, Namboodiri N, Nazarian S, Patton KK, Russo V, Sacher F, Santangeli P, Shen WK, Sobral Filho DC, Stambler BS, Stöllberger C, Wahbi K, Wehrens XHT, Weiner MM, Wheeler MT, Zeppenfeld K. 2022 HRS expert consensus statement on evaluation and management of arrhythmic risk in neuromuscular disorders. Heart Rhythm 2022; 19:e61-e120. [PMID: 35500790 DOI: 10.1016/j.hrthm.2022.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
This international multidisciplinary document is intended to guide electrophysiologists, cardiologists, other clinicians, and health care professionals in caring for patients with arrhythmic complications of neuromuscular disorders (NMDs). The document presents an overview of arrhythmias in NMDs followed by detailed sections on specific disorders: Duchenne muscular dystrophy, Becker muscular dystrophy, and limb-girdle muscular dystrophy type 2; myotonic dystrophy type 1 and type 2; Emery-Dreifuss muscular dystrophy and limb-girdle muscular dystrophy type 1B; facioscapulohumeral muscular dystrophy; and mitochondrial myopathies, including Friedreich ataxia and Kearns-Sayre syndrome, with an emphasis on managing arrhythmic cardiac manifestations. End-of-life management of arrhythmias in patients with NMDs is also covered. The document sections were drafted by the writing committee members according to their area of expertise. The recommendations represent the consensus opinion of the expert writing group, graded by class of recommendation and level of evidence utilizing defined criteria. The recommendations were made available for public comment; the document underwent review by the Heart Rhythm Society Scientific and Clinical Documents Committee and external review and endorsement by the partner and collaborating societies. Changes were incorporated based on these reviews. By using a breadth of accumulated available evidence, the document is designed to provide practical and actionable clinical information and recommendations for the diagnosis and management of arrhythmias and thus improve the care of patients with NMDs.
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Affiliation(s)
- William J Groh
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Deepak Bhakta
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | - Anthony Amato
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Denis Duboc
- Cardiology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Minoru Horie
- Shiga University of Medical Sciences, Otsu, Japan
| | | | | | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | | | - Neal K Lakdawala
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pier D Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, University College London, and St Bartholomew's Hospital London, London, United Kingdom
| | | | - Hugh J McMillan
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | | | | | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Frederic Sacher
- Bordeaux University Hospital, LIRYC Institute, Bordeaux, France
| | | | | | | | | | - Claudia Stöllberger
- Second Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstraße, Vienna, Austria
| | - Karim Wahbi
- Cardiology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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9
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Bourke J, Turner C, Bradlow W, Chikermane A, Coats C, Fenton M, Ilina M, Johnson A, Kapetanakis S, Kuhwald L, Morley-Davies A, Quinlivan R, Savvatis K, Schiava M, Yousef Z, Guglieri M. Cardiac care of children with dystrophinopathy and females carrying DMD-gene variations. Open Heart 2022; 9:e001977. [PMID: 36252992 PMCID: PMC9577913 DOI: 10.1136/openhrt-2022-001977] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/26/2022] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We provide succinct, evidence-based and/or consensus-based best practice guidance for the cardiac care of children living with Duchenne muscular dystrophy (DMD) as well as recommendations for screening and management of female carriers of mutations in the DMD-gene. METHODS Initiated by an expert working group of UK-based cardiologists, neuromuscular clinicians and DMD-patient representatives, draft guidelines were created based on published evidence, current practice and expert opinion. After wider consultation with UK-cardiologists, consensus was reached on these best-practice recommendations for cardiac care in DMD. RESULTS The resulting recommendations are presented in the form of a succinct care pathway flow chart with brief justification. The guidance signposts evidence on which they are based and acknowledges where there have been differences in opinion. Guidelines for cardiac care of patients with more advanced cardiac dystrophinopathy at any age have also been considered, based on the previous published work of Quinlivan et al and are presented here in a similar format. The recommendations have been endorsed by the British Cardiovascular Society. CONCLUSION These guidelines provide succinct, reasoned recommendations for all those managing paediatric patients with early or advanced stages of cardiomyopathy as well as females with cardiac dystrophinopathy. The hope is that this will result in more uniform delivery of high standards of care for children with cardiac dystrophinopathy, so improving heart health into adulthood through timely earlier interventions across the UK.
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Affiliation(s)
- John Bourke
- Department of Cardiology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Cathy Turner
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - William Bradlow
- Department of Paediatric Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ashish Chikermane
- Department of Cardiology, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Caroline Coats
- Department of Cardiology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Matthew Fenton
- Department of Paediatric Cardiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Maria Ilina
- Scottish Paediatric Cardiac Services, Royal Hospital for Children, Glasgow, UK
| | | | - Stam Kapetanakis
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Adrian Morley-Davies
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ros Quinlivan
- Department of Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, London, UK
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos Savvatis
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, UK
- Barts Heart Centre, Saint Bartholomew's Hospital Barts Heart Centre, London, UK
| | - Marianela Schiava
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Zaheer Yousef
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle University, Newcastle upon Tyne, UK
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10
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Birnkrant DJ, Bello L, Butterfield RJ, Carter JC, Cripe LH, Cripe TP, McKim DA, Nandi D, Pegoraro E. Cardiorespiratory management of Duchenne muscular dystrophy: emerging therapies, neuromuscular genetics, and new clinical challenges. THE LANCET RESPIRATORY MEDICINE 2022; 10:403-420. [DOI: 10.1016/s2213-2600(21)00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 01/06/2023]
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11
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Bourke JP, Watson G, Spinty S, Bryant A, Roper H, Chadwick T, Wood R, McColl E, Bushby K, Muntoni F, Guglieri M. Preventing Cardiomyopathy in DMD: A Randomized Placebo-Controlled Drug Trial. Neurol Clin Pract 2021; 11:e661-e668. [PMID: 34840880 DOI: 10.1212/cpj.0000000000001023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022]
Abstract
Objective To determine whether a combination of 2 heart medications would be tolerated and could prevent/delay the onset of cardiomyopathy in boys with Duchenne muscular dystrophy (DMD) compared with placebo. Methods This multicenter, parallel group, 1:1 patient randomized, placebo-controlled study of prophylactic perindopril and bisoprolol recruited boys with DMD aged 5-13 years, with normal ventricular function. Repeat assessments of left ventricular (LV) function, electrocardiogram, and adverse event reporting were performed 6 monthly. The primary outcome was change in ejection fraction between arms after 36 months. The study was approved by the National Research Ethics Service Committee East Midlands-Derby. Results Eighty-five boys were recruited (76% on steroid therapy) and randomized to combination heart drugs or matched placebo. Group change in left ventricular ejection fraction (LVEF%) at 36 months from baseline was -2.2% ± 6.0% and -2.9% ± 6.1% in active and placebo arms (adjusted mean difference: -2.1, 95% CI -5.2 to 1.1). There was no difference between treatment arms over repeated assessments (analysis of variance) up to 36 months (trial arms p = 0.53); arm-over-time (p = 0.44). Four participants on placebo but none on active therapy were withdrawn due to deteriorations in LV function. Secondary outcomes did not differ between arms either. Thirty-six serious adverse events occurred none due to cardiac events or trial medication. Conclusions Combination therapy was well tolerated. Consistent with the previous prophylactic perindopril heart study, there was no evidence of group benefit after 36-month treatment. Classification of Evidence This study provides Class I evidence that combination perindopril-bisoprolol therapy was well tolerated but did not change decline in LVEF significantly in boys with DMD.
