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Nona RJ, Henderson RD, McCombe PA. Neutrophil-to-lymphocyte ratio at diagnosis as a biomarker for survival of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:452-464. [PMID: 38745425 DOI: 10.1080/21678421.2024.2351187] [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: 11/01/2023] [Revised: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION The neutrophil-to-lymphocyte ratio (NLR) has previously been reported to be associated with survival in ALS. To provide further information about the role of NLR as a biomarker in ALS, we performed a systematic review, analyzed data from our local cohort of ALS subjects and performed a meta-analysis. METHODS (1) The systematic review used established methods. (2) Using data from our cohort of subjects, we analyzed the association of NLR with survival. (3) Meta-analysis was performed using previous studies and our local data. RESULTS (1) In the systematic review, higher NLR was associated with shorter survival in all studies. (2) In our subjects, survival was significantly shorter in patients in the highest NLR groups. (3) Meta-analysis showed subjects with highest NLR tertile or with NLR >3 had significantly shorter survival than other subjects. DISCUSSION This study supports NLR as a biomarker in ALS; high NLR is associated with poor survival.
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Affiliation(s)
- Robert J Nona
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia and
| | - Robert D Henderson
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia and
- Department of Neurology, The Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Pamela A McCombe
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia and
- Department of Neurology, The Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
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2
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Riva N, Domi T, Pozzi L, Lunetta C, Schito P, Spinelli EG, Cabras S, Matteoni E, Consonni M, Bella ED, Agosta F, Filippi M, Calvo A, Quattrini A. Update on recent advances in amyotrophic lateral sclerosis. J Neurol 2024; 271:4693-4723. [PMID: 38802624 PMCID: PMC11233360 DOI: 10.1007/s00415-024-12435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
In the last few years, our understanding of disease molecular mechanisms underpinning ALS has advanced greatly, allowing the first steps in translating into clinical practice novel research findings, including gene therapy approaches. Similarly, the recent advent of assistive technologies has greatly improved the possibility of a more personalized approach to supportive and symptomatic care, in the context of an increasingly complex multidisciplinary line of actions, which remains the cornerstone of ALS management. Against this rapidly growing background, here we provide an comprehensive update on the most recent studies that have contributed towards our understanding of ALS pathogenesis, the latest results from clinical trials as well as the future directions for improving the clinical management of ALS patients.
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Affiliation(s)
- Nilo Riva
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy.
| | - Teuta Domi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pozzi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Christian Lunetta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Milan Institute, 20138, Milan, Italy
| | - Paride Schito
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Gioele Spinelli
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Cabras
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico Matteoni
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Monica Consonni
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Eleonora Dalla Bella
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Federica Agosta
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Massimo Filippi
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Andrea Calvo
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Al-kuraishy HM, Jabir MS, Sulaiman GM, Mohammed HA, Al-Gareeb AI, Albuhadily AK, Jawad SF, Swelum AA, Abomughaid MM. The role of statins in amyotrophic lateral sclerosis: protective or not? Front Neurosci 2024; 18:1422912. [PMID: 38903602 PMCID: PMC11188367 DOI: 10.3389/fnins.2024.1422912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease of motor neurons characterized by muscle weakness, muscle twitching, and muscle wasting. ALS is regarded as the third-most frequent neurodegenerative disease, subsequent to Alzheimer's disease (AD) and Parkinson's disease (PD). The World Health Organization (WHO) in 2007 declared that prolonged use of statins may induce development of ALS-like syndrome and may increase ALS risk. Subsequently, different studies have implicated statins in the pathogenesis of ALS. In contrast, results from preclinical and clinical studies highlighted the protective role of statins against ALS neuropathology. Recently, meta-analyses and systematic reviews illustrated no association between long-term use of statins and ALS risk. These findings highlighted controversial points regarding the effects of statins on ALS pathogenesis and risk. The neuroprotective effects of statins against the development and progression of ALS may be mediated by regulating dyslipidemia and inflammatory changes. However, the mechanism for induction of ALS neuropathology by statins may be related to the dysregulation of liver X receptor signaling (LXR) signaling in the motor neurons and reduction of cholesterol, which has a neuroprotective effect against ALS neuropathology. Nevertheless, the exact role of statins on the pathogenesis of ALS was not fully elucidated. Therefore, this narrative review aims to discuss the role of statins in ALS neuropathology.
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Affiliation(s)
- Hayder M. Al-kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, Mustansiriyah University, Baghdad, Iraq
| | - Majid S. Jabir
- Department of Applied Sciences, University of Technology, Baghdad, Iraq
| | | | - Hamdoon A. Mohammed
- Department of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
- Department of Pharmacognosy and Medicinal Plants, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Ali I. Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, Jabir Ibn Hayyan Medical University, Kufa, Iraq
| | - Ali K. Albuhadily
- Department of Clinical Pharmacology and Medicine, College of Medicine, Mustansiriyah University, Baghdad, Iraq
| | - Sabrean F. Jawad
- Department of Pharmacy, Al-Mustaqbal University College, Hillah, Iraq
| | - Ayman A. Swelum
- Department of Animal Production, King Saud University, Riyadh, Saudi Arabia
| | - Mosleh M. Abomughaid
- Department of Medical Laboratory Sciences, College of Applied Medical Sciences, University of Bisha, Bisha, Saudi Arabia
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Tappenden P, Hardiman O, Kwon SH, Mon-Yee M, Galvin M, McDermott C. A Model-Based Economic Evaluation of Hypothetical Treatments for Amyotrophic Lateral Sclerosis in the UK: Implications for Pricing of New and Emerging Health Technologies. PHARMACOECONOMICS 2024:10.1007/s40273-024-01395-7. [PMID: 38819717 DOI: 10.1007/s40273-024-01395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a devastating disease which leads to loss of muscle function and paralysis. Historically, clinical drug development has been unsuccessful, but promising disease-modifying therapies (DMTs) may be on the horizon. OBJECTIVES The aims of this study were to estimate survival, quality-adjusted life-years (QALYs) and costs under current care, and to explore the conditions under which new therapies might be considered cost effective. METHODS We developed a health economic model to evaluate the cost effectiveness of future ALS treatments from a UK National Health Service and Personal Social Services perspective over a lifetime horizon using data from the ALS-CarE study. Costs were valued at 2021/22 prices. Two hypothetical interventions were evaluated: a DMT which delays progression and mortality, and a symptomatic therapy which improves utility only. Sensitivity analysis was conducted to identify key drivers of cost effectiveness. RESULTS Starting from King's stage 2, patients receiving current care accrue an estimated 2.27 life-years, 0.75 QALYs and lifetime costs of £68,047. Assuming a 50% reduction in progression rates and a UK-converted estimate of the price of edaravone, the incremental cost-effectiveness ratio for a new DMT versus current care is likely to exceed £735,000 per QALY gained. Symptomatic therapies may be more likely to achieve acceptable levels of cost effectiveness. CONCLUSIONS Regardless of efficacy, DMTs may struggle to demonstrate cost effectiveness, even at a low price. The cost effectiveness of DMTs is likely to be strongly influenced by drug price, the magnitude and durability of relative treatment effects, treatment starting/stopping rules and any additional utility benefits over current care.
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Affiliation(s)
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | | | - Mon Mon-Yee
- SCHARR, University of Sheffield, Sheffield, UK
| | - Miriam Galvin
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
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Parnianpour P, Benatar M, Briemberg H, Dey A, Dionne A, Dupré N, Evans KC, Frayne R, Genge A, Graham SJ, Korngut L, McLaren DG, Seres P, Welsh RC, Wilman A, Zinman L, Kalra S. Mismatch between clinically defined classification of ALS stage and the burden of cerebral pathology. J Neurol 2024; 271:2547-2559. [PMID: 38282082 DOI: 10.1007/s00415-024-12190-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: 11/16/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/30/2024]
Abstract
This study aimed to investigate the clinical stratification of amyotrophic lateral sclerosis (ALS) patients in relation to in vivo cerebral degeneration. One hundred forty-nine ALS patients and one hundred forty-four healthy controls (HCs) were recruited from the Canadian ALS Neuroimaging Consortium (CALSNIC). Texture analysis was performed on T1-weighted scans to extract the texture feature "autocorrelation" (autoc), an imaging biomarker of cerebral degeneration. Patients were stratified at baseline into early and advanced disease stages based on criteria adapted from ALS clinical trials and the King's College staging system, as well as into slow and fast progressors (disease progression rates, DPR). Patients had increased autoc in the internal capsule. These changes extended beyond the internal capsule in early-stage patients (clinical trial-based criteria), fast progressors, and in advanced-stage patients (King's staging criteria). Longitudinal increases in autoc were observed in the postcentral gyrus, corticospinal tract, posterior cingulate cortex, and putamen; whereas decreases were observed in corpus callosum, caudate, central opercular cortex, and frontotemporal areas. Both longitudinal increases and decreases of autoc were observed in non-overlapping regions within insula and precentral gyrus. Within-criteria comparisons of autoc revealed more pronounced changes at baseline and longitudinally in early- (clinical trial-based criteria) and advanced-stage (King's staging criteria) patients and fast progressors. In summary, comparative patterns of baseline and longitudinal progression in cerebral degeneration are dependent on sub-group selection criteria, with clinical trial-based stratification insufficiently characterizing disease stage based on pathological cerebral burden.
