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Giannotta G, Ruggiero M, De Rinaldis M, Trabacca A. Exploring variability in cognitive functioning in patients with spinal muscular atrophy: a scoping review. Neurol Sci 2024; 45:3699-3710. [PMID: 38580877 DOI: 10.1007/s10072-024-07503-x] [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: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 04/07/2024]
Abstract
The cognitive functioning of individuals with spinal muscular atrophy (SMA) is not well understood, prompting a call for more research to better grasp cognitive involvement in SMA. This study aims to explore recent findings regarding cognitive outcomes in SMA patients, including correlations between clinical features and cognitive abilities. The investigation seeks to identify commonly used measures for assessing cognitive function in this patient population. A scoping review following the Joanna Briggs Institute methodology examined literature until December 2023. Two databases were searched along with relevant article references using specific terms such as "spinal muscular atrophy," "SMA," "cognitive," "abilities," "functions," "intellective," or "intellectual." Screening focused on titles and abstracts from English language peer-reviewed journals. After the initial research, 1452 articles were identified. Subsequent screening and selection led to the inclusion of 13 articles in the review. Among these studies, four indicated a cognitive trend within the normal range for SMA patients. In four other studies, the majority of patients fell within the normal range. However, smaller proportions were observed to be either above or below the norm compared to the controls. Three studies reported noted cognitive performance below the average, while two showed above-average scores. The scoping review suggests that most SMA patients have cognitive abilities similar to the general population, with types II and III showing even lesser impact. However, certain cognitive domains may be affected in type I patients, highlighting the need for further research to fully understand cognitive involvement in SMA.
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Affiliation(s)
- Gabriele Giannotta
- Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Associazione "La Nostra Famiglia" - IRCCS "E. Medea", Scientific Hospital for Neurorehabilitation, Brindisi, Italy
| | - Marta Ruggiero
- Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Associazione "La Nostra Famiglia" - IRCCS "E. Medea", Scientific Hospital for Neurorehabilitation, Brindisi, Italy
| | - Marta De Rinaldis
- Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Associazione "La Nostra Famiglia" - IRCCS "E. Medea", Scientific Hospital for Neurorehabilitation, Brindisi, Italy
| | - Antonio Trabacca
- Scientific Institute IRCCS "E. Medea", Scientific Direction, Via Don L. Monza 20, 23842, Bosisio Parini (LC), Italy.
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Steffens P, Weiss D, Perez A, Appel M, Weber P, Weiss C, Stoltenburg C, Ehinger U, von der Hagen M, Schallner J, Claussen B, Lode I, Hahn A, Schuler R, Ruß L, Ziegler A, Denecke J, Johannsen J. Cognitive function in SMA patients with 2 or 3 SMN2 copies treated with SMN-modifying or gene addition therapy during the first year of life. Eur J Paediatr Neurol 2024; 51:17-23. [PMID: 38772209 DOI: 10.1016/j.ejpn.2024.05.002] [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: 02/12/2024] [Revised: 04/15/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Spinal muscular atrophy (SMA) is a neuromuscular disease, causing progressive muscle weakness due to loss of lower motoneurons. Since 2017, three therapies, two modifying gene transcription and one adding the defective gene, have been approved with comparable efficacy on motor outcome. Data on cognitive outcomes of treated SMA type 1 patients is limited. The aim of this study was to evaluate cognitive function in symptomatic and presymptomatic SMA type 1 patients with two or three SMN2 copies who received SMN-modifying or gene-addition therapy in the first year of life. METHODS Cognitive testing was performed in 20 patients, including 19 symptomatic SMA type 1 patients with up to three SMN2 copies and 1 pre-symptomatically treated patient. Children were tested using Bayley Scales of Infant Development (BSID-III) at the age of 2 or 3 years or the Wechsler Preschool and Primary Scale of Intelligence (WPSII-IV) at the of age of 5 years. RESULTS 11/20 patients showed subnormal cognitive development. Boys had significantly lower cognitive scores. Patients requiring assisted ventilation or feeding support were more likely to have cognitive deficits. Achieving more motor milestones was associated with a better cognitive outcome. CONCLUSION Treated patients with SMA type 1 have heterogeneous cognitive function with 55 % of patients showing deficits. Risk factors for cognitive impairment in our cohort were male gender and need for assisted ventilation or feeding support. Therefore, cognitive assessment should be included in the standard of care to allow early identification of deficits and potential therapeutic interventions.