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Affiliation(s)
- John P Bourke
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Gillian Watson
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Stefan Spinty
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Andrew Bryant
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Helen Roper
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Thomas Chadwick
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Ruth Wood
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Elaine McColl
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Kate Bushby
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Francesco Muntoni
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Michela Guglieri
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
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Weerkamp PM, Collin P, Maas RJ, Vermeulen RJ, Klinkenberg S, Hendriksen JG. Psychosocial adjustment in adults with Duchenne muscular dystrophy: A pilot study on a shortened parent-report questionnaire. Neuromuscul Disord 2021; 32:159-165. [DOI: 10.1016/j.nmd.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022]
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Ohlendieck K, Swandulla D. Complexity of skeletal muscle degeneration: multi-systems pathophysiology and organ crosstalk in dystrophinopathy. Pflugers Arch 2021; 473:1813-1839. [PMID: 34553265 PMCID: PMC8599371 DOI: 10.1007/s00424-021-02623-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 02/07/2023]
Abstract
Duchenne muscular dystrophy is a highly progressive muscle wasting disorder due to primary abnormalities in one of the largest genes in the human genome, the DMD gene, which encodes various tissue-specific isoforms of the protein dystrophin. Although dystrophinopathies are classified as primary neuromuscular disorders, the body-wide abnormalities that are associated with this disorder and the occurrence of organ crosstalk suggest that a multi-systems pathophysiological view should be taken for a better overall understanding of the complex aetiology of X-linked muscular dystrophy. This article reviews the molecular and cellular effects of deficiency in dystrophin isoforms in relation to voluntary striated muscles, the cardio-respiratory system, the kidney, the liver, the gastrointestinal tract, the nervous system and the immune system. Based on the establishment of comprehensive biomarker signatures of X-linked muscular dystrophy using large-scale screening of both patient specimens and genetic animal models, this article also discusses the potential usefulness of novel disease markers for more inclusive approaches to differential diagnosis, prognosis and therapy monitoring that also take into account multi-systems aspects of dystrophinopathy. Current therapeutic approaches to combat muscular dystrophy are summarised.
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Affiliation(s)
- Kay Ohlendieck
- Department of Biology, Maynooth University, National University of Ireland, Co. Kildare, Maynooth, W23F2H6, Ireland.
- Kathleen Lonsdale Institute for Human Health Research, Maynooth University, Co. Kildare, Maynooth, W23F2H6, Ireland.
| | - Dieter Swandulla
- Institute of Physiology, University of Bonn, 53115, Bonn, Germany.
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Murphy AP, Johnson A, Straub V, Heads-Baister A, Lord S, Bourke JP. Effects of cardiac medications on ventricular function in patients with Duchenne muscular dystrophy-related cardiomyopathy. Muscle Nerve 2021; 64:163-171. [PMID: 34050938 DOI: 10.1002/mus.27336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION/AIMS The DMD Care Considerations Working Group Guidelines 2010 recommended treating cardiac dystrophinopathy with angiotensin-converting enzyme-inhibitor (ACEi) and beta-blocker (BB) therapy to prevent the progressive decline in left ventricular function expected from earlier, natural history studies. The aim of this research was to audit change in measures of left ventricular function over 8 years to 4 years before and 4 years after deploying an ACEi/BB combination systematically at a dedicated "cardiology-muscle" clinic. METHODS This is an institutionally registered, retrospective, case-file-based audit of serial echocardiographic measures of left ventricular fractional shortening accumulated over the period 1995 to 2015. RESULTS Data from 104 genetically confirmed Duchenne muscular dystrophy (DMD) patients, aged 22.2 ± 5.3 years at data censure, were included. Mean age at first detection of left ventricular dysfunction was 15.1 ± 4.2 years, but older in those on maintenance steroid therapy (16.8 ± 4.2 vs 14.5 ± 4.1 years; P = .04). Group mean fractional shortening fell by 1.5%/year over the 4 years before therapy, but this decreased to 0.9%/year over the first 4 years after starting therapy. Analysis of limited left ventricular ejection fraction measures showed similar but nonsignificant changes. Neither age at detection of left ventricular dysfunction nor fractional shortening percent at time of therapy initiation affected the beneficial response. DISCUSSION The results support the international DMD recommendations of the time. This combination of cardiac medications helps stabilize heart function. For the best long-term effects, therapy needs to be initiated no later than on first detection left ventricular impairment.
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Affiliation(s)
- Alexander P Murphy
- The John Walton Muscular Dystrophy Research Centre, Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Anna Johnson
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Volker Straub
- The John Walton Muscular Dystrophy Research Centre, Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Alison Heads-Baister
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Lord
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John P Bourke
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Zhang S, Qin D, Wu L, Li M, Song L, Wei C, Lu C, Zhang X, Hong S, Ma M, Wu S. Genotype characterization and delayed loss of ambulation by glucocorticoids in a large cohort of patients with Duchenne muscular dystrophy. Orphanet J Rare Dis 2021; 16:188. [PMID: 33910603 PMCID: PMC8082961 DOI: 10.1186/s13023-021-01837-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is the most common genetic muscle disease in human. We aimed to describe the genotype distribution in a large cohort of Chinese DMD patients and their delayed loss of ambulation by glucocorticoid (GC) treatments. This is to facilitate protocol designs and outcome measures for the emerging DMD clinical trials. Results A total of 1163 patients with DMD were recruited and genotyped. Genotype variations were categorized as large deletions, large duplications, and small mutations. Large deletions were further analyzed for those amenable to exon-skipping therapies. Participants aged 5 years or older were grouped into GC-treated and GC-naïve groups. Clinical progression among different genotypes and their responses to GC treatments were measured by age at loss of ambulation (LOA). Among the mutation genotypes, large deletions, large duplications, and small mutations accounted for 68.79%, 7.14%, and 24.07%, respectively. The mean age at diagnosis was 4.59 years; the median ages at LOA for the GC-naïve, prednisone/prednisolone-treated, and deflazacort-treated groups were 10.23, 12.02, and 13.95 years, respectively. The “deletion amenable to skipping exon 44” subgroup and the nonsense-mutation subgroup had older ages at LOA than the “other deletions” subgroup. Subgroups were further analyzed by both genotypes and GC status. All genotypes showed significant beneficial responses to GC treatment. Deletions amenable to skipping exon 44 showed a lower hazard ratio (0.155). The mean age at death was 18.57 years in this DMD group. Conclusion Genotype variation influences clinical progression in certain DMD groups. Beneficial responses to GC treatment were observed among all DMD genotypes. Compared with other genotypes, deletions amenable to skipping exon 44 had a lower hazard ratio, which may indicate a stronger protective effect of GC treatments on this subgroup. These data are valuable for designing future clinical trials, as clinical outcomes may be influenced by the genotypes.
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Affiliation(s)
- Shu Zhang
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.,Department of Neurology, Third Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Dongdong Qin
- Department of Physiology, Yunnan University of Chinese Medicine, Kunming, 650500, Yunnan Province, China
| | - Liwen Wu
- Department of Neurology, Hunan Children's Hospital, Changsha, 410008, Hunan Province, China
| | - Man Li
- Department of Neurology, The Second Hospital of Shanxi Medical University, Taiyuan, 030001, Shanxi Province, China
| | - Lifang Song
- Department of Pediatric Neurology, Henan Children's Hospital, Zhengzhou, 450018, Henan Province, China
| | - Cuijie Wei
- Department of Pediatrics, Peking University First Hospital, Beijing, 100034, China
| | - Chunling Lu
- Department of Muscle Atrophy, Affiliated Yiling Hospital of Hebei Medical University, Shijiazhuang, 050091, Hebei Province, China
| | - Xiaoli Zhang
- Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Siqi Hong
- Department of Pediatrics, Chongqing Medical University Affiliated Children's Hospital, Chongqing, 400042, China
| | - Mingming Ma
- Department of Neurology, Affiliated People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan Province, China
| | - Shiwen Wu
- Department of Neurology, First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China. .,Department of Neurology, Third Medical Center of Chinese PLA General Hospital, Beijing, 100039, China. .,Department of Neurology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Birnkrant DJ, Carter JC. Cardiopulmonary phenotypic variability and discordance in Duchenne muscular dystrophy: Implications for new therapies. Pediatr Pulmonol 2021; 56:738-746. [PMID: 33049122 DOI: 10.1002/ppul.25111] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 01/16/2023]
Abstract
Neuromuscular respiratory medicine has traditionally focused on assisted lung ventilation and mucus clearance. These therapies have prolonged survival for patients with Duchenne muscular dystrophy (DMD). However, the field is rapidly evolving in a new direction: it is being revolutionized by molecular and genetic therapies. A good correlation between a patient's dystrophin mutation and his cardiopulmonary phenotype would allow accurate prediction of patient prognosis and would facilitate the design of studies that assess new DMD therapies. Instead, patient prognosis and the design of valid therapeutic studies are complicated by cardiopulmonary phenotypic discordance and variability, by which a notable proportion of DMD patients have unexpectedly good or poor cardiopulmonary function. The likely cause of phenotypic variability and discordance is genetic modifiers. Once the modifiers that affect cardiopulmonary function are better understood, it should be possible to create a personalized genetic profile that accurately predicts the prognosis of each individual DMD patient. This would allow investigators to assess the effect of new therapies in the context of each patient's particular cardiopulmonary natural history. Amplification of beneficial cardiopulmonary genetic modifiers and blocking of detrimental modifiers is a promising strategy for creating new DMD therapies. When patients with chronic respiratory failure are treated with assisted ventilation, cardiac function determines their survival. Therefore, prioritizing new cardiac therapies is most likely to prolong patient survival. By focusing on these topics we aim to move neuromuscular respiratory medicine beyond assisted ventilation and coughing and into the age of translational medicine.