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Affiliation(s)
- Pedram Parnianpour
- Neuroscience and Mental Health Institute, University of Alberta, 562 Heritage Medical Research Centre, 11313-87 Ave, Edmonton, AB, T6G2S2, Canada.
| | - Michael Benatar
- Department of Neurology, University of Miami Miller School of Medicine, Miami, USA
| | - Hannah Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Avyarthana Dey
- Neuroscience and Mental Health Institute, University of Alberta, 562 Heritage Medical Research Centre, 11313-87 Ave, Edmonton, AB, T6G2S2, Canada
| | - Annie Dionne
- Axe Neurosciences, CHU de Québec-Université Laval, Québec City, QC, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Nicolas Dupré
- Axe Neurosciences, CHU de Québec-Université Laval, Québec City, QC, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | | | - Richard Frayne
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Angela Genge
- Montreal Neurological Institute, McGill University, Montreal, Canada
| | - Simon J Graham
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Lawrence Korngut
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | | | - Peter Seres
- Department of Biomedical Engineering, University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Alan Wilman
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Lorne Zinman
- Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Sanjay Kalra
- Neuroscience and Mental Health Institute, University of Alberta, 562 Heritage Medical Research Centre, 11313-87 Ave, Edmonton, AB, T6G2S2, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, Canada
- Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Stenson K, Fecteau TE, O'Callaghan L, Bryden P, Mellor J, Wright J, Earl L, Thomas O, Iqbal H, Barlow S, Parvanta S. Health-related quality of life across disease stages in patients with amyotrophic lateral sclerosis: results from a real-world survey. J Neurol 2024; 271:2390-2404. [PMID: 38200398 PMCID: PMC11055770 DOI: 10.1007/s00415-023-12141-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is characterized by a rapid disease course, with disease severity being associated with declining health-related quality of life (HRQoL) in persons living with ALS (pALS). The main objective of this study was to assess the impact of disease progression on HRQoL across King's, Milano-Torino Staging (MiToS), and physician-judgement clinical staging. Additionally, we evaluated the impact of the disease on the HRQoL of care partners (cALS). METHODS Data were sourced from the Adelphi ALS Disease Specific Programme (DSP)™, a cross-sectional survey of neurologists, pALS and cALS presenting in a real-world clinical setting between July 2020 and March 2021 in Europe and the United States. RESULTS Neurologists (n = 142) provided data for 880 pALS. There were significant negative correlations between all three clinical staging systems and EuroQol (European Quality of Life) Five Dimension Five Level Scale (EQ-5D-5L) utility scores and visual analogue scale (VAS) ratings. Although not all differences were significant, 5-item Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-5) scores showed a stepwise increase in HRQoL impairment at each stage of the disease regardless of the staging system. At later stages, high levels of fatigue and substantial activity impairment were reported. As pALS disease states progressed, cALS also experienced a decline in HRQoL and increased burden. CONCLUSIONS Across outcomes, pALS and cALS generally reported worse outcomes at later stages of the disease, highlighting an unmet need in this population for strategies to maximise QoL despite disease progression. Recognition and treatment of symptoms such as pain and fatigue may lead to improved outcomes for pALS and cALS.
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Affiliation(s)
| | | | - L O'Callaghan
- Biogen, Cambridge, MA, USA
- Sage Therapeutics, Boston, MA, USA
| | | | - J Mellor
- Adelphi Real World, Bollington, UK
| | - J Wright
- Adelphi Real World, Bollington, UK
| | - L Earl
- Adelphi Real World, Bollington, UK
| | - O Thomas
- Adelphi Real World, Bollington, UK
| | - H Iqbal
- Adelphi Real World, Bollington, UK
| | - S Barlow
- Adelphi Real World, Bollington, UK
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Gebrehiwet P, Aggarwal S, Topaloglu O, Chiò A. Feasibility assessment of using the MiToS staging system for conducting economic evaluation in amyotrophic lateral sclerosis. Expert Rev Pharmacoecon Outcomes Res 2024; 24:447-458. [PMID: 38235589 DOI: 10.1080/14737167.2024.2306819] [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: 11/10/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVES This study assessed the feasibility of using the Milano-Torino staging (MiToS) system for conducting economic evaluation to measure health outcomes in amyotrophic lateral sclerosis (ALS). METHODS A Markov model was developed using the MiToS system and evaluated with a hypothetical treatment versus standard of care. Health utilities and transition probabilities were derived from the literature. Four-time horizons (1, 5, 10, and 20 years) were examined. Treatment effects of 20-35% relative risk reduction (RRR) of progressing to the next MiToS stage were assessed. Three patient distribution scenarios were tested: (1) all patients began in stage 0; (2) patient distribution based on real-world TONiC study; (3) distribution based on the PRO-ACT database. Health outcomes (quality-adjusted life-years [QALYs], life-years [LYs]) were reported with a 3% discount rate. RESULTS A time horizon of 10 years fully captured treatment benefits: incremental QALYs were 0.28-0.60, 0.21-0.45, and 0.26-0.55 for scenarios 1-3, respectively; incremental LYs were 0.56-1.17, 0.46-0.97, and 0.53-1.11, respectively. CONCLUSION MiToS-based staging can be used for conducting economic analyses in ALS. Estimated incremental QALY and LY gains were meaningful within the context of ALS, for hypothetical treatments with RRR of 20-35%.
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Affiliation(s)
- Paulos Gebrehiwet
- Health Economics and Outcomes Research, Cytokinetics, Incorporated, South San Francisco, CA, USA
| | | | | | - Adriano Chiò
- 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
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Di Lazzaro V, Ranieri F, Bączyk M, de Carvalho M, Dileone M, Dubbioso R, Fernandes S, Kozak G, Motolese F, Ziemann U. Novel approaches to motoneuron disease/ALS treatment using non-invasive brain and spinal stimulation: IFCN handbook chapter. Clin Neurophysiol 2024; 158:114-136. [PMID: 38218077 DOI: 10.1016/j.clinph.2023.12.012] [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: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024]
Abstract
Non-invasive brain stimulation techniques have been exploited in motor neuron disease (MND) with multifold objectives: to support the diagnosis, to get insights in the pathophysiology of these disorders and, more recently, to slow down disease progression. In this review, we consider how neuromodulation can now be employed to treat MND, with specific attention to amyotrophic lateral sclerosis (ALS), the most common form with upper motoneuron (UMN) involvement, taking into account electrophysiological abnormalities revealed by human and animal studies that can be targeted by neuromodulation techniques. This review article encompasses repetitive transcranial magnetic stimulation methods (including low-frequency, high-frequency, and pattern stimulation paradigms), transcranial direct current stimulation as well as experimental findings with the newer approach of trans-spinal direct current stimulation. We also survey and discuss the trials that have been performed, and future perspectives.