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Affiliation(s)
- Paula Steffens
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany.
| | - Deike Weiss
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany
| | - Anna Perez
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany
| | - Manuel Appel
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany
| | - Philipp Weber
- University Medical Center Hamburg-Eppendorf, Institute of Medical Biometry and Epidemiology, Hamburg, Germany
| | - Claudia Weiss
- Charité Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Corinna Stoltenburg
- Charité Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ute Ehinger
- Charité Universitätsmedizin Berlin, Department of Pediatric Neurology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jens Schallner
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Birte Claussen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ilka Lode
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andreas Hahn
- Department of General Pediatrics and Neonatology and Department of Child Neurology, University Hospital, Gießen, Germany
| | - Rahel Schuler
- Department of General Pediatrics and Neonatology and Department of Child Neurology, University Hospital, Gießen, Germany
| | - Lena Ruß
- Department of General Pediatrics and Neonatology and Department of Child Neurology, University Hospital, Gießen, Germany
| | - Andreas Ziegler
- Division of Child Neurology and Metabolic Medicine, Center for Child and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jonas Denecke
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany
| | - Jessika Johannsen
- University Medical Center Hamburg-Eppendorf, Department of Pediatrics, Hamburg, Germany
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Hu Y, Wei L, Li A, Liu T, Jiang Y, Xie C, Wang K. Cognitive impairment in Chinese adult patients with type III spinal muscular atrophy without disease-modifying treatment. Front Neurol 2023; 14:1226043. [PMID: 38020636 PMCID: PMC10655145 DOI: 10.3389/fneur.2023.1226043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Spinal muscular atrophy (SMA) is a neurodegenerative disorder characterized by the degeneration of motor neurons in the spinal cord. It remains uncertain whether the cognitive performance of adult patients with SMA is impaired. The objective of this study was to assess the cognitive profile of adult Chinese patients with SMA and the association between clinical features and cognitive ability, particularly executive function. Methods This cross-sectional study included 22 untreated adult patients with type III SMA and 20 healthy subjects. The following variables were assessed: general intelligence, memory, attention, language, executive function, depression, anxiety, and other demographic and clinical parameters. In addition, physical function was evaluated using the Hammersmith Functional Motor Scale Expanded (HFMSE), the Revised Upper Limb Module (RULM), and the 6-Minute Walk Test (6MWT). Results SMA patients had lower scores than healthy subjects in the Verbal Fluency Test, Stroop effect, Total Errors, Perseverative Responses, Perseverative Errors, and Non-perseverative Errors in the Wisconsin Card Sorting Test, showing impaired abilities of SMA patients in executive function. In the Attention Network Test (ANT), the results indicated that the SMA patients also had selective deficits in their executive control networks. Ambulant patients had better executive function test performance than non-ambulant ones. Compromised executive abilities in patients with SMA were correlated with a younger age at onset, poorer motor function, and higher levels of anxiety and depression. Conclusion Our study presented the distribution of cognitive impairment in a Chinese cohort with SMA. Patients with type III SMA showed selective deficits in executive function, which may be associated with disease severity, physical impairment, depression and anxiety. Future cognitive studies, accounting for motor and emotional impairment, are needed to evaluate if executive impairment is driven by specific brain changes or by those confounding factors.
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Affiliation(s)
- Ying Hu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Ling Wei
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Aonan Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Tingting Liu
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Yubao Jiang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Chengjuan Xie
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
- Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China
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Tosi M, Cumbo F, Catteruccia M, Carlesi A, Mizzoni I, De Luca G, Cherchi C, Cutrera R, Bertini E, D'Amico A. Neurocognitive profile of a cohort of SMA type 1 pediatric patients and emotional aspects, resilience and coping strategies of their caregivers. Eur J Paediatr Neurol 2023; 43:36-43. [PMID: 36893678 DOI: 10.1016/j.ejpn.2023.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 02/14/2023] [Accepted: 02/19/2023] [Indexed: 03/06/2023]
Abstract
Spinal muscular atrophy (SMA) type 1 represents the most severe condition of the spectrum of SMA 5q. In the absence of therapeutic interventions, patients do not achieve any motor milestone and their life expectancy does not exceed two years of age. To date, three disease-modifying drugs have been approved for SMA type I. These treatments have radically changed the natural history of the disease, improving motor, respiratory and bulbar functions. In recent years huge amount of data have been collected worldwide related to motor, respiratory and swallowing function outcome in treated patients, whereas the neurocognitive profile of treated patients has been poorly explored. Here we report the neurocognitive development profile of a cohort of SMA type I children treated with a disease modifying therapy. We also describe the burden and resilience as well as the coping strategies of their caregivers. Our finding show a global developmental delay in most patients and defects in gross motor functions contribute most to lower the general development quotient of Griffiths III, whereas the scores obtained on evaluating learning and language abilities scales suggest a positive trend in the developmental trajectory of general neurocognitive abilities. Some parents reported anxiety and stress but overall they were resilient (and had good coping strategies towards the burden of care for their child. These results reinforce the importance of routinely assessing the neurocognitive aspects in SMA type I patients and to offer an early intervention to favor the psychosocial development of these children.