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Affiliation(s)
- David J Birnkrant
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - John C Carter
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Abstract
Increased understanding of disease pathophysiology and advances in gene therapies and drug technologies are revolutionizing treatment of muscular dystrophies and motor neuron disorders (MNDs). New drugs have been approved for Duchenne muscular dystrophy, spinal muscular atrophy, and amyotrophic lateral sclerosis. For other diseases, new targets have been identified, and new therapies are in clinical trials. The impact of such therapies will be fully understood only in the next decades. Cost burden and accessibility are major challenges in the wide application of new drugs. This article reviews advances in gene therapies, newly approved drugs, and therapeutic promises in muscular dystrophies and MNDs.
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Abstract
Duchenne muscular dystrophy is a severe, progressive, muscle-wasting disease that leads to difficulties with movement and, eventually, to the need for assisted ventilation and premature death. The disease is caused by mutations in DMD (encoding dystrophin) that abolish the production of dystrophin in muscle. Muscles without dystrophin are more sensitive to damage, resulting in progressive loss of muscle tissue and function, in addition to cardiomyopathy. Recent studies have greatly deepened our understanding of the primary and secondary pathogenetic mechanisms. Guidelines for the multidisciplinary care for Duchenne muscular dystrophy that address obtaining a genetic diagnosis and managing the various aspects of the disease have been established. In addition, a number of therapies that aim to restore the missing dystrophin protein or address secondary pathology have received regulatory approval and many others are in clinical development.
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Affiliation(s)
- Dongsheng Duan
- Department of Molecular Microbiology and Immunology and Department of Neurology, School of Medicine; Department of Biomedical Sciences, College of Veterinary Medicine; Department of Biomedical, Biological & Chemical Engineering, College of Engineering, University of Missouri, Columbia, MO, USA
| | - Nathalie Goemans
- Department of Child Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Eugenio Mercuri
- Centro Clinico Nemo, Policlinico Gemelli, Rome, Italy
- Peadiatric Neurology, Catholic University, Rome, Italy
| | - Annemieke Aartsma-Rus
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands.
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Janisch M, Boehme K, Thiele S, Bock A, Kirschner J, Schara U, Walter MC, Nolte-Buchholtz S, von der Hagen M. Tasks and interfaces in primary and specialized palliative care for Duchenne muscular dystrophy - A patients' perspective. Neuromuscul Disord 2020; 30:975-985. [PMID: 33214012 DOI: 10.1016/j.nmd.2020.09.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/31/2020] [Accepted: 09/23/2020] [Indexed: 12/25/2022]
Abstract
In spite of the improvements in care and the emergence of disease-modifying treatments, Duchenne muscular dystrophy (DMD) remains a life-limiting disease of adolescence and (young) adulthood. Palliative care approaches and principles should be integrated from the point of diagnosis and implemented throughout the lifespan. A nationwide cross-sectional survey based on a mixed-method-design of qualitative and quantitative research approaches evaluated the structural implementation and perception of palliative care for DMD in Germany. Data analyses revealed that palliative care was predominantly provided at the primary care level by pediatricians, general practitioners and specialized multi-professional outpatient structures. The majority of patients did not utilize the scopes of specialized palliative structures. Simultaneously, insufficiently treated complex symptoms, emergent and elective hospitalizations and barriers in transitioning into adult care presented a considerable burden. A collaborative integrated model with a close cooperation of patients, families and care providers is proposed involving task areas and interfaces complementing primary and specialized palliative care (1) management of complex symptoms, (2) crisis support, (3) intermittent relief of the strain for caregivers, (4) coordination of care, (5) advance care planning and (6) end-of-life care. Specialized palliative care should be used as an "add-on" approach in time of need rather than as a prognosis or disease stage.
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Affiliation(s)
- Maria Janisch
- Pediatric Palliative Care Centre, Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Kristin Boehme
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Simone Thiele
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Ziemssenstr. 1, 80336 Munich, Germany
| | - Annette Bock
- Social pediatric centre, Stiftung Kreuznacher Diakonie, Ringstraße 58, 55543 Bad Kreuznach, Bad Kreuznach, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrike Schara
- Department of Neuropediatrics and Neuromuscular Centre for Children and Adolescents, Children's Hospital, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Maggie C Walter
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Ziemssenstr. 1, 80336 Munich, Germany
| | - Silke Nolte-Buchholtz
- Pediatric Palliative Care Centre, Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Thangarajh M, Elfring GL, Trifillis P. Longitudinal Evaluation of Working Memory in Duchenne Muscular Dystrophy. J Clin Med 2020; 9:jcm9092940. [PMID: 32933029 PMCID: PMC7563441 DOI: 10.3390/jcm9092940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/16/2020] [Accepted: 09/02/2020] [Indexed: 01/16/2023] Open
Abstract
Objective: The developmental maturation of forward and backward digit spans—indices of working memory—in boys with nonsense (nm) Duchenne muscular dystrophy (DMD) (nmDMD) was assessed using prospective, longitudinal data. Methods: Fifty-five boys of the 57 subjects with genetically confirmed nmDMD—who were from the placebo arm of a 48-week-long phase 2b clinical trial—were evaluated. Forward and backward digit spans were obtained every 12 weeks for a total of five assessments in all study subjects. Changes in forward and backward digit spans were evaluated based on age, corticosteroid treatment, and DMD mutation location. Results: Boys with nmDMD had lower mean scores on normalized forward digit span. Normalized forward digit spans were comparable between subjects stratified by age and between corticosteroid-naïve and corticosteroid-treated subjects. When stratified by DMD mutation location, normalized forward digit spans were lower in nmDMD subjects with mutations downstream of DMD exon 30, exon 45, and exon 63, both at baseline evaluation and at follow-up evaluation at 48 weeks. On average, normalized backward digit span scores were stable over 48 weeks in these subjects. Developmental growth modeling showed that subjects with nmDMD mutations upstream of DMD exon 30, upstream of DMD exon 45, and upstream of DMD exon 63 appeared to make better gains in working memory than subjects with mutations downstream of DMD exon 30, downstream of DMD exon 45, and downstream of DMD exon 63. Conclusion: Performance in working memory shows deficits in nmDMD and differed based on nmDMD location. Maturation in cognition was seen over a 48-week period. The developmental trajectory of working memory in this cohort was influenced by DMD mutation location.
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Affiliation(s)
- Mathula Thangarajh
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, P.O. Box 980599, Richmond, VA 23298, USA
- Correspondence: ; Tel.: +1-804-628-0396
| | - Gary L. Elfring
- PTC Therapeutics Inc., South Plainfield, NJ 07080, USA; (G.L.E.); (P.T.)
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Wonkam‐Tingang E, Nguefack S, Esterhuizen AI, Chelo D, Wonkam A. DMD-related muscular dystrophy in Cameroon: Clinical and genetic profiles. Mol Genet Genomic Med 2020; 8:e1362. [PMID: 32543101 PMCID: PMC7434738 DOI: 10.1002/mgg3.1362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Most of the previous studies on Duchenne Muscular Dystrophy (DMD) were conducted in Caucasian, Asian, and Arab populations. Therefore, little is known about the features of this disease in Africans. In this study, we aimed to determine the clinical characteristics of DMD, and the common mutations associated with this condition in a group of Cameroonian patients. METHODS We recruited DMD patients and performed a general physical examination on each of them. Multiplex ligand-dependant probe amplification was carried out to investigate exon deletions and duplications in the DMD gene (OMIM: 300377) of patients and their mothers. RESULTS A total of 17 male patients from 14 families were recruited, aged 14 ± 5.1 (8-23) years. The mean age at onset of symptoms was 4.6 ± 1.5 years, and the mean age at diagnosis was 12.1 ± 5.2 years. Proximal muscle weakness was noted in all patients and calf hypertrophy in the large majority of them (88.2%; 15/17). Flexion contractures were particularly frequent on the ankle (85.7%; 12/14). Wasting of shoulder girdle and thigh muscles was present in 50% (6/12) and 46.2% (6/13) of patients, respectively. No patient presented with hearing impairment. Deletions in DMD gene (OMIM: 300377) occurred in 45.5% of patients (5/11), while duplications were observed in 27.3% (3/11). Both mutation types were clustered between exons 45 and 50, and the proportion of de novo mutation was estimated at 18.2% (2/11). CONCLUSION Despite the first symptoms of DMD occurring in infancy, the diagnosis is frequently made later in adolescence, indicating an underestimation of the number of cases of DMD in Cameroon. Future screening of deletions and duplications in patients from Cameroon should focus on the distal part of the gene.
