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Erdem Ozdamar S, Koc AF, Durmus Tekce H, Kotan D, Ekmekci AH, Sengun IS, Yuceyar AN, Uluc K. Expert opinion on the diagnostic odyssey and management of late-onset Pompe disease: a neurologist's perspective. Front Neurol 2023; 14:1095134. [PMID: 37265469 PMCID: PMC10229878 DOI: 10.3389/fneur.2023.1095134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/14/2023] [Indexed: 06/03/2023] Open
Abstract
This consensus statement by a panel of neurology experts aimed to provide a practical and implementable guidance document to assist clinicians with the best clinical practice in terms of diagnosis, treatment, and monitoring of late-onset Pompe disease (LOPD). The participating experts consider the clinical suspicion of LOPD by the physician to be of utmost importance in the prevention of diagnostic and therapeutic delay in LOPD patients. A diagnostic algorithm is proposed to facilitate the diagnosis of LOPD in patients presenting with unexplained proximal/axial weakness (with or without respiratory symptoms) or restrictive respiratory insufficiency with hyperCKemia and/or exercise intolerance as the red flag symptoms/signs that raise the index of suspicion for LOPD diagnosis. The diagnosis is based on the subsequent use of dried blood spot (DBS) assay, and the DBS assay can be confirmed by acid alpha-glucosidase (GAA) tissue analysis in leukocytes, fibroblasts, or muscle fibers and/or genetic mutation analysis. Accordingly, experts consider increased awareness among physicians about potential presenting characteristics with a high index of suspicion for LOPD to be crucial to suspect and consider LOPD in the differential diagnosis, while strongly suggesting the use of a diagnostic algorithm combined with DBS assay and confirmatory tests in the timely diagnosis of LOPD and implementation of best practice patterns.
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Affiliation(s)
- Sevim Erdem Ozdamar
- Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Ayse Filiz Koc
- Department of Neurology, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Hacer Durmus Tekce
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Dilcan Kotan
- Department of Neurology, Sakarya University Faculty of Medicine, Sakarya, Türkiye
| | - Ahmet Hakan Ekmekci
- Department of Neurology, Selcuk University Faculty of Medicine, Konya, Türkiye
| | - Ihsan Sukru Sengun
- Department of Neurology, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
| | - Ayse Nur Yuceyar
- Department of Neurology, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Kayihan Uluc
- Department of Neurology, Marmara University School of Medicine, Istanbul, Türkiye
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Lin S, Nateqi J, Weingartner-Ortner R, Gruarin S, Marling H, Pilgram V, Lagler FB, Aigner E, Martin AG. An artificial intelligence-based approach for identifying rare disease patients using retrospective electronic health records applied for Pompe disease. Front Neurol 2023; 14:1108222. [PMID: 37153672 PMCID: PMC10160659 DOI: 10.3389/fneur.2023.1108222] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/03/2023] [Indexed: 05/10/2023] Open
Abstract
Objective We retrospectively screened 350,116 electronic health records (EHRs) to identify suspected patients for Pompe disease. Using these suspected patients, we then describe their phenotypical characteristics and estimate the prevalence in the respective population covered by the EHRs. Methods We applied Symptoma's Artificial Intelligence-based approach for identifying rare disease patients to retrospective anonymized EHRs provided by the "University Hospital Salzburg" clinic group. Within 1 month, the AI screened 350,116 EHRs reaching back 15 years from five hospitals, and 104 patients were flagged as probable for Pompe disease. Flagged patients were manually reviewed and assessed by generalist and specialist physicians for their likelihood for Pompe disease, from which the performance of the algorithms was evaluated. Results Of the 104 patients flagged by the algorithms, generalist physicians found five "diagnosed," 10 "suspected," and seven patients with "reduced suspicion." After feedback from Pompe disease specialist physicians, 19 patients remained clinically plausible for Pompe disease, resulting in a specificity of 18.27% for the AI. Estimating from the remaining plausible patients, the prevalence of Pompe disease for the greater Salzburg region [incl. Bavaria (Germany), Styria (Austria), and Upper Austria (Austria)] was one in every 18,427 people. Phenotypes for patient cohorts with an approximated onset of symptoms above or below 1 year of age were established, which correspond to infantile-onset Pompe disease (IOPD) and late-onset Pompe disease (LOPD), respectively. Conclusion Our study shows the feasibility of Symptoma's AI-based approach for identifying rare disease patients using retrospective EHRs. Via the algorithm's screening of an entire EHR population, a physician had only to manually review 5.47 patients on average to find one suspected candidate. This efficiency is crucial as Pompe disease, while rare, is a progressively debilitating but treatable neuromuscular disease. As such, we demonstrated both the efficiency of the approach and the potential of a scalable solution to the systematic identification of rare disease patients. Thus, similar implementation of this methodology should be encouraged to improve care for all rare disease patients.