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Affiliation(s)
- Michele Tosi
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Cumbo
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Michela Catteruccia
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adelina Carlesi
- Developmental Neurology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Irene Mizzoni
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giacomo De Luca
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudio Cherchi
- Center for Pediatric Palliative Care, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Enrico Bertini
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adele D'Amico
- Unit of Muscular and Neurodegenerative Disorders, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Yae Y, Yuge K, Maeda T, Ichinose F, Matsuo M, Kobayashi O, Okanari K, Baba Y, Yonee C, Maruyama S, Shibata M, Fujii T, Chinen M, Yamashita Y. Exploratory evaluation of an eye-tracking system in patients with advanced spinal muscular atrophy type I receiving nusinersen. Front Neurol 2022; 13:918255. [PMID: 36247789 PMCID: PMC9563313 DOI: 10.3389/fneur.2022.918255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThis study evaluated the feasibility of a matching-pair test using eye-tracking technology to assess nusinersen effectiveness in patients with advanced spinal muscular atrophy (SMA) type I.MethodsThis prospective, observational study enrolled patients with 5q-SMA type I who had lost gross motor function. Three different levels of matching-pair tests were conducted using the eye-gaze system (My Tobii; TobiiDynavox Inc.) at baseline, and after 9 and 24 weeks of nusinersen treatment. The primary endpoint was the change from baseline in matching-pair test scores and response times (i.e., the time to answer matching-pair test) at 24 weeks from baseline. Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND), Pediatric Quality of Life inventory for patients with Neuromuscular Disease (PedsQL-NM) and Numerical Rating Scale (NRS) scores were also assessed as secondary endpoints. Analysis of ocular fixation was performed as an additional analysis. This study was registered at https://www.umin.ac.jp/ctr/ (UMIN000033935).ResultsSeven patients (one male, six female) aged 5–21 years (median 11 years) were enrolled; all patients were bedridden and six patients were ventilated. All seven patients were able to conduct level 1 matching-pair tests at each assessment; five patients were also able to conduct levels 2 and 3. Two patients (those with the highest CHOP-INTEND scores) were able to complete all tests correctly within 60 s. There was a non-significant trend toward improvement in CHOP-INTEND, PedsQL-NM, and NRS scores over the 6-month period. There were no significant differences in the number of actions, errors, correct answers, or response times between baseline and Week 9 or 24 at any level. However, the result of an additional analysis suggests that detection of eye movement would be useful to evaluate for advanced SMA.ConclusionsEye-tracking systems are possibly feasible for the assessment of treatment efficacy in patients with advanced SMA type I.
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Affiliation(s)
- Yukako Yae
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kotaro Yuge
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
- *Correspondence: Kotaro Yuge
| | - Toshiyuki Maeda
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumio Ichinose
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Osamu Kobayashi
- Department of Pediatrics, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kazuo Okanari
- Department of Pediatrics, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Yusei Baba
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Chihiro Yonee
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Shinsuke Maruyama
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Minoru Shibata
- Department of Pediatrics, Shiga Medical Center for Children, Moriyama, Japan
| | - Tatsuya Fujii
- Department of Pediatrics, Shiga Medical Center for Children, Moriyama, Japan
| | | | - Yushiro Yamashita
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Losito L, Gennaro L, Lucarelli E, Trabacca A. Brain MRI abnormalities in a child with spinal muscular atrophy type II. Acta Neurol Belg 2021; 121:1883-1885. [PMID: 33079332 DOI: 10.1007/s13760-020-01524-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/08/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Luciana Losito
- Scientific Institute I.R.C.C.S. "Eugenio Medea", "La Nostra Famiglia", Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Brindisi Research Centre, Ex Complesso Ospedaliero "A. Di Summa", Piazza "A. Di Summa", 72100, Brindisi, Italy
| | - Leonarda Gennaro
- Scientific Institute I.R.C.C.S. "Eugenio Medea", "La Nostra Famiglia", Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Brindisi Research Centre, Ex Complesso Ospedaliero "A. Di Summa", Piazza "A. Di Summa", 72100, Brindisi, Italy
| | - Elisabetta Lucarelli
- Scientific Institute I.R.C.C.S. "Eugenio Medea", "La Nostra Famiglia", Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Brindisi Research Centre, Ex Complesso Ospedaliero "A. Di Summa", Piazza "A. Di Summa", 72100, Brindisi, Italy
| | - Antonio Trabacca
- Scientific Institute I.R.C.C.S. "Eugenio Medea", "La Nostra Famiglia", Unit for Severe Disabilities in Developmental Age and Young Adults (Developmental Neurology and Neurorehabilitation), Brindisi Research Centre, Ex Complesso Ospedaliero "A. Di Summa", Piazza "A. Di Summa", 72100, Brindisi, Italy.