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Affiliation(s)
- Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy.
| | - Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Marcin Bączyk
- Department of Neurobiology, Poznań University of Physical Education, Królowej Jadwigi Street 27/39, 61-871 Poznań, Poland
| | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine-JLA, Egas Moniz Study Centre, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal; Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - Michele Dileone
- Faculty of Health Sciences, UCLM Talavera de la Reina, Toledo, Spain; Neurology Department, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Raffaele Dubbioso
- Neurophysiology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Sofia Fernandes
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016-Lisboa, Portugal
| | - Gabor Kozak
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Francesco Motolese
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Ulf Ziemann
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Cassereau J, Bernard E, Genestet S, Chebbah M, Le Clanche S, Verschueren A, Couratier P. Management of amyotrophic lateral sclerosis in clinical practice: Results of the expert consensus using the Delphi methodology. Rev Neurol (Paris) 2023; 179:1134-1144. [PMID: 37827930 DOI: 10.1016/j.neurol.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 10/14/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare disease characterized by a progressive and irreversible degeneration of upper and lower motor neurons leading to death. In France, limited data exist describing the criteria used in clinical practice for diagnosis and follow-up, and how novel therapies may fit in. The objective of this Delphi panel was to obtain an overview of current French practices in ALS diagnosis, management, and follow-up by determining the scales and criteria used in clinical practice outside of clinical trials, as well as the place of a future treatment like AMX0035, acting on endoplasmic reticulum (ER) stress and mitochondrial dysfunction, in the current therapeutic strategies. A questionnaire was administered to 24 ALS healthcare providers practicing in ALS centers in France. Two rounds of remote voting were organized, before proposition of final consensus statements. Consensus was considered reached when at least 66% of the voters agreed. Consensus were obtained to define the new Gold Coast criteria as the ones used in clinical practice to establish the diagnosis of ALS, thus replacing the revised El Escorial criteria, considered too complex and now mainly used to characterize the patient populations to be included in clinical trials. The clinical factors considered to establish ALS diagnosis are mainly the demonstration of progression of the motor deficit and elimination of differential diagnoses. The ALSFRS-R scale is used in daily clinical practice to assess patient's functional impairment in terms of number of points lost, with the bulbar, respiratory, and fine motor subscores being the most important to evaluate independently. A critical medical need was identified regarding the provision of new therapeutic alternatives in ALS. The panel members would support the earliest management of patients. In this landscape, based on data from a very encouraging phase II (Centaur trial), AMX0035 represents a new tool of choice in current treatment strategies for all patients for whom experts are confident in the diagnosis of ALS, in combination with riluzole. These results will need to be confirmed by the ongoing phase III trial (Phoenix trial).
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Affiliation(s)
- J Cassereau
- Service de neurologie, CRC-SLA d'Angers, CHU d'Angers, 4, rue Larrey, 49933 Angers, France.
| | - E Bernard
- Centre SLA de Lyon, hôpital neurologique P. Wertheimer, hospices civils de Lyon, université de Lyon, 59, boulevard Pinel, 69677 Bron cedex, France; Institut NeuroMyoGène, faculté de médecine Rockefeller, CNRS UMR5310, INSERM U1217, université Claude-Bernard Lyon I, 8, avenue Rockefeller, 69373 Lyon cedex 08, France
| | - S Genestet
- Explorations fonctionnelles neurologiques, CRC SLA et maladies du motoneurone, hôpital Cavale-Blanche, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest, France
| | - M Chebbah
- Public Health Expertise, département affaires médicales, 10, boulevard de Sébastopol, 75004 Paris, France
| | - S Le Clanche
- Public Health Expertise, département affaires médicales, 10, boulevard de Sébastopol, 75004 Paris, France
| | - A Verschueren
- Centre de référence pour les maladies neuromusculaires et la SLA, hôpital de la Timone, CHU de Marseille, Marseille, France
| | - P Couratier
- Neurosciences tête, cou et os, service de neurologie, centre référence maladies rares SLA & autres maladies du neurone moteur, hôpital Dupuytren 1, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
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10
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Ortholand J, Pradat PF, Tezenas du Montcel S, Durrleman S. Interaction of sex and onset site on the disease trajectory of amyotrophic lateral sclerosis. J Neurol 2023; 270:5903-5912. [PMID: 37615751 DOI: 10.1007/s00415-023-11932-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Studies showed the impact of sex and onset site (spinal or bulbar) on disease onset and survival in ALS. However, they mainly result from cross-sectional or survival analysis, and the interaction of sex and onset site on the different proxies of disease trajectory has not been fully investigated. METHODS We selected all patients with repeated observations in the PRO-ACT database. We divided them into four groups depending on their sex and onset site. We estimated a multivariate disease progression model, named ALS Course Map, to investigate the combined temporal changes of the four sub-scores of the revised ALS functional rating scale (ALSFRSr), the forced vital capacity (FVC), and the body mass index (BMI). We then compared the progression rate, the estimated age at onset, and the relative progression of the outcomes across each group. RESULTS We included 1438 patients from the PRO-ACT database. They were 51% men with spinal onset, 12% men with bulbar onset, 26% women with spinal onset, and 11% women with bulbar onset. We showed a significant influence of both sex and onset site on the ALSFRSr progression. The BMI decreased 8.9 months earlier (95% CI [3.9, 13.8]) in women than men, after correction for the onset site. Among patients with bulbar onset, FVC was impaired 2.6 months earlier (95% CI [0.6, 4.6]) in women. CONCLUSION Using a multivariable disease modelling approach, we showed that sex and onset site are important drivers of the progression of motor function, BMI, and FVC decline.
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Affiliation(s)
- Juliette Ortholand
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, CNRS, InriaInserm, AP-HP, Hôpital de La Pitié Salpêtrière, 75013, Paris, France.
| | - Pierre-François Pradat
- Laboratoire d'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, C-TRIC, Altnagelvin Hospital, Derry, Londonderry, UK
| | - Sophie Tezenas du Montcel
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, CNRS, InriaInserm, AP-HP, Hôpital de La Pitié Salpêtrière, 75013, Paris, France
| | - Stanley Durrleman
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, CNRS, InriaInserm, AP-HP, Hôpital de La Pitié Salpêtrière, 75013, Paris, France
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11
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Abstract
Although the past two decades have produced exciting discoveries in the genetics and pathology of amyotrophic lateral sclerosis (ALS), progress in developing an effective therapy remains slow. This review summarizes the critical discoveries and outlines the advances in disease characterization, diagnosis, imaging, and biomarkers, along with the current status of approaches to ALS care and treatment. Additional knowledge of the factors driving disease progression and heterogeneity will hopefully soon transform the care for patients with ALS into an individualized, multi-prong approach able to prevent disease progression sufficiently to allow for a dignified life with limited disability.
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Affiliation(s)
- Hristelina Ilieva
- Jefferson Weinberg ALS Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Justin Kwan
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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12
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Martin Schaff C, Kurent JE, Kolodziejczak S, Milic M, Foster LA, Mehta AK. Neuroprognostication for Patients with Amyotrophic Lateral Sclerosis: An Updated, Evidence-Based Review. Semin Neurol 2023; 43:776-790. [PMID: 37751856 DOI: 10.1055/s-0043-1775595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder that presents and progresses in various ways, making prognostication difficult. Several paradigms exist for providers to elucidate prognosis in a way that addresses not only the amount of time a patient has to live, but also a patient's quality of their life moving forward. Prognostication, with regard to both survivability and quality of life, is impacted by several features that include, but are not limited to, patient demographics, clinical features on presentation, and over time, access to therapy, and access to multidisciplinary clinics. An understanding of the impact that these features have on the life of a patient with ALS can help providers to develop a better and more personalized approach for patients related to their clinical prognosis after a diagnosis is made. The ultimate goal of prognostication is to empower patients with ALS to take control and make decisions with their care teams to ensure that their goals are addressed and met.
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Affiliation(s)
| | - Jerome E Kurent
- Department of Neurology and Medicine, Medical University of South Carolina, Charleston, South Carolina
- Department of Neurology, ALS Multidisciplinary Clinic, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
| | - Sherry Kolodziejczak
- ALS Clinic Treatment Center of Excellence, Crestwood Medical Center, Huntsville, Alabama
| | - Michelle Milic
- Division of Pulmonary, Critical Care, and Sleep Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia
- Division of Palliative Care Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Laura A Foster
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ambereen K Mehta
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Palliative Care Program, Division of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Stenson K, O'Callaghan L, Mellor J, Wright J, Gibson G, Earl L, Barlow S, Fournier CN. Healthcare resource utilization at different stages of amyotrophic lateral sclerosis: Results from a real-world survey. J Neurol Sci 2023; 452:120764. [PMID: 37639764 DOI: 10.1016/j.jns.2023.120764] [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: 02/17/2023] [Revised: 07/17/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023]
Abstract
People with amyotrophic lateral sclerosis (pALS) require complex, multi-disciplinary care, resulting in extensive healthcare resource utilization (HCRU). To investigate the relationship between HCRU and ALS progression, the study objectives were (i) to characterize HCRU in pALS and (ii) to establish whether this varied according to disease stage, as defined using three different methodologies: neurologist-defined early/mid/late stage, the King's clinical staging system for ALS, and the Milan Torino Staging system for ALS (MiToS). Real-world data were drawn from the Adelphi ALS Disease-Specific Programme™, a point-in-time survey of neurologists in France, Germany, Italy, Spain, the UK, and the USA conducted July 2020-March 2021. The analysis included survey responses from 142 physicians with respect to 880 pALS. With advancing ALS stage, significant differences were observed in the number of healthcare professional consultations and X-rays per person (both p < 0.05 for all staging systems), and the proportion of pALS with emergency room admissions, intensive care unit admissions, and assisted ventilation (all p < 0.05 for all staging systems). Across stages, >55% of pALS received care from a general neurologist and a general/primary care practitioner. With increasing stage, there was a significant difference in the proportion receiving care from a physical therapist, pulmonologist/respiratory care practitioner, respiratory therapist, speech/language therapist, and palliative care team, and in the proportion receiving care only from professional caregivers (all p < 0.05 for all staging systems). This study confirmed the substantial HCRU required to support pALS through all stages of ALS and highlighted an increasing need for healthcare resources as the disease progresses.