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Affiliation(s)
- Edmond Wonkam‐Tingang
- Division of Human GeneticsDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
| | - Séraphin Nguefack
- Department of PaediatricsFaculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
- Paediatrics UnitDivision of Paediatric NeurologyGynaeco‐Obstetric and Paediatric HospitalYaoundéCameroon
| | - Alina I. Esterhuizen
- Division of Human GeneticsDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
- National Health Laboratory ServiceGroote Schuur HospitalCape TownSouth Africa
| | - David Chelo
- Department of PaediatricsFaculty of Medicine and Biomedical SciencesUniversity of Yaoundé IYaoundéCameroon
- Division of Paediatric Cardiology, Mother and Child HospitalYaoundéCameroon
| | - Ambroise Wonkam
- Division of Human GeneticsDepartment of PathologyUniversity of Cape TownCape TownSouth Africa
- Department of MedicineUniversity of Cape TownCape TownSouth Africa
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22
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Hiermeier UM, Baker C, Bourke JP. Exploring the acceptability of implantable defibrillators in patients with cardiac dystrophinopathy and carers. Open Heart 2020; 7:e001230. [PMID: 32399251 PMCID: PMC7204554 DOI: 10.1136/openhrt-2019-001230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/14/2020] [Indexed: 01/14/2023] Open
Abstract
Objective Unlike for patients with other forms of cardiomyopathies, those with severe ventricular dysfunction due to Duchenne muscular dystrophy (DMD) are not offered implantable cardioverter-defibrillator (ICD) therapy routinely. This prospective study aimed to determine the views of DMD-patients and their carers about discussing sudden death risk and their acceptance of ICDs. Design and setting Adults with DMD (n=9) and parents/carers (n=9) participated in audio-recorded, 60–90 min focus group sessions (patients 2; parents/carers 2) conducted through either a face-to-face session at a neutral venue or a videoconference. Sessions were facilitated by a clinical psychologist, experienced in conducting focus group research. All participants understood the rationale for the study and the nature of ICD therapy. The same predefined themes were explored with each group. Recordings were transcribed, analysed thematically by two researchers, working independently and then agreed. Differences in responses between patient and carer groups were also studied and compared. Participants all provided informed written consent and the study had ethical approval. Results Three main themes emerged: (1) access to/quality of information provided by professionals and patient engagement with them; (2) decision-making about ICDs; (3) individuals’ own ‘lived experience’ of DMD. Conclusions The main findings were: (1) patients with DMD want to have their risk of sudden arrhythmic death discussed, when relevant and (2) if ICD therapy were established as beneficial, they would welcome an individualised discussion about its appropriateness for them.
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Affiliation(s)
- Ursula M Hiermeier
- Department of Clinical Health Psychology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Christine Baker
- Department of Clinical Health Psychology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John P Bourke
- Department of Cardiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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23
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Wittlieb‑Weber CA, Knecht KR, Villa CR, Cunningham C, Conway J, Bock MJ, Gambetta KE, Lal AK, Schumacher KR, Law SP, Deshpande SR, West SC, Friedland‑Little JM, Lytrivi ID, McCulloch MA, Butts RJ, Weber DR, Johnson JN. Risk Factors for Cardiac and Non-cardiac Causes of Death in Males with Duchenne Muscular Dystrophy. Pediatr Cardiol 2020; 41:764-771. [PMID: 32016582 PMCID: PMC7328368 DOI: 10.1007/s00246-020-02309-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/22/2020] [Indexed: 01/14/2023]
Abstract
As survival and neuromuscular function in Duchenne muscular dystrophy (DMD) have improved with glucocorticoid (GC) therapy and ventilatory support, cardiac deaths are increasing. Little is known about risk factors for cardiac and non-cardiac causes of death in DMD. A multi-center retrospective cohort study of 408 males with DMD, followed from January 1, 2005 to December 31, 2015, was conducted to identify risk factors for death. Those dying of cardiac causes were compared to those dying of non-cardiac causes and to those alive at study end. There were 29 (7.1%) deaths at a median age of 19.5 (IQR: 16.9-24.6) years; 8 (27.6%) cardiac, and 21 non-cardiac. Those living were younger [14.9 (IQR: 11.0-19.1) years] than those dying of cardiac [18 (IQR 15.5-24) years, p = 0.03] and non-cardiac [19 (IQR: 16.5-23) years, p = 0.002] causes. GC use was lower for those dying of cardiac causes compared to those living [2/8 (25%) vs. 304/378 (80.4%), p = 0.001]. Last ejection fraction prior to death/study end was lower for those dying of cardiac causes compared to those living (37.5% ± 12.8 vs. 54.5% ± 10.8, p = 0.01) but not compared to those dying of non-cardiac causes (37.5% ± 12.8 vs. 41.2% ± 19.3, p = 0.58). In a large DMD cohort, approximately 30% of deaths were cardiac. Lack of GC use was associated with cardiac causes of death, while systolic dysfunction was associated with death from any cause. Further work is needed to ensure guideline adherence and to define optimal management of systolic dysfunction in males with DMD with hopes of extending survival.
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Affiliation(s)
- Carol A. Wittlieb‑Weber
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, NY, USA,Present Address: Division of Cardiology, The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Kenneth R. Knecht
- Arkansas Children’s Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Chet R. Villa
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Chentel Cunningham
- Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Conway
- Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | - Matthew J. Bock
- Loma Linda University Children’s Hospital, Loma Linda, CA, USA
| | - Katheryn E. Gambetta
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ashwin K. Lal
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT, USA
| | - Kurt R. Schumacher
- C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Sabrina P. Law
- Morgan Stanley Children’s Hospital of New York Presbyterian, New York, NY, USA
| | | | - Shawn C. West
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | - Irene D. Lytrivi
- Morgan Stanley Children’s Hospital of New York Presbyterian, New York, NY, USA
| | | | - Ryan J. Butts
- Children’s Medical Center of Dallas, UT Southwestern Medical Center, Dallas, TX, USA
| | - David R. Weber
- Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, NY, USA
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24
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Takeuchi F, Nakamura H, Yonemoto N, Komaki H, Rosales RL, Kornberg AJ, Bretag AH, Dejthevaporn C, Goh KJ, Jong YJ, Kim DS, Khadilkar SV, Shen D, Wong KT, Chai J, Chan SHS, Khan S, Ohnmar O, Nishino I, Takeda S, Nonaka I. Clinical practice with steroid therapy for Duchenne muscular dystrophy: An expert survey in Asia and Oceania. Brain Dev 2020; 42:277-288. [PMID: 31980267 DOI: 10.1016/j.braindev.2019.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Several studies on clinical practice for Duchenne muscular dystrophy (DMD) have been conducted in Western countries. However, there have been only a few similar studies in Asia and Oceania. Here, we investigate the steroid therapy-related clinical practice for DMD among the local experts. In 2015, we conducted a DMD expert survey in Asia and Oceania to acquire information regarding patients with DMD and to assess current clinical practice with the cooperation of Asian and Oceanian Myology Centre, a neuromuscular disease research network. RESULTS We obtained survey responses from 87 out of 148 clinicians (62%) from 13 countries and regions. In China, 1385 DMD patients were followed-up by 5 respondent neurologists, and 84% were between 0 and 9 years of age (15% were 10-19 years, 1% > 19 years). While in Japan, 1032 patients were followed-up by 20 clinicians, and the age distribution was similar between the 3 groups (27% were 0-9 years, 35% were 10-19 years, 38% were >19 years). Most respondent clinicians (91%) were aware of DMD standard of care recommendations. Daily prednisolone/prednisone administration was used most frequently at initiation (N = 45, 64%). Inconsistent opinion on steroid therapy after loss of ambulation and medication for bone protection was observed. CONCLUSIONS Rare disease research infrastructures have been underdeveloped in many of Asian and Oceanian countries. In this situation, our results show the snapshots of current medical situation and clinical practice in DMD. For further epidemiological studies, expansion of DMD registries is necessary.