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Assessing Cognitive Function in Neuromuscular Diseases: A Pilot Study in a Sample of Children and Adolescents. J Clin Med 2021; 10:jcm10204777. [PMID: 34682900 PMCID: PMC8537027 DOI: 10.3390/jcm10204777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 12/29/2022] Open
Abstract
Central nervous system (CNS) involvement has been variously studied in pediatric neuromuscular disorders (NMDs). The primary goal of this study was to assess cognitive functioning in NMDs, and secondary aims were to investigate possible associations of cognitive impairment with motor impairment, neurodevelopmental delay, and genotype. This was a cross-sectional study of 43 pediatric patients, affected by six NMDs. Myotonic dystrophy type 1 (DM1) and glycogen storage disease type 2 (GSD2) patients had a delay on the Bayley-III scales. On Wechsler scales, DMD and DM1 patients showed lower FSIQ scores, with an intellectual disability (ID) in 27% and 50%, respectively. FSIQ was normal in Becker muscular dystrophy (BMD), GSD2, and hereditary motor sensory neuropathy (HMSN) patients, while higher individual scores were found in the spinal muscular atrophy (SMA) group. In the DM1 cohort, lower FSIQ correlated with worse motor performance (ρ = 0.84, p < 0.05), and delayed speech acquisition was associated with ID (p = 0.048), with worse cognitive impairment in the congenital than in the infantile form (p = 0.04). This study provides further evidence of CNS in some NMDs and reinforces the need to include cognitive assessment in protocols of care of selected pediatric NMDs.
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Kizina K, Akkaya Y, Jokisch D, Stolte B, Totzeck A, Munoz-Rosales J, Thimm A, Bolz S, Brakemeier S, Pul R, Aslan D, Hackert J, Kleinschnitz C, Hagenacker T. Cognitive Impairment in Adult Patients with 5q-Associated Spinal Muscular Atrophy. Brain Sci 2021; 11:brainsci11091184. [PMID: 34573206 PMCID: PMC8471736 DOI: 10.3390/brainsci11091184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
In previous studies, a below-average, average, or above-average intelligence quotient (IQ) in children with SMA was detected but, aside from a severe physical disability, the cognitive performance of adult SMA patients has not yet been evaluated. The intelligence test used in this study, the Wechsler Adult Intelligence Scale, fourth edition (WAIS-IV), was used to measure major intelligence components of adult SMA patients. The WAIS-IV determines four index scores representing verbal comprehension, perceptual reasoning, working memory, and processing speed. Due to time-dependent demands on motor function, the processing speed index score was excluded. IQ index scores of 33 adult SMA patients did not differ from IQ index scores of the normal population. In SMA type-3 patients, the index scores for verbal comprehension, perceptual reasoning, and working memory did not differ from the normal population but showed a trend of IQ scores towards lower points. Patients with SMA type 2 had lower IQ index scores for working memory (90.33 ± 12.95; p = 0.012) and perceptual reasoning (90.73 ± 12.58; p = 0.013) than the normal population. This study provided further evidence that SMA is a multi-systemic disease and may refute the widespread hypothesis that SMA patients might improve their cognitive skills to compensate for their physical impairment.