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14
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Soares DF, Henriques R, Gromicho M, de Carvalho M, Madeira SC. Triclustering-based classification of longitudinal data for prognostic prediction: targeting relevant clinical endpoints in amyotrophic lateral sclerosis. Sci Rep 2023; 13:6182. [PMID: 37061549 PMCID: PMC10105751 DOI: 10.1038/s41598-023-33223-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/10/2023] [Indexed: 04/17/2023] Open
Abstract
This work proposes a new class of explainable prognostic models for longitudinal data classification using triclusters. A new temporally constrained triclustering algorithm, termed TCtriCluster, is proposed to comprehensively find informative temporal patterns common to a subset of patients in a subset of features (triclusters), and use them as discriminative features within a state-of-the-art classifier with guarantees of interpretability. The proposed approach further enhances prediction with the potentialities of model explainability by revealing clinically relevant disease progression patterns underlying prognostics, describing features used for classification. The proposed methodology is used in the Amyotrophic Lateral Sclerosis (ALS) Portuguese cohort (N = 1321), providing the first comprehensive assessment of the prognostic limits of five notable clinical endpoints: need for non-invasive ventilation (NIV); need for an auxiliary communication device; need for percutaneous endoscopic gastrostomy (PEG); need for a caregiver; and need for a wheelchair. Triclustering-based predictors outperform state-of-the-art alternatives, being able to predict the need for auxiliary communication device (within 180 days) and the need for PEG (within 90 days) with an AUC above 90%. The approach was validated in clinical practice, supporting healthcare professionals in understanding the link between the highly heterogeneous patterns of ALS disease progression and the prognosis.
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Affiliation(s)
- Diogo F Soares
- LASIGE, Faculdade de Ciências, Universidade de Lisboa, Lisbon, Portugal.
| | - Rui Henriques
- INESC-ID and Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Marta Gromicho
- Instituto de Medicina Molecular and Instituto de Fisiologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Instituto de Fisiologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sara C Madeira
- LASIGE, Faculdade de Ciências, Universidade de Lisboa, Lisbon, Portugal
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15
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Vacchiano V, Mastrangelo A, Zenesini C, Baiardi S, Avoni P, Polischi B, Capellari S, Salvi F, Liguori R, Parchi P. Elevated plasma p-tau181 levels unrelated to Alzheimer's disease pathology in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2023; 94:428-435. [PMID: 37012065 DOI: 10.1136/jnnp-2022-330709] [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: 11/08/2022] [Accepted: 03/15/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Phosphorylated-tau181 (p-tau181), a specific marker of Alzheimer's disease (AD) pathology, was found elevated in plasma but not in cerebrospinal fluid (CSF) of patients with amyotrophic lateral sclerosis (ALS). We expanded these findings in a larger patient cohort, exploring clinical/electrophysiological associations, prognostic value and longitudinal trajectories of the biomarker. METHODS We obtained baseline plasma samples from 148 ALS, 12 spinal muscular atrophy (SMA), and 88 AD patients, and 60 healthy controls. Baseline CSF and longitudinal plasma samples were from 130 and 39 patients with ALS. CSF AD markers were measured with the Lumipulse platform, and plasma p-tau181 with SiMoA. RESULTS Patients with ALS showed higher plasma p-tau181 levels than controls (p<0.001) and lower than AD participants (p=0.02). SMA patients had higher levels than controls (p=0.03). In patients with ALS, CSF p-tau and plasma p-tau181 did not correlate (p=0.37). Plasma p-tau181 significantly increased with the number of regions showing clinical/neurophysiological lower motor neurons (LMN) signs (p=0.007) and correlated with the degree of denervation in the lumbosacral area (r=0.51, p<0.0001). Plasma p-tau181 levels were higher in classic and LMN-predominant than in bulbar phenotype (p=0.004 and p=0.006). Multivariate Cox regression confirmed plasma p-tau181 as an independent prognostic factor in ALS (HR 1.90, 95% CI 1.25 to 2.90, p=0.003). Longitudinal analysis showed a significant rise in plasma p-tau181 values over time, especially in fast progressors. CONCLUSIONS Plasma p-tau181 is elevated in patients with ALS, independently from CSF levels, and is firmly associated with LMN dysfunction. The finding indicates that p-tau181 of putative peripheral origin might represent a confounding factor in using plasma p-tau181 for AD pathology screening, which deserves further investigation.
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Affiliation(s)
- Veria Vacchiano
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Mastrangelo
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Simone Baiardi
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Patrizia Avoni
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Barbara Polischi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Sabina Capellari
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Fabrizio Salvi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Rocco Liguori
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Piero Parchi
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum Università di Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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16
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Milella G, Introna A, Mezzapesa DM, D'Errico E, Fraddosio A, Ucci M, Zoccolella S, Simone IL. Clinical Profiles and Patterns of Neurodegeneration in Amyotrophic Lateral Sclerosis: A Cluster-Based Approach Based on MR Imaging Metrics. AJNR Am J Neuroradiol 2023; 44:403-409. [PMID: 36958798 PMCID: PMC10084907 DOI: 10.3174/ajnr.a7823] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE The previous studies described phenotype-associated imaging findings in amyotrophic lateral sclerosis (ALS) with a prior categorization of patients based on clinical characteristics. We investigated the natural segregation of patients through a radiologic cluster-based approach without a priori patient categorization using 3 well-known prognostic MR imaging biomarkers in ALS, namely bilateral precentral and paracentral gyrus cortical thickness and medulla oblongata volume. We aimed to identify clinical/prognostic features that are cluster-associated. MATERIALS AND METHODS Bilateral precentral and paracentral gyri and medulla oblongata volume were calculated using FreeSurfer in 90 patients with amyotrophic lateral sclerosis and 25 healthy controls. A 2-step cluster analysis was performed using precentral and paracentral gyri (averaged pair-wise) and medulla oblongata volume. RESULTS We identified 3 radiologic clusters: 28 (31%) patients belonged to "cluster-1"; 51 (57%), to "cluster 2"; and 11 (12%), to "cluster 3." Patients in cluster 1 showed statistically significant cortical thinning of the analyzed cortical areas and lower medulla oblongata volume compared with subjects in cluster 2 and cluster 3, respectively. Patients in cluster 3 exhibited significant cortical thinning of both paracentral and precentral gyri versus those in cluster 2, and this latter cluster showed lower medulla oblongata volume than cluster 3. Patients in cluster 1 were characterized by older age, higher female prevalence, greater disease severity, higher progression rate, and lower survival compared with patients in clusters 2 and 3. CONCLUSIONS Patients with amyotrophic lateral sclerosis spontaneously segregate according to age and sex-specific patterns of neurodegeneration. Some patients with amyotrophic lateral sclerosis showed an early higher impairment of cortical motor neurons with relative sparing of bulbar motor neurons (cluster 3), while others expressed an opposite pattern (cluster 2). Moreover, 31% of patients showed an early simultaneous impairment of cortical and bulbar motor neurons (cluster 1), and they were characterized by higher disease severity and lower survival.
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Affiliation(s)
- G Milella
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - A Introna
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - D M Mezzapesa
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - E D'Errico
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - A Fraddosio
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - M Ucci
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - S Zoccolella
- Azienda Sanitaria Locale Bari (S.Z.), San Paolo Hospital, Bari, Italy
| | - I L Simone
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
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17
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Nigri A, Dalla Bella E, Ferraro S, Medina Carrion JP, Demichelis G, Bersano E, Consonni M, Bischof A, Stanziano M, Palermo S, Lauria G, Bruzzone MG, Papinutto N. Cervical spinal cord atrophy in amyotrophic lateral sclerosis across disease stages. Ann Clin Transl Neurol 2023; 10:213-224. [PMID: 36599092 PMCID: PMC9930423 DOI: 10.1002/acn3.51712] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/11/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Spinal cord degeneration is a hallmark of amyotrophic lateral sclerosis. The assessment of gray matter and white matter cervical spinal cord atrophy across clinical stages defined using the King's staging system could advance the understanding of amyotrophic lateral sclerosis progression. METHODS We assessed the in vivo spatial pattern of gray and white matter atrophy along cervical spinal cord (C2 to C6 segments) using 2D phase-sensitive inversion recovery imaging in a cohort of 44 amyotrophic lateral sclerosis patients, evaluating its change across the King's stages and the correlation with disability scored by the amyotrophic lateral sclerosis functional rating scale revised (ALSFRS-R) and disease duration. A mathematical model inferring the potential onset of cervical gray matter atrophy was developed. RESULTS In amyotrophic lateral sclerosis patients at King's stage 1, significant cervical spinal cord alterations were mainly identified in gray matter, whereas they involved both gray and white matter in patients at King's stage ≥ 2. Gray and white matter areas correlated with clinical disability at all cervical segments. C3-C4 level was the segment showing early gray matter atrophy starting about 7 to 20 months before symptom onset according to our model. INTERPRETATION Our findings suggest that cervical spinal cord atrophy spreads from gray to white matter across King's stages in amyotrophic lateral sclerosis, making spinal cord magnetic resonance imaging an in vivo assessment tool to measure the progression of the disease.