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Affiliation(s)
- Simon Lin
- Science Department, Symptoma GmbH, Vienna, Austria
- Department of Internal Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jama Nateqi
- Science Department, Symptoma GmbH, Vienna, Austria
- Department of Internal Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | | | | | - Vinzenz Pilgram
- Medical and Information Technology - MIT, University Hospital Salzburg (SALK), Salzburg, Austria
| | - Florian B. Lagler
- Medical and Information Technology - MIT, University Hospital Salzburg (SALK), Salzburg, Austria
- Department of Pediatrics and Institute for Inherited Metabolic Diseases, Paracelsus Medical University, Salzburg, Austria
| | - Elmar Aigner
- Department of Internal Medicine, Paracelsus Medical University, Salzburg, Austria
- Medical and Information Technology - MIT, University Hospital Salzburg (SALK), Salzburg, Austria
| | - Alistair G. Martin
- Science Department, Symptoma GmbH, Vienna, Austria
- *Correspondence: Alistair G. Martin
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Al Shehri A, Al-Asmi A, Al Salti AM, Almadani A, Hassan A, Bamaga AK, Cupler EJ, Al-Hashel J, Alabdali MM, Alanazy MH, Noori S. A Multidisciplinary Perspective Addressing the Diagnostic Challenges of Late-Onset Pompe Disease in the Arabian Peninsula Region Developed From an Expert Group Meeting. J Neuromuscul Dis 2022; 9:661-673. [PMID: 35754286 PMCID: PMC9535603 DOI: 10.3233/jnd-220819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pompe disease is a rare, metabolic, autosomal recessive disorder. Early diagnosis is critical for progressive Pompe disease as delays can significantly alter the clinical course of the disease. Diagnostic modalities, including dried blood spot testing and genetic testing, are available and are effective for diagnosing patients with late-onset Pompe disease (LOPD). However, clinicians face numerous clinical challenges related to the diagnosis of the disease. Two expert group committee meetings, involving 11 experts from the United Arab Emirates, Kuwait, the Kingdom of Saudi Arabia, and Oman, were convened in October 2019 and November 2020 respectively to develop a uniform diagnostic algorithm for the diagnosis of pediatric and adult LOPD in the Arabian Peninsula region. During the first meeting, the specialty-specific clinical presentation of LOPD was defined. During the second meeting, a diagnostic algorithm was developed after a thorough validation of clinical presentation or symptoms, which was performed with the aid of existing literature and expert judgement. A consensus was reached on the diagnostic algorithm for field specialists, such as neurologists, rheumatologists, general practitioners/internal medicine specialists, orthopedic specialists, and pulmonologists. This specialty-specific diagnostic referral algorithm for pediatric and adult LOPD will guide clinicians in the differential diagnosis of LOPD.