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McKenna MC, Corcia P, Couratier P, Siah WF, Pradat PF, Bede P. Frontotemporal Pathology in Motor Neuron Disease Phenotypes: Insights From Neuroimaging. Front Neurol 2021; 12:723450. [PMID: 34484106 PMCID: PMC8415268 DOI: 10.3389/fneur.2021.723450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/22/2021] [Indexed: 01/18/2023] Open
Abstract
Frontotemporal involvement has been extensively investigated in amyotrophic lateral sclerosis (ALS) but remains relatively poorly characterized in other motor neuron disease (MND) phenotypes such as primary lateral sclerosis (PLS), progressive muscular atrophy (PMA), spinal muscular atrophy (SMA), spinal bulbar muscular atrophy (SBMA), post poliomyelitis syndrome (PPS), and hereditary spastic paraplegia (HSP). This review focuses on insights from structural, metabolic, and functional neuroimaging studies that have advanced our understanding of extra-motor disease burden in these phenotypes. The imaging literature is limited in the majority of these conditions and frontotemporal involvement has been primarily evaluated by neuropsychology and post mortem studies. Existing imaging studies reveal that frontotemporal degeneration can be readily detected in ALS and PLS, varying degree of frontotemporal pathology may be captured in PMA, SBMA, and HSP, SMA exhibits cerebral involvement without regional predilection, and there is limited evidence for cerebral changes in PPS. Our review confirms the heterogeneity extra-motor pathology across the spectrum of MNDs and highlights the role of neuroimaging in characterizing anatomical patterns of disease burden in vivo. Despite the contribution of neuroimaging to MND research, sample size limitations, inclusion bias, attrition rates in longitudinal studies, and methodological constraints need to be carefully considered. Frontotemporal involvement is a quintessential clinical facet of MND which has important implications for screening practices, individualized management strategies, participation in clinical trials, caregiver burden, and resource allocation. The academic relevance of imaging frontotemporal pathology in MND spans from the identification of genetic variants, through the ascertainment of presymptomatic changes to the design of future epidemiology studies.
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Affiliation(s)
- Mary Clare McKenna
- Computational Neuroimaging Group, Trinity College Dublin, Dublin, Ireland
| | - Philippe Corcia
- Department of Neurology-Neurophysiology, CRMR ALS, Tours, France.,UMR 1253 iBrain, University of Tours, Tours, France.,LITORALS, Federation of ALS Centres: Tours-Limoges, Limoges, France
| | - Philippe Couratier
- LITORALS, Federation of ALS Centres: Tours-Limoges, Limoges, France.,ALS Centre, Limoges University Hospital (CHU de Limoges), Limoges, France
| | - We Fong Siah
- Computational Neuroimaging Group, Trinity College Dublin, Dublin, Ireland
| | | | - Peter Bede
- Computational Neuroimaging Group, Trinity College Dublin, Dublin, Ireland.,Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
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Masson R, Brusa C, Scoto M, Baranello G. Brain, cognition, and language development in spinal muscular atrophy type 1: a scoping review. Dev Med Child Neurol 2021; 63:527-536. [PMID: 33452688 DOI: 10.1111/dmcn.14798] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/01/2023]
Abstract
AIM To summarize the current knowledge on brain involvement in spinal muscular atrophy (SMA) type 1, focusing on brain pathology, cognition, and speech/language development. METHOD A scoping review was performed using the methodology of the Joanna Briggs Institute. Five databases and references from relevant articles were searched up to December 2019. Articles were screened on the basis of titles and abstracts. Full-text papers published in peer-reviewed journals in English were selected. RESULTS Nineteen articles met eligibility criteria. Eight case series/reports on brain pathology showed abnormalities in few SMA type 0/1 cases, supported by findings in three post-mortem examinations in mice. Four studies (three case-control, one cross-sectional) on cognition reported contradictory results, with impaired cognitive performances in recent, small groups with SMA type 1. Four studies (three cross-sectional, one observational) on speech/language showed that untreated SMA type 1 patients rarely achieve functional and intelligible speech, with data limited to parent reports/non-formal evaluations. INTERPRETATION Brain involvement is an under-investigated aspect of SMA type 1, requiring further exploration in longitudinal studies. A deeper knowledge of brain involvement would improve the interpretation of clinical phenotypes and the personalization of rehabilitation programmes supporting patients' autonomies and quality of life. Additionally, it may help to define further outcome measures testing the efficacy of current and new developing drugs on this domain. WHAT THIS PAPER ADDS Brain involvement is under-investigated in spinal muscular atrophy (SMA) type 1. Neuropathological data suggest progressive brain involvement in severe forms of SMA. Impaired cognitive performances are reported in small groups with SMA type 1. Data on language in those with SMA type 1 are limited to parent reports and non-formal assessments.