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Affiliation(s)
- Anna Nigri
- Neuroradiology UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Eleonora Dalla Bella
- 3rd Neurology Unit and Motor Neuron Disease CentreFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Stefania Ferraro
- Neuroradiology UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly,School of Life Science and Technology, MOE Key Laboratory for NeuroinformationUniversity of Electronic Science and Technology of ChinaChengduChina
| | | | - Greta Demichelis
- Neuroradiology UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Enrica Bersano
- 3rd Neurology Unit and Motor Neuron Disease CentreFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly,Department of Medical Biotechnology and Translational MedicineUniversity of MilanMilanItaly
| | - Monica Consonni
- 3rd Neurology Unit and Motor Neuron Disease CentreFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Antje Bischof
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA,Department of Neurology with Institute for Translational NeurologyUniversity Hospital MünsterMünsterGermany
| | - Mario Stanziano
- Neuroradiology UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly,ALS Centre, “Rita Levi Montalcini” Department of NeuroscienceUniversity of TurinTurinItaly
| | - Sara Palermo
- Neuroradiology UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Giuseppe Lauria
- 3rd Neurology Unit and Motor Neuron Disease CentreFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly,Department of Medical Biotechnology and Translational MedicineUniversity of MilanMilanItaly
| | | | - Nico Papinutto
- Weill Institute for Neurosciences, Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
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18
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Maier A, Boentert M, Reilich P, Witzel S, Petri S, Großkreutz J, Metelmann M, Lingor P, Cordts I, Dorst J, Zeller D, Günther R, Hagenacker T, Grehl T, Spittel S, Schuster J, Ludolph A, Meyer T. ALSFRS-R-SE: an adapted, annotated, and self-explanatory version of the revised amyotrophic lateral sclerosis functional rating scale. Neurol Res Pract 2022; 4:60. [PMID: 36522775 PMCID: PMC9753252 DOI: 10.1186/s42466-022-00224-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The ALS Functional Rating Scale in its revised version (ALSFRS-R) is a disease-specific severity score that reflects motor impairment and functional deterioration in people with amyotrophic lateral sclerosis (ALS). It has been widely applied in both clinical practice and ALS research. However, in Germany, several variants of the scale, each differing slightly from the others, have developed over time and are currently in circulation. This lack of uniformity potentially hampers data interpretation and may decrease item validity. Furthermore, shortcomings within the standard ALSFRS-R questions and answer options can limit the quality and conclusiveness of collected data. METHODS In a multistage consensus-building process, 18 clinical ALS experts from the German ALS/MND network analyzed the ALSFRS-R in its current form and created an adapted, annotated, and revised scale that closely adheres to the well-established standardized English version. RESULTS Ten German-language variants of the ALSFRS-R were collected, three of which contained instructions for self-assessment. All of these variants were compiled and a comprehensive linguistic revision was undertaken. A short introduction was added to the resulting scale, comprising general instructions for use and explanations for each of the five reply options per item. This adapted version of the scale, named ALSFRS-R-SE (with the "SE" referring to "self-explanatory"), was carefully reviewed for language and comprehensibility, in both German and English. CONCLUSION An adapted and annotated version of the ALSFRS-R scale was developed through a multistage consensus process. The decision to include brief explanations of specific scale items and reply options was intended to facilitate ALSFRS-R-SE assessments by both healthcare professionals and patients. Further studies are required to investigate the accuracy and utility of the ALSFRS-R-SE in controlled trials and clinical real-world settings.
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Affiliation(s)
- André Maier
- grid.6363.00000 0001 2218 4662Department of Neurology, Center for ALS and Other Motor Neuron Disorders, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Matthias Boentert
- grid.16149.3b0000 0004 0551 4246Department of Neurology, Universitätsklinikum Münster, Münster, Germany ,Department of Medicine, UKM-Marienhospital Steinfurt, Steinfurt, Germany
| | - Peter Reilich
- grid.411095.80000 0004 0477 2585Friedrich-Baur-Institut und Neurologische Klinik und Poliklinik, LMU Klinikum, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Simon Witzel
- grid.410712.10000 0004 0473 882XKlinik für Neurologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Susanne Petri
- grid.10423.340000 0000 9529 9877Hannover Medical School, Department of Neurology, Hannover, Germany
| | - Julian Großkreutz
- grid.412468.d0000 0004 0646 2097Department of Neurology, Campus Lübeck, Universitätsmedizin Schleswig-Holstein, Lübeck, Germany
| | - Moritz Metelmann
- grid.411339.d0000 0000 8517 9062Department of Neurology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paul Lingor
- grid.15474.330000 0004 0477 2438Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Isabell Cordts
- grid.15474.330000 0004 0477 2438Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Johannes Dorst
- grid.410712.10000 0004 0473 882XKlinik für Neurologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Daniel Zeller
- grid.411760.50000 0001 1378 7891Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - René Günther
- grid.4488.00000 0001 2111 7257Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany ,grid.424247.30000 0004 0438 0426DZNE, German Center for Neurodegenerative Diseases, Research Site Dresden, Dresden, Germany
| | - Tim Hagenacker
- grid.477805.90000 0004 7470 9004Klinik für Neurologie und Center for Translational Neuro- and Behavioral Science, Universitätsmedizin Essen, Essen, Germany
| | - Torsten Grehl
- grid.476313.4Department of Neurology, Centre for ALS and Other Motor Neuron Disorders, Alfried Krupp Krankenhaus, Essen, Germany
| | | | - Joachim Schuster
- grid.410712.10000 0004 0473 882XKlinik für Neurologie, Universitätsklinikum Ulm, Ulm, Germany ,grid.424247.30000 0004 0438 0426DZNE, German Centre for Neurodegenerative Diseases, Research Site Ulm, Ulm, Germany
| | - Albert Ludolph
- grid.410712.10000 0004 0473 882XKlinik für Neurologie, Universitätsklinikum Ulm, Ulm, Germany ,grid.424247.30000 0004 0438 0426DZNE, German Centre for Neurodegenerative Diseases, Research Site Ulm, Ulm, Germany
| | - Thomas Meyer
- grid.6363.00000 0001 2218 4662Department of Neurology, Center for ALS and Other Motor Neuron Disorders, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
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19
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Genge A, Chio A. The future of ALS diagnosis and staging: where do we go from here? Amyotroph Lateral Scler Frontotemporal Degener 2022; 24:165-174. [PMID: 36503299 DOI: 10.1080/21678421.2022.2150555] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare, progressive multi-system neurodegenerative disorder. Its clinical presentation varies considerably leading to delays in diagnosis, which has dire consequences in a disease where early intervention is key to optimize outcomes and limit care giver burden. There are a range of diagnostic criteria available to aid ALS diagnosis, as well staging methods to assess disease progression. However, they all suffer from inter-rater variability, complexity, and confusion in use. Such difficulties, when medical appointment times are limited and becoming more virtually based, have the potential to amplify uncertainty and errors in ALS diagnosis and prognosis. This review provides a clinical overview of the best way to balance the needs of evidence-based medicine and the patient. We focus on ALS diagnostic criteria and staging systems currently in use in clinical practice and explore factors that could enhance diagnostic efficiency and assessment of disease progression.