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Affiliation(s)
- Fumi Takeuchi
- Department of Clinical Research Support, Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan
| | - Harumasa Nakamura
- Department of Clinical Research Support, Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan.
| | - Naohiro Yonemoto
- Department of Biostatistics, Kyoto University School of Public Health, Yoshidakonoe, Sakyo, Kyoto, Kyoto 606-8501, Japan
| | - Hirofumi Komaki
- Department of Clinical Research Support, Translational Medical Center, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan; Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan
| | - Raymond L Rosales
- The Department of Neurology & Psychiatry and The NeuroScience Institute, University of Santo Tomas Hospital, España Blvd, Sampaloc, Manila, 1008 Metro Manila, Philippines
| | - Andrew J Kornberg
- Children's Neuroscience Centre, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, Victoria 3052, Melbourne, Australia
| | - Allan H Bretag
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Charungthai Dejthevaporn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Yuh-Jyh Jong
- Departments of Pediatrics and Laboratory Medicine, Kaohsiung Medical University Hospital/Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Taiwan 100, Shih-Chuan 1st Rd, Kaohsiung 80708, Taiwan; College of Biological Science and Technology, National Chiao Tung University, 75 Po-Ai St, Hsinchu 30068, Taiwan
| | - Dae-Seong Kim
- Department of Neurology, Pusan National University Yangsan Hospital, 20 Kumo-ro, Yangsan, Gyeongnam, Republic of Korea
| | - Satish V Khadilkar
- Department of Neurology, Bombay Hospital Institute of Medical Sciences, 12, Marine Lines, Mumbai, Maharashtra 40020, India
| | - Dingguo Shen
- Fudan University, 220 Handan Rd, WuJiaoChang, Yangpu District, Shanghai 200433, China
| | - Kum Thong Wong
- Department of Pathology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Josiah Chai
- Department of Neurology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Sophelia Hoi-Shan Chan
- Division of Paediatric Neurology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Sara Khan
- Department of Neurology, Aga Khan University Hospital, Stadium Rd, Karachi, Karachi City, Sindh 74800, Pakistan
| | - Ohnmar Ohnmar
- Department of Medical Neurology, University of Medicine 1, No. 245, Myoma Kyaung Street, Lanmadaw Township, Yangon, Myanmar
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neurosciences, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan
| | - Shin'ichi Takeda
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan
| | - Ikuya Nonaka
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan; Department of Neuromuscular Research, National Institute of Neurosciences, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-higashi, Kodaira, Tokyo 187-8551, Japan
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25
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Crescimanno G, Greco F, D'Alia R, Messina L, Marrone O. Quality of life in long term ventilated adult patients with Duchenne muscular dystrophy. Neuromuscul Disord 2019; 29:569-575. [PMID: 31395305 DOI: 10.1016/j.nmd.2019.06.599] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/17/2019] [Accepted: 06/26/2019] [Indexed: 12/01/2022]
Abstract
The aim of this study was to evaluate quality of life (QoL) and its possible determinants in patients affected by Duchenne muscular dystrophy (DMD) in late stages of their disease, when non-invasive ventilation (NIV) is already established. Forty-eight DMD patients who were treated by NIV were enrolled. QoL was assessed by the Individualized Neuromuscular Quality of Life (INQoL) questionnaire. By this questionnaire, different aspects of QoL were assessed on a scale from 0 (best) to 100 (worst). In addition, motor and respiratory function tests were performed. Dysautonomia symptoms, sleep quality, sleepiness, anxiety, and depression were evaluated by validated questionnaires. The global INQoL score was 42.8 ± 19, reflecting a moderately altered QoL. The physical health domain was heavily impaired while the psychosocial domain was only mildly affected. Independence had the highest scores (81.1 ± 21.2), proving to be the most affected item. On multivariate analysis, maximal inspiratory pressure and Pittsburgh Sleep Quality Index, but not daily duration of NIV therapy, predicted global INQoL score. Respiratory impairment and sleep quality were independent predictors of poor QoL in DMD patients under NIV. Sleep quality in DMD is often disregarded, while it should be carefully addressed to ensure a better QoL.
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Affiliation(s)
- Grazia Crescimanno
- Italian National Research Council, Institute of Biomedicine and Molecular Immunology, Via Ugo La Malfa, 153, 90146 Palermo, Italy; Regional center for prevention and treatment of respiratory complications of rare genetic neuromuscular diseases, Villa Sofia-Cervello Hospital, Palermo, Italy.
| | | | | | - Luigi Messina
- Italian Union Against Muscular Dystrophy (UILDM), Italy
| | - Oreste Marrone
- Italian National Research Council, Institute of Biomedicine and Molecular Immunology, Via Ugo La Malfa, 153, 90146 Palermo, Italy
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26
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Dittrich S, Graf E, Trollmann R, Neudorf U, Schara U, Heilmann A, von der Hagen M, Stiller B, Kirschner J, Pozza RD, Müller-Felber W, Weiss K, von Au K, Khalil M, Motz R, Korenke C, Lange M, Wilichowski E, Pattathu J, Ebinger F, Wiechmann N, Schröder R. Effect and safety of treatment with ACE-inhibitor Enalapril and β-blocker metoprolol on the onset of left ventricular dysfunction in Duchenne muscular dystrophy - a randomized, double-blind, placebo-controlled trial. Orphanet J Rare Dis 2019; 14:105. [PMID: 31077250 PMCID: PMC6509833 DOI: 10.1186/s13023-019-1066-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 04/17/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND X-linked Duchenne muscular dystrophy (DMD), the most frequent human hereditary skeletal muscle myopathy, inevitably leads to progressive dilated cardiomyopathy. We assessed the effect and safety of a combined treatment with the ACE-inhibitor enalapril and the β-blocker metoprolol in a German cohort of infantile and juvenile DMD patients with preserved left ventricular function. METHODS TRIAL DESIGN Sixteen weeks single-arm open run-in therapy with enalapril and metoprolol followed by a two-arm 1:1 randomized double-blind placebo-controlled treatment in a multicenter setting. INCLUSION CRITERIA DMD boys aged 10-14 years with left ventricular fractional shortening [LV-FS] ≥ 30% in echocardiography. Primary endpoint: time from randomization to first occurrence of LV-FS < 28%. Secondary: changes of a) LV-FS from baseline, b) blood pressure, c), heart rate and autonomic function in ECG and Holter-ECG, e) cardiac biomarkers and neurohumeral serum parameters, f) quality of life, and g) adverse events. RESULTS From 3/2010 to 12/2013, 38 patients from 10 sites were centrally randomized after run-in, with 21 patients continuing enalapril and metoprolol medication and 17 patients receiving placebo. Until end of study 12/2015, LV-FS < 28% was reached in 6/21 versus 7/17 patients. Cox regression adjusted for LV-FS after run-in showed a statistically non-significant benefit for medication over placebo (hazard ratio: 0.38; 95% confidence interval: 0.12 to 1.22; p = 0.10). Analysis of secondary outcome measures revealed a time-dependent deterioration of LV-FS with no statistically significant differences between the two study arms. Blood pressure, maximal heart rate and mean-NN values were significantly lower at the end of open run-in treatment compared to baseline. Outcome analysis 19 months after randomization displayed significantly lower maximum heart rate and higher noradrenalin and renin values in the intervention group. No difference between treatments was seen for quality of life. As a single, yet important adverse event, the reversible deterioration of walking abilities of one DMD patient during the run-in period was observed. CONCLUSIONS Our analysis of enalapril and metoprolol treatment in DMD patients with preserved left ventricular function is suggestive to delay the progression of the intrinsic cardiomyopathy to left ventricular failure, but did not reach statistical significance, probably due to insufficient sample size. CLINICAL TRIAL REGISTRATION DRKS-number 00000115, EudraCT-number 2009-009871-36.
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Affiliation(s)
- Sven Dittrich
- Department Pediatric Cardiology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestraße 15, 91054, Erlangen, Germany. .,German Competence Network for Congenital Heart Defects partner site, Berlin, Germany.