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Affiliation(s)
- Riccardo Masson
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Chiara Brusa
- The Dubowitz Neuromuscular Centre, UCL NIHR GOSH Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK.,Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy.,Department of Public Health and Paediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Mariacristina Scoto
- The Dubowitz Neuromuscular Centre, UCL NIHR GOSH Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Giovanni Baranello
- Developmental Neurology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.,The Dubowitz Neuromuscular Centre, UCL NIHR GOSH Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK
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Zappa G, LoMauro A, Baranello G, Cavallo E, Corti P, Mastella C, Costantino MA. Intellectual abilities, language comprehension, speech, and motor function in children with spinal muscular atrophy type 1. J Neurodev Disord 2021; 13:9. [PMID: 33530934 PMCID: PMC7856807 DOI: 10.1186/s11689-021-09355-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/19/2021] [Indexed: 11/18/2022] Open
Abstract
Background Spinal muscular atrophy (SMA) is a chronic, neuromuscular disease characterized by degeneration of spinal cord motor neurons, resulting in progressive muscular atrophy and weakness. SMA1 is the most severe form characterized by significant bulbar, respiratory, and motor dysfunction. SMA1 prevents children from speaking a clearly understandable and fluent language, with their communication being mainly characterized by eye movements, guttural sounds, and anarthria (type 1a); severe dysarthria (type 1b); and nasal voice and dyslalia (type 1c). The aim of this study was to analyze for the first time cognitive functions, language comprehension, and speech in natural history SMA1 children according to age and subtypes, to develop cognitive and language benchmarks that provide outcomes for the clinical medication trials that are changing SMA1 course/trajectory. Methods This is a retrospective study including 22 children with SMA1 (10 affected by subtype 1a-1b: AB and 12 by 1c: C) aged 3–11 years in clinical stable condition with a coded way to communicate “yes” and “no”. Data from the following assessments have been retrieved from patient charts: one-dimensional Raven test (RCPM), to evaluate cognitive development (IQ); ALS Severity Score (ALSSS) to evaluate speech disturbances; Brown Bellugy modified for Italian standards (TCGB) to evaluate language comprehension; and Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) to assess motor functioning. Results SMA 1AB and 1C children were similar in age, with the former characterized by lower CHOP-INTEND scores compared to the latter. All 22 children had collaborated to RCPM and their median IQ was 120 with no difference (p = 0.945) between AB and C. Global median score of the speech domain of the ALSSS was 5; however, it was 2 in AB children, being significantly lower than C (6.5, p < 0.001). TCGB test had been completed by 13 children, with morphosyntactic comprehension being in the normal range (50). Although ALSSS did not correlate with both IQ and TCGB, it had a strong (p < 0.001) correlation with CHOP-INTEND described by an exponential rise to maximum. Conclusions Although speech and motor function were severely compromised, children with SMA1 showed general intelligence and language comprehension in the normal range. Speech impairment was strictly related to global motor impairment.
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Affiliation(s)
- Grazia Zappa
- SAPRE, Child and Adolescent Neuropsychiatric Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Viale Ungheria 29, 20138, Milan, Italy.
| | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo Da Vinci, Milan, Italy
| | - Giovanni Baranello
- Dubowitz Neuromuscular Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London, UK.,UO Neurologia dello Sviluppo, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Emilia Cavallo
- Child and Adolescent Neuropsychiatric Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Priscilla Corti
- SAPRE, Child and Adolescent Neuropsychiatric Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Viale Ungheria 29, 20138, Milan, Italy
| | - Chiara Mastella
- SAPRE, Child and Adolescent Neuropsychiatric Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Viale Ungheria 29, 20138, Milan, Italy
| | - Maria Antonella Costantino
- Child and Adolescent Neuropsychiatric Service, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Tharaneetharan A, Cole M, Norman B, Romero NC, Wooltorton JRA, Harrington MA, Sun J. Functional Abnormalities of Cerebellum and Motor Cortex in Spinal Muscular Atrophy Mice. Neuroscience 2020; 452:78-97. [PMID: 33212215 DOI: 10.1016/j.neuroscience.2020.10.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
Spinal muscular atrophy (SMA) is a devastating genetic neuromuscular disease. Diffuse neuropathology has been reported in SMA patients and mouse models, however, functional changes in brain regions have not been studied. In the SMNΔ7 mouse model, we identified three types of differences in neuronal function in the cerebellum and motor cortex from two age groups: P7-9 (P7) and P11-14 (P11). Microelectrode array studies revealed significantly lower spontaneous firing and network activity in the cerebellum of SMA mice in both age groups, but it was more profound in the P11 group. In the motor cortex, however, neural activity was not different in either age group. Whole-cell patch-clamp was used to study the function of output neurons in both brain regions. In cerebellar Purkinje cells (PCs) of SMA mice, the input resistance was larger at P7, while capacitance was smaller at P11. In the motor cortex, no difference was observed in the passive membrane properties of layer V pyramidal neurons (PN5s). The action potential threshold of both types of output neurons was depolarized in the P11 group. We also observed lower spontaneous excitatory and inhibitory synaptic activity in PN5s and PCs respectively from P11 SMA mice. Overall, these differences suggest functional alterations in the neural network in these motor regions that change during development. Our results also suggest that neuronal dysfunction in these brain regions may contribute to the pathology of SMA. Comprehensive treatment strategies may consider motor regions outside of the spinal cord for better outcomes.