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Affiliation(s)
- Angela Genge
- Clinical Research Unit, ALS Clinic, Montreal, Canada and
| | - Adriano Chio
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Turin, Italy
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20
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Gebrehiwet P, Meng L, Rudnicki SA, Sarocco P, Wei J, Wolff AA, Chiò A, Andrews JA, Genge A, Jackson CE, Lechtzin N, Miller TM, Shefner JM. MiToS and King’s staging as clinical outcome measures in ALS: a retrospective analysis of the FORTITUDE-ALS trial. Amyotroph Lateral Scler Frontotemporal Degener 2022; 24:304-310. [PMID: 36503310 DOI: 10.1080/21678421.2022.2154678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the Milano-Torino staging (MiToS) and King's staging systems as potential outcome measures for clinical trials in amyotrophic lateral sclerosis (ALS) by assessing these outcomes in FORTITUDE-ALS. METHODS This was a post hoc analysis of the phase 2b FORTITUDE-ALS trial (NCT03160898), a double-blind, randomized, dose-ranging, placebo-controlled, parallel-group study of reldesemtiv in patients with ALS. The treatment period was 12 weeks, with a follow-up assessment at week 16. Patients were retrospectively classified into MiToS and King's stages. Outcomes were the mean time maintaining baseline stage and risk of progression from the baseline stage to a later stage. RESULTS The full analysis set consisted of 456 patients randomized 3:1 (reldesemtiv n = 342, placebo n = 114) who received at least one dose of double-blind study drug and had at least one post-baseline assessment. At baseline, MiToS and King's stages were balanced between the reldesemtiv and placebo groups: >99% of patients were in MiToS stage 0 or 1 and King's stage 1, 2 or 3. Time of maintaining the baseline stage was similar in both groups, for each staging system. The two staging systems exhibited considerably disparate results for risk of progression from baseline to a later stage: hazard ratio (HR) = 0.62 (95% confidence interval [CI] 0.38, 0.99) for MiToS and HR = 0.96 (95% CI 0.63, 1.44) for King's. CONCLUSION This exploratory analysis showed the feasibility of MiToS and King's staging as potential outcome measures in ALS. Additional studies of these staging systems are needed to further explore their utility in ALS clinical trials.
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Affiliation(s)
| | - Lisa Meng
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | | | - Phil Sarocco
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | - Jenny Wei
- Cytokinetics, Incorporated, South San Francisco, CA, USA
| | | | - Adriano Chiò
- Rita Levi Montalcini Department of Neuroscience, University of Turin, Turin, Italy
| | - Jinsy A. Andrews
- The Neurological Institute, Columbia University, New York, NY, USA
| | - Angela Genge
- Montreal Neurological Institute, Montreal, QC, Canada
| | | | - Noah Lechtzin
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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21
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Feldman EL, Goutman SA, Petri S, Mazzini L, Savelieff MG, Shaw PJ, Sobue G. Amyotrophic lateral sclerosis. Lancet 2022; 400:1363-1380. [PMID: 36116464 PMCID: PMC10089700 DOI: 10.1016/s0140-6736(22)01272-7] [Citation(s) in RCA: 252] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/24/2022] [Accepted: 06/23/2022] [Indexed: 01/07/2023]
Abstract
Amyotrophic lateral sclerosis is a fatal CNS neurodegenerative disease. Despite intensive research, current management of amyotrophic lateral sclerosis remains suboptimal from diagnosis to prognosis. Recognition of the phenotypic heterogeneity of amyotrophic lateral sclerosis, global CNS dysfunction, genetic architecture, and development of novel diagnostic criteria is clarifying the spectrum of clinical presentation and facilitating diagnosis. Insights into the pathophysiology of amyotrophic lateral sclerosis, identification of disease biomarkers and modifiable risks, along with new predictive models, scales, and scoring systems, and a clinical trial pipeline of mechanism-based therapies, are changing the prognostic landscape. Although most recent advances have yet to translate into patient benefit, the idea of amyotrophic lateral sclerosis as a complex syndrome is already having tangible effects in the clinic. This Seminar will outline these insights and discuss the status of the management of amyotrophic lateral sclerosis for the general neurologist, along with future prospects that could improve care and outcomes for patients with amyotrophic lateral sclerosis.
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Affiliation(s)
- Eva L Feldman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Stephen A Goutman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Letizia Mazzini
- ALS Centre, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy; Department of Neurology, University of Piemonte Orientale, Novara, Italy
| | - Masha G Savelieff
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Gen Sobue
- Department of Neurology, Aichi Medical University, Nagakute, Aichi, Japan
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22
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Romano A, Trosi Lopez E, Liparoti M, Polverino A, Minino R, Trojsi F, Bonavita S, Mandolesi L, Granata C, Amico E, Sorrentino G, Sorrentino P. The progressive loss of brain network fingerprints in Amyotrophic Lateral Sclerosis predicts clinical impairment. Neuroimage Clin 2022; 35:103095. [PMID: 35764029 PMCID: PMC9241102 DOI: 10.1016/j.nicl.2022.103095] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/31/2022] [Accepted: 06/19/2022] [Indexed: 10/25/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterised by functional connectivity alterations in both motor and extra-motor brain regions. Within the framework of network analysis, fingerprinting represents a reliable approach to assess subject-specific connectivity features within a given population (healthy or diseased). Here, we applied the Clinical Connectome Fingerprint (CCF) analysis to source-reconstructed magnetoencephalography (MEG) signals in a cohort of seventy-eight subjects: thirty-nine ALS patients and thirty-nine healthy controls. We set out to develop an identifiability matrix to assess the extent to which each patient was recognisable based on his/her connectome, as compared to healthy controls. The analysis was performed in the five canonical frequency bands. Then, we built a multilinear regression model to test the ability of the "clinical fingerprint" to predict the clinical evolution of the disease, as assessed by the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-r), the King's disease staging system, and the Milano-Torino Staging (MiToS) disease staging system. We found a drop in the identifiability of patients in the alpha band compared to the healthy controls. Furthermore, the "clinical fingerprint" was predictive of the ALSFRS-r (p = 0.0397; β = 32.8), the King's (p = 0.0001; β = -7.40), and the MiToS (p = 0.0025; β = -4.9) scores. Accordingly, it negatively correlated with the King's (Spearman's rho = -0.6041, p = 0.0003) and MiToS scales (Spearman's rho = -0.4953, p = 0.0040). Our results demonstrated the ability of the CCF approach to predict the individual motor impairment in patients affected by ALS. Given the subject-specificity of our approach, we hope to further exploit it to improve disease management.
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Affiliation(s)
- Antonella Romano
- Department of Motor Sciences and Wellness - University of Naples "Parthenope", via Medina 40, 80133 Naples, Italy
| | - Emahnuel Trosi Lopez
- Department of Motor Sciences and Wellness - University of Naples "Parthenope", via Medina 40, 80133 Naples, Italy
| | - Marianna Liparoti
- Department of Social and Developmental Psychology, University of Rome "Sapienza", Italy
| | - Arianna Polverino
- Institute of Diagnosis and Treatment Hermitage Capodimonte, via Cupa delle Tozzole 2, 80131 Naples, Italy
| | - Roberta Minino
- Department of Motor Sciences and Wellness - University of Naples "Parthenope", via Medina 40, 80133 Naples, Italy
| | - Francesca Trojsi
- Department of Advanced Medical and Surgical Sciences, Division of Neurology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, Division of Neurology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Laura Mandolesi
- Department of Humanistic Studies, University of Naples Federico II, via Porta di Massa 1, 80133, Naples, Italy
| | - Carmine Granata
- Institute of Applied Sciences and Intelligent Systems, CNR, via Campi Flegrei 34, 80078 Pozzuoli, NA, Italy
| | - Enrico Amico
- Institute of Bioengineering, Center for Neuroprosthetics, EPFL, Geneva, Switzerland; Department of Radiology and Medical Informatics, University of Geneva (UNIGE), Geneva, Switzerland
| | - Giuseppe Sorrentino
- Department of Motor Sciences and Wellness - University of Naples "Parthenope", via Medina 40, 80133 Naples, Italy; Institute of Diagnosis and Treatment Hermitage Capodimonte, via Cupa delle Tozzole 2, 80131 Naples, Italy; Institute of Applied Sciences and Intelligent Systems, CNR, via Campi Flegrei 34, 80078 Pozzuoli, NA, Italy.
| | - Pierpaolo Sorrentino
- Institute of Applied Sciences and Intelligent Systems, CNR, via Campi Flegrei 34, 80078 Pozzuoli, NA, Italy; Institut de Neurosciences des Systèmes, Aix-Marseille Université, Marseille, France
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23
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Goutman SA, Hardiman O, Al-Chalabi A, Chió A, Savelieff MG, Kiernan MC, Feldman EL. Recent advances in the diagnosis and prognosis of amyotrophic lateral sclerosis. Lancet Neurol 2022; 21:480-493. [PMID: 35334233 PMCID: PMC9513753 DOI: 10.1016/s1474-4422(21)00465-8] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/24/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
The diagnosis of amyotrophic lateral sclerosis can be challenging due to its heterogeneity in clinical presentation and overlap with other neurological disorders. Diagnosis early in the disease course can improve outcomes as timely interventions can slow disease progression. An evolving awareness of disease genotypes and phenotypes and new diagnostic criteria, such as the recent Gold Coast criteria, could expedite diagnosis. Improved prognosis, such as that achieved with the survival model from the European Network for the Cure of ALS, could inform the patient and their family about disease course and improve end-of-life planning. Novel staging and scoring systems can help monitor disease progression and might potentially serve as clinical trial outcomes. Lastly, new tools, such as fluid biomarkers, imaging modalities, and neuromuscular electrophysiological measurements, might increase diagnostic and prognostic accuracy.