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Regina Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrich Neudorf
- Clinic for Pediatrics III, University Hospital Essen, Essen, Germany
| | - Ulrike Schara
- Department of Neuropediatrics, University Hospital Essen, Essen, Germany
| | - Antje Heilmann
- Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Maja von der Hagen
- Department of Neurological Surgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Dresden, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, University Medical Center, Freiburg, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology, Ludwig Maximilians-University of Munich, Munich, Germany
| | - Wolfgang Müller-Felber
- Department of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians- University of Munich, Munich, Germany
| | - Katja Weiss
- Pediatric Cardiology and Congenital Heart Disease, University Hospital Charité, Berlin, Germany
| | - Katja von Au
- Department of Pediatrics, Division of Neurology, University Hospital Charité, Berlin, Germany
| | - Markus Khalil
- Division of Pediatric Heart Surgery, Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Reinald Motz
- Department of Pediatric Cardiology, Elisabeth Children's Hospital, Oldenburg, Germany
| | | | - Martina Lange
- Department of Pediatric Cardiology and Intensive Care Medicine, Heart Center, University Medical Center Göttingen, Göttingen, Germany
| | - Ekkehard Wilichowski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Joseph Pattathu
- Department of Pediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Nicola Wiechmann
- Clinical Trials Unit of the Medical Center, University of Freiburg, Freiburg, Germany
| | - Rolf Schröder
- Institute of Neuropathology, Erlangen University Hospital, Erlangen, Germany
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27
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Bell M, Biesecker BB, Bodurtha J, Peay HL. Uncertainty, hope, and coping efficacy among mothers of children with Duchenne/Becker muscular dystrophy. Clin Genet 2019; 95:677-683. [PMID: 30847900 DOI: 10.1111/cge.13528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 11/29/2022]
Abstract
Uncertainty is a challenging aspect of caring for children with Duchenne/Becker muscular dystrophies (DBMD). Although uncertainty is often perceived as a state to be avoided, hope may influence caregivers' perceptions of uncertainty as opportunity. The goal of this cross-sectional quantitative study was to pilot a novel measure of state-based hope, and test relationships among uncertainty, hope, spirituality, and coping efficacy in mothers of children with DBMD. Mothers (n = 202) were recruited through DuchenneConnect, Parent Project Muscular Dystrophy, and Cincinnati's Children Hospital. A one-component solution for the novel Parent Hope Scale explained 44.3% of the variance, and the measure showed high internal consistency. Higher hope (P < 0.001), further disease progression (P = 0.042), and older mother's age (P = 0.001) were significantly associated with lower perceptions of uncertainty. Mothers reporting less hope (P < 0.001), higher perceptions of uncertainty (P < 0.001), and less spirituality (P = 0.001) reported lower coping efficacy. As such, hope appears to be a key variable in shaping uncertainty appraisals and facilitating coping efficacy. While further research is needed, counseling aimed at bolstering hope, particularly among less-hopeful mothers, and interventions to reappraise uncertainty, may be helpful in promoting coping efficacy.
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Affiliation(s)
- Megan Bell
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland.,Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland.,Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Joann Bodurtha
- McKusick-Nathans Institute of Genetics Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Holly L Peay
- RTI International, Research Triangle Park, North Carolina
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28
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Camfield PR, Andrade D, Camfield CS, Carrizosa-Moog J, Appleton R, Baulac M, Brown L, Menachem EB, Cross H, Desguerre I, Grant C, Hosny H, Jurasek L, Mula M, Pfäfflin M, Rheims S, Ring H, Shellhaas RA, Vinayan KP, Wirrell E, Nabbout R. How can transition to adult care be best orchestrated for adolescents with epilepsy? Epilepsy Behav 2019; 93:138-147. [PMID: 30642688 DOI: 10.1016/j.yebeh.2018.12.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/16/2018] [Indexed: 01/03/2023]
Abstract
Objective evidence is limited for the value of transition programs for youth with chronic illness moving from pediatric to adult care; however, such programs intuitively "make sense". We describe the strengths and weaknesses of a variety of transition programs from around the world for adolescents with epilepsy. Consequences of poorly organized transition beyond suboptimal seizure control may include an increased risk of sudden unexpected death in epilepsy (SUDEP), poor psychological and social outcome, and inadequate management of comorbidities. The content of transition programs for those with normal intelligence differs from those with intellectual disability, but both groups may benefit from an emphasis on sporting activities. Concerns that may interfere with optimal transition include lack of nursing or social work services, limited numbers of adult neurologists/epileptologists confident in the treatment of complex pediatric epilepsy problems, institutional financial support, and time constraints for pediatric and adult physicians who treat epilepsy and the provision of multidisciplinary care. Successful programs eventually need to rely on a several adult physicians, nurses, and other key healthcare providers and use novel approaches to complex care. More research is needed to document the value and effectiveness of transition programs for youth with epilepsy to persuade institutions and healthcare professionals to support these ventures.
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Affiliation(s)
- Peter R Camfield
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Danielle Andrade
- Krembil Neurosciences Epilepsy Genetics Program, Division of Neurology, Department of Medicine, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Carole S Camfield
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jaime Carrizosa-Moog
- Pediatric Department - Adolescent Service, University of Antioquia School of Medicine, Medellín, Colombia
| | - Richard Appleton
- Department of Neurology, Alder Hey Children's Health Park, Liverpool, UK
| | - Michel Baulac
- Hopital Pitié-Salpêtrière, Sorbonne Université, Institut du Cerveau et de la Moelle, Paris, France
| | - Lawrence Brown
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eleonor Ben Menachem
- Institute of Clinical Neuroscience, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
| | - Helen Cross
- University College London, Great Ormond Street Institute of Child Health, London, UK; Great Ormond Street Hospital for Children, London, UK
| | - Isabelle Desguerre
- Department of Pediatric Neurology, Hôpital Necker Enfants Malades, Université Paris Descartes, Institut Imagine (INSERM UMR 1163), Paris, France
| | - Christina Grant
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Hassan Hosny
- Neurology Department, Cairo University, Cairo, Egypt
| | - Laura Jurasek
- Stollery Childrens Hospital and the University of Alberta, Edmonton, Alberta, Canada
| | - Marco Mula
- Institute of Medical and Biomedical Education, St George's University of London, London, UK; The Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and University of Lyon, Lyon, France; Lyon's Neuroscience Research Center, INSERM U1028, CNRS UMR5292, Lyon, France
| | - Howard Ring
- Department of Psychiatry, University of Cambridge, Cambridgeshire and Peterborough NHS Trust, UK
| | - Renée A Shellhaas
- Department of Pediatrics & Communicable Diseases, Division of Pediatric Neurology, Michigan Medicine, Ann Arbor, MI, USA
| | - K P Vinayan
- Division of Pediatric Neurology, Department of Neurology, Amrita Institute of Medical Sciences, Cochin, Kerala, India
| | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Rima Nabbout
- Department of Pediatric Neurology, Hôpital Necker Enfants Malades, Université Paris Descartes, Institut Imagine (INSERM UMR 1163), Paris, France
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Abstract
Muscular dystrophies represent a complex, varied, and important subset of neuromuscular disorders likely to require the care of a pulmonologist. The spectrum of conditions encapsulated by this subset ranges from severe and fatal congenital muscular dystrophies with onset in infancy to mild forms of limb and girdle weakness with onset in adulthood and minimal respiratory compromise. The list and classification of muscular dystrophies are undergoing near-constant revision, based largely on new insights from genetics and molecular medicine. The authors present an overview of the muscular dystrophies, including their basic features, common clinical phenotypes, and important facets of management.
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Jin JB, Carter JC, Sheehan DW, Birnkrant DJ. Cardiopulmonary phenotypic discordance is common in Duchenne muscular dystrophy. Pediatr Pulmonol 2019; 54:186-193. [PMID: 30549455 DOI: 10.1002/ppul.24205] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/29/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the prevalence of discordant cardiopulmonary function among patients with Duchenne muscular dystrophy (DMD) in our clinic. METHODS Retrospective chart review from 1999 to 2017. INCLUSION CRITERIA DMD patients age ≥ 18 years, alive, with discordant cardiopulmonary function. No patients received glucocorticoid therapy. Discordant cardiopulmonary function was defined as either: good heart function (EF ≥ 40%) and bad lung function (FVC < 1 L) (Group A); or, bad heart function (EF < 40%) and good lung function (FVC ≥ 1 L) (Group B). RESULTS Among 74 eligible patients, 25 patients (34%) had discordant cardiopulmonary function (21 patients in Group A and 4 patients in Group B). Three dystrophin mutations were shared by >2 patients (nine patients with deletion of exon 44; three patients with deletion of exon 51; three patients with duplication of exon 2). Among the 15 patients with a shared genotype, eight patients (53%) had discordant cardiopulmonary function (five patients in group A, three patients in group B). Twenty-six patients had a deletion involving or distal to exon 45. Ten of these patients (38%) had discordant cardiopulmonary function (eight patients in Group A, two patients in Group B). CONCLUSION In our cohort of DMD patients, discordant cardiopulmonary function was common (present in one-third of our patients), and the dystrophin genotype did not reliably predict a patient's cardiopulmonary phenotype. If confirmed by larger, multi-center studies, our findings have significant implications for predicting patient prognosis, evaluating DMD therapies, and designing new DMD therapies.