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Affiliation(s)
- Arumugarajah Tharaneetharan
- Delaware Center for Neuroscience Research, Department of Biological Sciences, Delaware State University, Dover, DE, USA
| | - Madison Cole
- Department of Psychology, Washington College, Chestertown, MD, USA
| | - Brandon Norman
- Department of Biology, Salisbury University, Salisbury, MD, USA
| | - Nayeli C Romero
- Department of Agriculture and Natural Science, Delaware State University, Dover, DE, USA
| | - Julian R A Wooltorton
- Delaware Center for Neuroscience Research, Department of Biological Sciences, Delaware State University, Dover, DE, USA
| | - Melissa A Harrington
- Delaware Center for Neuroscience Research, Department of Biological Sciences, Delaware State University, Dover, DE, USA
| | - Jianli Sun
- Delaware Center for Neuroscience Research, Department of Biological Sciences, Delaware State University, Dover, DE, USA.
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Polido GJ, de Miranda MMV, Carvas N, Mendonça RDH, Caromano FA, Reed UC, Zanoteli E, Voos MC. Cognitive performance of children with spinal muscular atrophy: A systematic review. Dement Neuropsychol 2019; 13:436-443. [PMID: 31844498 PMCID: PMC6907703 DOI: 10.1590/1980-57642018dn13-040011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Spinal muscular atrophy (SMA) is genetic and progressive, caused by large
bi-allelic deletions in the SMN1 gene, or the association of a large deletion
and a null variant.
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Affiliation(s)
- Graziela Jorge Polido
- Programa de Pós-Graduação em Ciências da Reabilitação, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | | | - Nelson Carvas
- Programa de Pós-Graduação em Ciências da Saúde do Instituto de Assistência Médica ao Servidor Público Estadual de São Paulo, SP, Brasil
| | - Rodrigo de Holanda Mendonça
- Departamento de Neurologia, Departamento de Neurologia Clínica, Universidade Federal de São Paulo, SP, Brasil
| | - Fátima Aparecida Caromano
- Programa de Pós-Graduação em Ciências da Reabilitação, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
| | - Umbertina Conti Reed
- Departamento de Neurologia, Departamento de Neurologia Clínica, Universidade Federal de São Paulo, SP, Brasil
| | - Edmar Zanoteli
- Departamento de Neurologia, Departamento de Neurologia Clínica, Universidade Federal de São Paulo, SP, Brasil
| | - Mariana Callil Voos
- Programa de Pós-Graduação em Ciências da Reabilitação, Faculdade de Medicina, Universidade de São Paulo, SP, Brasil
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Mendonça RH, Rocha AJ, Lozano‐Arango A, Diaz AB, Castiglioni C, Silva AMS, Reed UC, Kulikowski L, Paramonov I, Cuscó I, Tizzano EF, Zanoteli E. Severe brain involvement in 5q spinal muscular atrophy type 0. Ann Neurol 2019; 86:458-462. [DOI: 10.1002/ana.25549] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Rodrigo H. Mendonça
- Department of Neurology, Faculdade de MedicinaUniversidade de São Paulo (FMUSP) São Paulo Brazil
| | - Antônio J. Rocha
- Neuroradiology SectionHigh Diagnostic Excellence (DASA Group) São Paulo Brazil
| | | | - Astry B. Diaz
- Hernan Henriquez Aravena Regional Hospital Temuco Chile
| | | | - André M. S. Silva
- Department of Neurology, Faculdade de MedicinaUniversidade de São Paulo (FMUSP) São Paulo Brazil
| | - Umbertina C. Reed
- Department of Neurology, Faculdade de MedicinaUniversidade de São Paulo (FMUSP) São Paulo Brazil
| | - Leslie Kulikowski
- Department of Pathology, Faculdade de MedicinaUniversidade de São Paulo (FMUSP) São Paulo Brazil
| | - Ida Paramonov
- Department of Clinical and Molecular Genetics, Valle Hebron University HospitalMedicine Genetics Group, Valle Hebron Research Institute Barcelona Spain
| | - Ivon Cuscó
- Department of Clinical and Molecular Genetics, Valle Hebron University HospitalMedicine Genetics Group, Valle Hebron Research Institute Barcelona Spain
| | - Eduardo F. Tizzano
- Department of Clinical and Molecular Genetics, Valle Hebron University HospitalMedicine Genetics Group, Valle Hebron Research Institute Barcelona Spain
| | - Edmar Zanoteli
- Department of Neurology, Faculdade de MedicinaUniversidade de São Paulo (FMUSP) São Paulo Brazil
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Ball LJ, Chavez S, Perez G, Bharucha-Goebel D, Smart K, Kundrat K, Carruthers L, Brady C, Leach M, Evans S. Communication skills among children with spinal muscular atrophy type 1: A parent survey. Assist Technol 2019; 33:38-48. [DOI: 10.1080/10400435.2019.1586788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Laura J. Ball