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Affiliation(s)
- Ali Al Shehri
- Neuromuscular Integrated Practice Unit, Neuroscience Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdullah Al-Asmi
- Neurology Unit, Medicine Department, College of Medicine and Health Sciences andSultan Qabos University Hospital, Sultan Qaboos University, Muscat, Oman
| | | | | | - Ali Hassan
- Head of Neurology Department, Tawam Hospital, AlAin, Abu Dhabi, UAE
| | - Ahmed K Bamaga
- Neurology Division, Pediatric Department, Faculty of Medicine, King Abdulaziz University Hospital, King Abdulaziz University, Pediatric Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Edward J Cupler
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Jasem Al-Hashel
- Head of Department Neurology, Ebn Sina Neurosurgery Center, Al Jahra, Kuwait
| | - Majed M Alabdali
- Department of Neurology, College of Medicine, Imam Abdulrahman bin Faisal University
| | - Mohammed H Alanazy
- Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Suzan Noori
- Head of Department Neurology, University Hospital of Sharjah (UHS), Milahah, UAE
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Harlaar L, Ciet P, van Tulder G, Pittaro A, van Kooten HA, van der Beek NAME, Brusse E, Wielopolski PA, de Bruijne M, van der Ploeg AT, Tiddens HAWM, van Doorn PA. Chest MRI to diagnose early diaphragmatic weakness in Pompe disease. Orphanet J Rare Dis 2021; 16:21. [PMID: 33413525 PMCID: PMC7789462 DOI: 10.1186/s13023-020-01627-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background In Pompe disease, an inherited metabolic muscle disorder, severe diaphragmatic weakness often occurs. Enzyme replacement treatment is relatively ineffective for respiratory function, possibly because of irreversible damage to the diaphragm early in the disease course. Mildly impaired diaphragmatic function may not be recognized by spirometry, which is commonly used to study respiratory function. In this cross-sectional study, we aimed to identify early signs of diaphragmatic weakness in Pompe patients using chest MRI. Methods Pompe patients covering the spectrum of disease severity, and sex and age matched healthy controls were prospectively included and studied using spirometry-controlled sagittal MR images of both mid-hemidiaphragms during forced inspiration. The motions of the diaphragm and thoracic wall were evaluated by measuring thoracic cranial-caudal and anterior–posterior distance ratios between inspiration and expiration. The diaphragm shape was evaluated by measuring the height of the diaphragm curvature. We used multiple linear regression analysis to compare different groups. Results We included 22 Pompe patients with decreased spirometry results (forced vital capacity in supine position < 80% predicted); 13 Pompe patients with normal spirometry results (forced vital capacity in supine position ≥ 80% predicted) and 18 healthy controls. The mean cranial-caudal ratio was only 1.32 in patients with decreased spirometry results, 1.60 in patients with normal spirometry results and 1.72 in healthy controls (p < 0.001). Anterior–posterior ratios showed no significant differences. The mean height ratios of the diaphragm curvature were 1.41 in patients with decreased spirometry results, 1.08 in patients with normal spirometry results and 0.82 in healthy controls (p = 0.001), indicating an increased curvature of the diaphragm during inspiration in Pompe patients. Conclusions Even in early-stage Pompe disease, when spirometry results are still within normal range, the motion of the diaphragm is already reduced and the shape is more curved during inspiration. MRI can be used to detect early signs of diaphragmatic weakness in patients with Pompe disease, which might help to select patients for early intervention to prevent possible irreversible damage to the diaphragm.
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Affiliation(s)
- Laurike Harlaar
- Center for Lysosomal and Metabolic Diseases, Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Pierluigi Ciet
- Departments of Radiology and Nuclear Medicine, Paediatrics, and Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Gijs van Tulder
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alice Pittaro
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harmke A van Kooten
- Center for Lysosomal and Metabolic Diseases, Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Nadine A M E van der Beek
- Center for Lysosomal and Metabolic Diseases, Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Esther Brusse
- Center for Lysosomal and Metabolic Diseases, Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Piotr A Wielopolski
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marleen de Bruijne
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Ans T van der Ploeg
- Center for Lysosomal and Metabolic Diseases, Department of Paediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harm A W M Tiddens
- Departments of Radiology and Nuclear Medicine, Paediatrics, and Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter A van Doorn
- Center for Lysosomal and Metabolic Diseases, Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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