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Affiliation(s)
- Justin B Jin
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John C Carter
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Daniel W Sheehan
- Oishei Children's Hospital, University at Buffalo, Buffalo, New York
| | - David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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Dombernowsky NW, Ölmestig JNE, Witting N, Kruuse C. Role of neuronal nitric oxide synthase (nNOS) in Duchenne and Becker muscular dystrophies - Still a possible treatment modality? Neuromuscul Disord 2018; 28:914-926. [PMID: 30352768 DOI: 10.1016/j.nmd.2018.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/07/2018] [Accepted: 09/05/2018] [Indexed: 02/08/2023]
Abstract
Neuronal nitric oxide synthase (nNOS) is involved in nitric oxide (NO) production and suggested to play a crucial role in blood flow regulation of skeletal muscle. During activation of the muscle, NO helps attenuate the sympathetic vasoconstriction to accommodate increased metabolic demands, a phenomenon known as functional sympatholysis. In inherited myopathies such as the dystrophinopathies Duchenne and Becker muscle dystrophies (DMD and BMD), nNOS is lost from the sarcolemma. The loss of nNOS may cause functional ischemia contributing to skeletal and cardiac muscle cell injury. Effects of NO is augmented by inhibiting degradation of the second messenger cyclic guanosine monophosphate (cGMP) using sildenafil and tadalafil, both of which inhibit the enzyme phosphodiesterase 5 (PDE5). In animal models of DMD, PDE5-inhibitors prevent functional ischemia, reduce post-exercise skeletal muscle pathology and fatigue, show amelioration of cardiac muscle cell damage and increase cardiac performance. However, effect on clinical outcomes in DMD and BMD patients have been disappointing with minor effects on upper limb performance and none on ambulation. This review aims to summarize the current knowledge of nNOS function related to functional sympatholysis in skeletal muscle and studies on PDE5-inhibitor treatment in nNOS-deficient animal models and patients.
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Affiliation(s)
- Nanna W Dombernowsky
- Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Denmark
| | - Joakim N E Ölmestig
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Denmark
| | - Nanna Witting
- Department of Neurology, Rigshospitalet Glostrup, University of Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev Gentofte Hospital, University of Copenhagen, Denmark; PDE Research Group, Lundbeck Foundation Center for Neurovascular Research (LUCENS), Denmark.
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Deo P, Bach JR. Noninvasive ventilatory support to reverse weight loss in Duchenne muscular dystrophy: A case series. Pulmonology 2018; 25:79-82. [PMID: 30033339 DOI: 10.1016/j.pulmoe.2018.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/15/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022] Open
Abstract
This case series of five patients with Duchenne muscular dystrophy demonstrates the nutritional advantages of instituting noninvasive intermittent positive pressure ventilatory support via 15mm angled mouthpieces to relieve tachypnea and provide more time to swallow food safely. In each case weight loss was reversed.
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Affiliation(s)
- P Deo
- BA Rutgers University - New Jersey Medical School, Newark, NJ, USA
| | - J R Bach
- Department of Physical Medicine and Rehabilitation, Rutgers University - New Jersey Medical School, Newark, NJ, USA.
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Andrews JG, Conway K, Westfield C, Trout C, Meaney FJ, Mathews K, Ciafaloni E, Cunniff C, Fox DJ, Matthews D, Pandya S. Implementation of Duchenne Muscular Dystrophy Care Considerations. Pediatrics 2018; 142:peds.2017-4006. [PMID: 29925575 DOI: 10.1542/peds.2017-4006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is an X-linked disorder characterized by progressive muscle weakness and multisystem involvement. Recent advances in management of individuals with DMD have prolonged survival. Lack of standardized care spurred an international collaboration to develop consensus-based care considerations for diagnosis and management. In this study, we evaluate adherence to considerations at selected sites. METHODS We collaborated with the Muscular Dystrophy Surveillance, Tracking, and Research Network. Our sample included males with DMD and Becker muscular dystrophy <21 years as of December 31, 2010, with 1 health care encounter on or after January 1, 2012. We collected data from medical records on encounters occurring January 1, 2012, through December 31, 2014. Adherence was determined when frequency of visits or assessments were at or above recommendations for selected care considerations. RESULTS Our analytic sample included 299 individuals, 7% of whom (20/299) were classified as childhood-onset Becker muscular dystrophy. Adherence for neuromuscular and respiratory clinician visits was 65% for the cohort; neuromuscular assessments and corticosteroid side effect monitoring measures ranged from 16% to 68%. Adherence was 83% for forced vital capacity and ≤58% for other respiratory diagnostics. Cardiologist assessments and echocardiograms were found for at least 84%. Transition planning for education or health care was documented for 31% of eligible males. CONCLUSIONS Medical records data were used to identify areas in which practice aligns with the care considerations. However, there remains inconsistency across domains and insufficiency in critical areas. More research is needed to explain this variability and identify reliable methods to measure outcomes.
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Affiliation(s)
| | | | | | | | - F John Meaney
- Department of Pediatrics, University of Arizona, Tucson, Arizona
| | | | - Emma Ciafaloni
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Christopher Cunniff
- Department of Pediatrics, Weill Cornell Medical College, New York City, New York; and
| | - Deborah J Fox
- Bureau of Environmental and Occupational Epidemiology
| | - Dennis Matthews
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado, Aurora, Colorado
| | - Shree Pandya
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, New York
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Araujo APQC, Nardes F, Fortes CPDD, Pereira JA, Rebel MF, Dias CM, Barbosa RDCGA, Lopes MVR, Langer AL, Neves FR, Reis EF. Brazilian consensus on Duchenne muscular dystrophy. Part 2: rehabilitation and systemic care. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:481-489. [DOI: 10.1590/0004-282x20180062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 04/30/2018] [Indexed: 12/19/2022]
Abstract
ABSTRACT Significant advances in the understanding and management of Duchenne muscular dystrophy (DMD) have occurred since the publication of international guidelines for DMD care in 2010. Our objective was to provide an evidence-based national consensus statement for multidisciplinary care of DMD in Brazil. A combination of the Delphi technique with a systematic review of studies from 2010 to 2016 was employed to classify evidence levels and grade of recommendations for the guideline. Our recommendations were divided in two parts. Guideline methodology and overall disease concept descriptions are found in Part 1. Here we present Part 2, where we provide the results and recommendations on rehabilitation and systemic care for DMD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Edna Fátima Reis
- Associação Brasileira de Distrofia Muscular Viver Bem sem Limite, Brasil; Associação de Assistência à Criança Deficiente, Brasil
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Abstract
PURPOSE OF REVIEW Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness. Neuromuscular disorders (NMDs) are characterized by progressive muscle weakness, leading to pronounced and incapacitating physical disabilities. Most NMDs are not amenable to curative treatment and would thus qualify for palliative care. Amyotrophic lateral sclerosis is a relentlessly progressive disease, which leads to death about 2 years after onset due to respiratory muscle weakness. Increasingly, neurologists caring for these patients learn to apply the principles of palliative care. However, this does not yet apply to other well known and frequently occurring NMDs. RECENT FINDINGS There is sparse literature on palliative care in NMDs such as Duchenne muscular dystrophy, spinal muscular atrophy, muscular dystrophies, some congenital myopathies, Pompe's disease and myotonic dystrophy type 1. These NMDs are often associated with imminent respiratory insufficiency and/or heart failure leading to a reduced life expectancy. Reasons for underutilization may include misconceptions about palliative care amongst patients, family carers and healthcare professionals or lack of awareness of the usefulness of this approach in these severely affected patients and the possibilities of integration of palliative principles into care for children and adults with NMDs. SUMMARY There is an urgent need for increased attention to the development of palliative care in chronic progressive neuromuscular diseases associated with increasing functional incapacities and premature death. This will require education and training of the healthcare professionals, involvement of patient associations and funding to perform research.