- Center for Translational Science, Children’s National Health System, Washington DC, USA
- Department of Physical Medicine and Rehabilitation, Children’s National Health System, Washington DC, USA
| | - Stephen Chavez
- Department of Nutrition, Children’s National Health System, Washington DC, USA
| | - Geovanny Perez
- Department of Pulmonology, Children’s National Health System, Washington DC, USA
| | | | - Kathleen Smart
- Department of Neurology, Children’s National Health System, Washington DC, USA
| | - Katherine Kundrat
- Department of Physical Medicine and Rehabilitation, Children’s National Health System, Washington DC, USA
| | - Lauren Carruthers
- Department of Physical Medicine and Rehabilitation, Children’s National Health System, Washington DC, USA
| | - Caitlin Brady
- Department of Physical Medicine and Rehabilitation, Children’s National Health System, Washington DC, USA
| | - Meganne Leach
- Department of Pediatrics, Oregon Health Science University, Portland, Oregon, USA
| | - Sally Evans
- Department of Physical Medicine and Rehabilitation, Children’s National Health System, Washington DC, USA
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Al-Zaidy S, Pickard AS, Kotha K, Alfano LN, Lowes L, Paul G, Church K, Lehman K, Sproule DM, Dabbous O, Maru B, Berry K, Arnold WD, Kissel JT, Mendell JR, Shell R. Health outcomes in spinal muscular atrophy type 1 following AVXS-101 gene replacement therapy. Pediatr Pulmonol 2019; 54:179-185. [PMID: 30548438 PMCID: PMC6590370 DOI: 10.1002/ppul.24203] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/04/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal Muscular Atrophy type 1 (SMA1) is a rare genetic neuromuscular disease where 75% of SMA1 patients die/require permanent-ventilation by 13.6 months. This study assessed the health outcomes of SMA1 infants treated with AVXS-101 gene replacement therapy. METHODS Twelve genetically confirmed SMA1 infants with homozygous deletions of the SMN1 gene and two SMN2 gene copies received a one-time intravenous proposed therapeutic dose of AVXS-101 in an open label study conducted between December 2014 and 2017. Patients were followed for 2-years post-treatment for outcomes including (1) pulmonary interventions; (2) nutritional interventions; (3) swallow function; (4) hospitalization rates; and (5) motor function. RESULTS All 12 patients completed the study. Seven infants did not require noninvasive ventilation (NIV) by study completion. Eleven patients had stable or improved swallow function, demonstrated by the ability to feed orally; 11 patients were able to speak. The mean proportion of time hospitalized was 4.4%; the mean unadjusted annualized hospitalization rate was 2.1 (range = 0, 7.6), with a mean length of stay/hospitalization of 6.7 (range = 3, 12.1) days. Eleven patients achieved full head control and sitting unassisted and two patients were walking independently. CONCLUSIONS AVXS-101 treatment in SMA1 was associated with reduced pulmonary and nutritional support requirements, improved motor function, and decreased hospitalization rate over the follow-up period. This contrasts with the natural history of progressive respiratory failure and reduced survival. The reduced healthcare utilization could potentially alleviate patient and caregiver burden, suggesting an overall improved quality of life following gene replacement therapy. TRIAL REGISTRATION ClinicalTrials.gov number, NCT02122952.
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Affiliation(s)
- Samiah Al-Zaidy
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois, Chicago, Illinois
| | - Kavitha Kotha
- Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - Lindsay N Alfano
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - Linda Lowes
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - Grace Paul
- Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - Kathleen Church
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - Kelly Lehman
- Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | | | | | | | - Katherine Berry
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio
| | - W David Arnold
- Department of Neurology, Ohio State University, Columbus, Ohio
| | - John T Kissel
- Department of Pediatrics, Ohio State University, Columbus, Ohio
| | - Jerry R Mendell
- Department of Pediatrics, Ohio State University, Columbus, Ohio.,Center for Gene Therapy Nationwide Children's Hospital, Columbus, Ohio.,Department of Neurology, Ohio State University, Columbus, Ohio
| | - Richard Shell
- Department of Pediatrics, Ohio State University, Columbus, Ohio
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