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Affiliation(s)
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, and Department of Neurology, King's College London, London, UK
| | - Adriano Chió
- Rita Levi Montalcini Department of Neurosciences, University of Turin, Turin, Italy
| | | | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
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24
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Londral A. Assistive Technologies for Communication Empower Patients With ALS to Generate and Self-Report Health Data. Front Neurol 2022; 13:867567. [PMID: 35557618 PMCID: PMC9090469 DOI: 10.3389/fneur.2022.867567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/25/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ana Londral
- Value for Health CoLAB, Lisbon, Portugal
- Comprehensive Health Research Center, Nova Medical School, Nova University of Lisbon, Lisbon, Portugal
- *Correspondence: Ana Londral
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25
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Clusters of anatomical disease-burden patterns in ALS: a data-driven approach confirms radiological subtypes. J Neurol 2022; 269:4404-4413. [PMID: 35333981 PMCID: PMC9294023 DOI: 10.1007/s00415-022-11081-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 12/28/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is associated with considerable clinical heterogeneity spanning from diverse disability profiles, differences in UMN/LMN involvement, divergent progression rates, to variability in frontotemporal dysfunction. A multitude of classification frameworks and staging systems have been proposed based on clinical and neuropsychological characteristics, but disease subtypes are seldom defined based on anatomical patterns of disease burden without a prior clinical stratification. A prospective research study was conducted with a uniform imaging protocol to ascertain disease subtypes based on preferential cerebral involvement. Fifteen brain regions were systematically evaluated in each participant based on a comprehensive panel of cortical, subcortical and white matter integrity metrics. Using min–max scaled composite regional integrity scores, a two-step cluster analysis was conducted. Two radiological clusters were identified; 35.5% of patients belonging to ‘Cluster 1’ and 64.5% of patients segregating to ‘Cluster 2’. Subjects in Cluster 1 exhibited marked frontotemporal change. Predictor ranking revealed the following hierarchy of anatomical regions in decreasing importance: superior lateral temporal, inferior frontal, superior frontal, parietal, limbic, mesial inferior temporal, peri-Sylvian, subcortical, long association fibres, commissural, occipital, ‘sensory’, ‘motor’, cerebellum, and brainstem. While the majority of imaging studies first stratify patients based on clinical criteria or genetic profiles to describe phenotype- and genotype-associated imaging signatures, a data-driven approach may identify distinct disease subtypes without a priori patient categorisation. Our study illustrates that large radiology datasets may be potentially utilised to uncover disease subtypes associated with unique genetic, clinical or prognostic profiles.
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26
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Introna A, Milella G, Morea A, Ucci M, Fraddosio A, Zoccolella S, D'Errico E, Simone IL. King's college progression rate at first clinical evaluation: A new measure of disease progression in amyotrophic lateral sclerosis. J Neurol Sci 2021; 431:120041. [PMID: 34736124 DOI: 10.1016/j.jns.2021.120041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND To estimate King's college clinical stage progression rate (ΔKC) at first clinical evaluation in order to define its predictive and prognostic role on survival in a large cohort of Amyotrophic Lateral Sclerosis (ALS) patients. METHODS The ΔKC was calculated with the following formula: 0 - KC clinical stage at first clinical evaluation/disease duration from onset to first evaluation, and each result was reported as absolute value. All the evaluations were performed in two cohorts: one from our tertiary centre for motor neuron disease and the other one from a pooled resource open-access ALS clinical trials (PRO-ACT) database. C-statistic was used to evaluate the model discrimination of survival at different time points (1-3 years). Cox proportional hazard model was used to identify factors associated with survival. RESULTS ΔKC predicted survival at three years in our centre and in the PRO-ACT cohort (C-statistic 0.83, 95% CI 0.8-0.86, p < 0.0001; 0.7, 95% CI 0.68-0.73, p < 0.0001, respectively). At multivariate analysis, ΔKC was independently associated with survival both in our cohort (HR 3.62 95% CI 2.71-4.83 p = 0.001) and in the PRO-ACT cohort (HR 2.75 95% CI 2.1-3.6 p = 0.001). CONCLUSIONS Based on our results, ΔKC could be used as a novel measure of disease progression, hence as an accurate predictor of survival in ALS patients. Indeed, greater values of ΔKC were associated with a 3.5-fold higher risk to experience the event, confirming its robust prognostic value.
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Affiliation(s)
- Alessandro Introna
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Giammarco Milella
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Antonella Morea
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Maria Ucci
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Angela Fraddosio
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | | | - Eustachio D'Errico
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Isabella Laura Simone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", piazza Giulio Cesare 11, 70100 Bari, Italy.
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Dalgıç ÖO, Wu H, Safa Erenay F, Sir MY, Özaltın OY, Crum BA, Pasupathy KS. Mapping of critical events in disease progression through binary classification: Application to amyotrophic lateral sclerosis. J Biomed Inform 2021; 123:103895. [PMID: 34450286 DOI: 10.1016/j.jbi.2021.103895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/05/2021] [Accepted: 08/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The progression of many degenerative diseases is tracked periodically using scales evaluating functionality in daily activities. Although estimating the timing of critical events (i.e., disease tollgates) during degenerative disease progression is desirable, the necessary data may not be readily available in scale records. Further, analysis of disease progression poses data challenges, such as censoring and misclassification errors, which need to be addressed to provide meaningful research findings and inform patients. METHODS We developed a novel binary classification approach to map scale scores into disease tollgates to describe disease progression leveraging standard/modified Kaplan-Meier analyses. The approach is demonstrated by estimating progression pathways in amyotrophic lateral sclerosis (ALS). Tollgate-based ALS Staging System (TASS) specifies the critical events (i.e., tollgates) in ALS progression. We first developed a binary classification predicting whether each TASS tollgate was passed given the itemized ALSFRS-R scores using 514 ALS patients' data from Mayo Clinic-Rochester. Then, we utilized the binary classification to translate/map the ALSFRS-R data of 3,264 patients from the PRO-ACT database into TASS. We derived the time trajectories of ALS progression through tollgates from the augmented PRO-ACT data using Kaplan-Meier analyses. The effects of misclassification errors, condition-dependent dropouts, and censored data in trajectory estimations were evaluated with Interval Censored Kaplan Meier Analysis and Multistate Model for Panel Data. RESULTS The approach using Mayo Clinic data accurately estimated tollgate-passed states of patients given their itemized ALSFRS-R scores (AUCs > 0.90). The tollgate time trajectories derived from the augmented PRO-ACT dataset provide valuable insights; we predicted that the majority of the ALS patients would have modified arm function (67%) and require assistive devices for walking (53%) by the second year after ALS onset. By the third year, most (74%) ALS patients would occasionally use a wheelchair, while 48% of the ALS patients would be wheelchair-dependent by the fourth year. Assistive speech devices and feeding tubes were needed in 49% and 30% of the patients by the third year after ALS onset, respectively. The onset body region alters some tollgate passage time estimations by 1-2 years. CONCLUSIONS The estimated tollgate-based time trajectories inform patients and clinicians about prospective assistive device needs and life changes. More research is needed to personalize these estimations according to prognostic factors. Further, the approach can be leveraged in the progression of other diseases.