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Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Colvin MK, Cripe L, Herron AR, Kennedy A, Kinnett K, Naprawa J, Noritz G, Poysky J, Street N, Trout CJ, Weber DR, Ward LM. Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Lancet Neurol 2018; 17:445-455. [PMID: 29398641 PMCID: PMC5902408 DOI: 10.1016/s1474-4422(18)30026-7] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 11/22/2017] [Accepted: 01/12/2018] [Indexed: 11/17/2022]
Abstract
Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Katharine Bushby
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | - Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Mary K Colvin
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Linda Cripe
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Adrienne R Herron
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA; Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Annie Kennedy
- Parent Project Muscular Dystrophy, Hackensack, NJ, USA
| | - Kathi Kinnett
- Parent Project Muscular Dystrophy, Hackensack, NJ, USA
| | - James Naprawa
- Emergency Department, University of California San Francisco Benioff Children's Hospital, Oakland, CA, USA
| | - Garey Noritz
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | - Natalie Street
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christina J Trout
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
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Pandya S, James KA, Westfield C, Thomas S, Fox DJ, Ciafaloni E, Moxley RT. Health profile of a cohort of adults with Duchenne muscular dystrophy. Muscle Nerve 2018; 58:219-223. [PMID: 29543994 DOI: 10.1002/mus.26129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION As the Duchenne muscular dystrophy (DMD) population ages, it is essential that we understand the late-stage health profile and provide the appropriate care for this emerging population. METHODS We undertook a descriptive study to document the health profile of a cohort of adults with DMD using data from the Muscular Dystrophy Surveillance Tracking and Research network (MD STARnet). Data included information collected from Arizona, Colorado, Iowa, Georgia, and 12 counties in western New York on individuals born since January 1982 and followed through December 2012. RESULTS In 208 adults with DMD, the number of individuals (N) and median ages (years) at which certain critical milestones were crossed and interventions initiated were as follows: development of cardiomyopathy, N = 145 (16.7); initiation of non-invasive ventilation, N = 99 (18.0); gastrostomy, N = 47 (19.0); and death, N = 59 (21.8). DISCUSSION These population-based data provide critical information about late-stage health profiles among adults with DMD for developing appropriate models of care. Muscle Nerve 58: 219-223, 2018.
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Affiliation(s)
- Shree Pandya
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
| | - Katherine A James
- Colorado School of Public Health, University of Colorado, Aurora Colorado, USA
| | | | - Shiny Thomas
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, Albany, New York, USA
| | - Deborah J Fox
- Congenital Malformations Registry, New York State Department of Health, Albany, New York, USA
| | - Emma Ciafaloni
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
| | - Richard T Moxley
- Department of Neurology, School of Medicine and Dentistry, University of Rochester, Rochester, Box 673, 601 Elmwood Avenue, New York, 14642, USA
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Kervin T, Thangarajh M. The Relationship Between Bone Mineral Density and Cardiovascular Function in Duchenne Muscular Dystrophy: A Retrospective Cohort Study. PLOS CURRENTS 2018; 10. [PMID: 29623244 PMCID: PMC5878101 DOI: 10.1371/currents.md.ee7ac0ec8c19a47b114737f9c2714779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION: Duchenne muscular dystrophy (DMD) is an X-linked genetic disorder that causes progressive skeletal and cardiac muscle weakness in boys. Cardiac dysfunction is a frequent cause of death in DMD. Glucocorticoids are the standard of care in DMD. The long-term use of oral glucocorticoids in DMD is complicated by poor bone health. Epidemiological studies suggest a biological link between the loss of bone mineral density (BMD) and cardiovascular disease, including coronary artery and cerebrovascular diseases. Whether an association between low BMD and cardiac dysfunction occurs in DMD boys has not yet been studied. The objective of this retrospective cohort study was to examine the relationship between BMD and cardiovascular health in DMD. METHODS: Retrospective data analyses was performed from de-identified medical records from a tertiary academic medical center. Whole body BMD was measured using dual-energy xray absorptiometry (DEXA) scan and left ventricular ejection fraction (LVEF) was measured using echocardiogram. Linear regression was used to evaluate the relationship between BMD and LVEF. RESULTS: Data was analyzed from a total of 32 boys with DMD. The mean age at which baseline BMD measurements was obtained of 11±3 (SD) years. The worst LVEF was measured at a mean of 23.7±21.8 (SD) months after the baseline BMD measurement. The final adjusted linear regression of the relationship between baseline BMD z-score and worst LVEF was not statistically significant (ß=0.41, p‑value=0.6455). DISCUSSION: In this cohort of boys with DMD, BMD was not associated with LVEF dysfunction up to 79 months later. Future research with a longer longitudinal follow-up period is warranted to evaluate the relationship between BMD and cardiovascular disease in DMD.
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Affiliation(s)
- Tara Kervin
- Statistics Collaborative, Inc., Washington, D.C., USA
| | - Mathula Thangarajh
- Department of Neurology, Children's National Health System, George Washington School of Medicine, Washington, D.C., USA
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Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Brumbaugh D, Case LE, Clemens PR, Hadjiyannakis S, Pandya S, Street N, Tomezsko J, Wagner KR, Ward LM, Weber DR. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and neuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional management. Lancet Neurol 2018; 17:251-267. [PMID: 29395989 PMCID: PMC5869704 DOI: 10.1016/s1474-4422(18)30024-3] [Citation(s) in RCA: 666] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 10/03/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022]
Abstract
Since the publication of the Duchenne muscular dystrophy (DMD) care considerations in 2010, multidisciplinary care of this severe, progressive neuromuscular disease has evolved. In conjunction with improved patient survival, a shift to more anticipatory diagnostic and therapeutic strategies has occurred, with a renewed focus on patient quality of life. In 2014, a steering committee of experts from a wide range of disciplines was established to update the 2010 DMD care considerations, with the goal of improving patient care. The new care considerations aim to address the needs of patients with prolonged survival, to provide guidance on advances in assessments and interventions, and to consider the implications of emerging genetic and molecular therapies for DMD. The committee identified 11 topics to be included in the update, eight of which were addressed in the original care considerations. The three new topics are primary care and emergency management, endocrine management, and transitions of care across the lifespan. In part 1 of this three-part update, we present care considerations for diagnosis of DMD and neuromuscular, rehabilitation, endocrine (growth, puberty, and adrenal insufficiency), and gastrointestinal (including nutrition and dysphagia) management.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Katharine Bushby
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | - Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | | | - David Brumbaugh
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, Aurora, CO, USA
| | - Laura E Case
- Doctor of Physical Therapy Division, Department of Orthopaedics, Duke University School of Medicine, Durham, NC, USA
| | - Paula R Clemens
- Department of Neurology, University of Pittsburgh School of Medicine, and Neurology Service, Department of Veterans Affairs Medical Center, Pittsburgh, PA, USA
| | - Stasia Hadjiyannakis
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
| | - Shree Pandya
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Natalie Street
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jean Tomezsko
- Medical Nutrition Consulting of Media LLC, and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathryn R Wagner
- Center for Genetic Muscle Disorders, Kennedy Krieger Institute, and Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
| | - David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Adachi K, Hashiguchi S, Saito M, Kashiwagi S, Miyazaki T, Kawai H, Yamada H, Iwase T, Akaike M, Takao S, Kobayashi M, Ishizaki M, Matsumura T, Mori-Yoshimura M, Kimura E. Detection and management of cardiomyopathy in female dystrophinopathy carriers. J Neurol Sci 2018; 386:74-80. [DOI: 10.1016/j.jns.2017.12.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/27/2017] [Accepted: 12/18/2017] [Indexed: 01/16/2023]
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A comparative study of care practices for young boys with Duchenne muscular dystrophy between Japan and European countries: Implications of early diagnosis. Neuromuscul Disord 2017; 27:894-904. [PMID: 28807665 DOI: 10.1016/j.nmd.2017.06.557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/29/2017] [Accepted: 06/30/2017] [Indexed: 11/20/2022]
Abstract
Early diagnosis of Duchenne muscular dystrophy (DMD) is widely advocated to initiate proactive interventions and genetic counselling. Genetic testing now allows the diagnosis of DMD even prior to the onset of symptoms. However, little is known about care practices and their impact on young DMD boys and families after receiving an early diagnosis. We analysed 64 young boys (Japan, 19; the United Kingdom, 10; Germany, 18; Hungary, 6; Poland, 5; and the Czech Republic, 6) aged <5 years and diagnosed at ≤2 years old among the participants of the cross-sectional study about care practice in DMD. A combination of elevated serum creatine kinase and genetic testing usually led to the diagnosis (n = 31, 48%); 41 boys visited neuromuscular clinics more than once a year. Early diagnosis did not generally result in higher satisfaction among DMD families, and country-specific differences were observed. Psychosocial support following early diagnosis was perceived as insufficient in most countries, and deficits in access and uptake of genetic counselling resulted in lower satisfaction in the Japanese cohort. In conclusion, seamless and comprehensive support for DMD families following early diagnosis at presymptomatic stages should be taken into consideration if early genetic testing or newborn screening is made available more widely.
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