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Affiliation(s)
- Özden O Dalgıç
- Harvard Medical School, Boston, MA, USA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Haoran Wu
- Department of Management Sciences, University of Waterloo, Waterloo, ON, Canada; School of Business, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - F Safa Erenay
- Department of Management Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Mustafa Y Sir
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Mayo Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Osman Y Özaltın
- E. P. Fitts Department of Industrial and Systems Engineering, NC State University, Raleigh, NC, USA
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kalyan S Pasupathy
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Mayo Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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28
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Milano-Torino Staging and Long-Term Survival in Chinese Patients with Amyotrophic Lateral Sclerosis. Cells 2021; 10:cells10051220. [PMID: 34067647 PMCID: PMC8156970 DOI: 10.3390/cells10051220] [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: 03/26/2021] [Revised: 04/25/2021] [Accepted: 05/13/2021] [Indexed: 12/03/2022] Open
Abstract
(1) Background: The aim of this longitudinal study was to evaluate the association between disease progression according to the Milano–Torino staging (MITOS) system and long-term survival in Chinese patients with amyotrophic lateral sclerosis (ALS). We also examined factors affecting MITOS progression. (2) Methods: Patients were enrolled and underwent follow-up at 6, 12, 18, and 24 months, and their demographic and clinical data, including the Milano–Torino stage, Amyotrophic Lateral Sclerosis Functional Rating Scale—Revised (ALSFRS-R) score and neuropsychiatric data, were evaluated. The sensitivity and specificity of predicting survival outcomes based on MITOS progression and ALSFRS-R score decline from baseline to 6 months were compared. The associations between MITOS progression from baseline to 6 months and survival outcome at 12, 18 and 24 months were examined, and factors associated with disease progression were evaluated with subgroup analyses. (3) Results: Among the 100 patients included, 74% were in stage 0 at baseline, and approximately 95% progressed to a higher stage of the MITOS system at 24 months. MITOS progression from baseline to 6 months and ALSFRS-R decline showed comparable value for predicting survival at 12, 18, and 24 months. MITOS progression from baseline to 6 months is strongly associated with death outcomes. Older age at onset and increased depression and anxiety scores may be related to disease progression. (4) Conclusions: MITOS progression during the early disease course could serve as a prognostic marker of long-term survival and may have utility in clinical trials. Age at onset and diagnosis and neuropsychiatric factors might be associated with disease progression.
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29
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Cicardi ME, Marrone L, Azzouz M, Trotti D. Proteostatic imbalance and protein spreading in amyotrophic lateral sclerosis. EMBO J 2021; 40:e106389. [PMID: 33792056 PMCID: PMC8126909 DOI: 10.15252/embj.2020106389] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/18/2020] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder whose exact causative mechanisms are still under intense investigation. Several lines of evidence suggest that the anatomical and temporal propagation of pathological protein species along the neural axis could be among the main driving mechanisms for the fast and irreversible progression of ALS pathology. Many ALS-associated proteins form intracellular aggregates as a result of their intrinsic prion-like properties and/or following impairment of the protein quality control systems. During the disease course, these mutated proteins and aberrant peptides are released in the extracellular milieu as soluble or aggregated forms through a variety of mechanisms. Internalization by recipient cells may seed further aggregation and amplify existing proteostatic imbalances, thus triggering a vicious cycle that propagates pathology in vulnerable cells, such as motor neurons and other susceptible neuronal subtypes. Here, we provide an in-depth review of ALS pathology with a particular focus on the disease mechanisms of seeding and transmission of the most common ALS-associated proteins, including SOD1, FUS, TDP-43, and C9orf72-linked dipeptide repeats. For each of these proteins, we report historical, biochemical, and pathological evidence of their behaviors in ALS. We further discuss the possibility to harness pathological proteins as biomarkers and reflect on the implications of these findings for future research.
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Affiliation(s)
- Maria Elena Cicardi
- Department of NeuroscienceWeinberg ALS CenterVickie and Jack Farber Institute for NeuroscienceThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Lara Marrone
- Department of NeuroscienceSheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Mimoun Azzouz
- Department of NeuroscienceSheffield Institute for Translational Neuroscience (SITraN)University of SheffieldSheffieldUK
| | - Davide Trotti
- Department of NeuroscienceWeinberg ALS CenterVickie and Jack Farber Institute for NeuroscienceThomas Jefferson UniversityPhiladelphiaPAUSA
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30
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Bella ED, Bersano E, Antonini G, Borghero G, Capasso M, Caponnetto C, Chiò A, Corbo M, Filosto M, Giannini F, Spataro R, Lunetta C, Mandrioli J, Messina S, Monsurrò MR, Mora G, Riva N, Rizzi R, Siciliano G, Silani V, Simone I, Sorarù G, Tugnoli V, Verriello L, Volanti P, Furlan R, Nolan JM, Abgueguen E, Tramacere I, Lauria G. The unfolded protein response in amyotrophic later sclerosis: results of a phase 2 trial. Brain 2021; 144:2635-2647. [PMID: 33905493 PMCID: PMC8557337 DOI: 10.1093/brain/awab167] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/26/2021] [Accepted: 04/16/2021] [Indexed: 11/14/2022] Open
Abstract
Strong evidence suggests that endoplasmic reticulum (ER) stress plays a critical role in the pathogenesis of amyotrophic lateral sclerosis (ALS) through an altered regulation of proteostasis. Robust preclinical findings demonstrated that guanabenz selectively inhibits ER stress-induced eIF2α-phosphatase allowing misfolded protein clearance, reduces neuronal death and prolongs survival in in vitro and in vivo models. Its efficacy and safety in ALS patients are unknown. To address these issues, we conducted a multicentre, randomised, double-blind trial, with futility design. ALS patients with onset of symptoms within the previous 18 months were randomly assigned to receive in a 1:1:1:1 ratio guanabenz 64 mg, 32 mg, 16 mg or placebo daily for 6 months as add-on therapy to riluzole. The purpose of the placebo group blinding was safety but not efficacy. The primary outcome was the proportion of patients progressing to higher stages of disease in 6 months as measured by the ALS Milano-Torino staging compared to a historical cohort of 200 ALS patients. The secondary outcomes were the rate of decline in ALSFRS-R total score, slow vital capacity change, time to death, tracheotomy or permanent ventilation and serum light neurofilament level at 6 months. The primary analysis of efficacy was performed by intention-to-treat. Guanabenz 64 mg and 32 mg arms, both alone and combined, reached the primary hypothesis of non-futility with proportions of patients who progressed to higher stage of disease at 6 months significantly lower than that expected under the hypothesis of non-futility and significantly lower difference in the median rate of change of the ALSFRS-R total score. This effect was driven by patients with bulbar onset, none of whom (0/18) progressed to a higher stage of disease at 6 months compared with those in guanabenz 16 mg (4/8; 50%), historical cohort alone (21/49; 43%; p = 0.001) or plus placebo (25/60; 42%; p = 0.001). The proportion of patients who experienced at least one adverse event was higher in any guanabenz arm than in the placebo arm, with higher dosing arms having significantly higher proportion of drug-related side effects and the 64 mg arm significantly higher drop-out rate. The number of serious adverse events did not significantly differ between guanabenz arms and placebo. Our findings indicate that a larger trial with a molecule targeting the UPR pathway without the alpha-2 adrenergic related side-effect profile of guanabenz is warranted.
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Affiliation(s)
- Eleonora Dalla Bella
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Enrica Bersano
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Giovanni Antonini
- NESMOS Department, Neuromuscolar Disease Unit, Sant'Andrea Hospital and University of Rome "Sapienza", Rome, Italy
| | | | | | | | - Adriano Chiò
- ALS Centre "Rita Levi Montalcini", Department of Neuroscience, University of Turin, Turin, Italy.,Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Massimo Corbo
- Department of Neurorehabilitaton, Casa Cura Policlinico, Milan, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili Brescia and NeMO-Brescia Clinical Centre for Neuromuscular Diseases, Brescia, Italy
| | - Fabio Giannini
- Department of Medical and Surgery Sciences and Neurosciences, University of Siena, Italy
| | | | | | - Jessica Mandrioli
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Sonia Messina
- Unit of Neurology and Neuromuscular Disorders, Department of Clinical and Experimental Medicine and University of Messina, AOU Policlinico "G. Martino", Messina, Italy.,NEuroMuscular Omnicentre of Messina, University Hospital "G. Martino", Messina, Italy
| | | | | | - Nilo Riva
- Department of Neurology IRCCS "San Raffaele" Hospital, Milan, Italy
| | - Romana Rizzi
- Neurology Unit, Department of Neuro-Motor Diseases, Azienda Unità Sanitaria Locale, IRCCS of Reggio Emilia, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Vincenzo Silani
- Department of Neurology-Stroke Unit and Laboratory of Neuroscience, Istituto Auxologico Italiano IRCCS, Milan, Italy.,Department of Pathophysiology and Transplantation, "Dino Ferrari" Centre and Centre for Neurotechnology and Brain Therapeutics, University of Milan, Milan, Italy
| | - Isabella Simone
- Department of Neurology and Psychiatry, University of Bari, Italy
| | - Gianni Sorarù
- Department of Neurosciences, University of Padua, Italy
| | - Valeria Tugnoli
- Department of Neuroscience and Rehabilitation, Division of Neurology, University Hospital of Ferrara, Ferrara, Italy
| | - Lorenzo Verriello
- Neurology Unit, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Paolo Volanti
- Intensive Neurorehabilitation Unit, ICS Maugeri IRCCS, Mistretta, Italy
| | - Roberto Furlan
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Milan, Italy
| | - John M Nolan
- Drew University, Caspersen School of Graduate Studies, Madison, NJ, USA
| | | | - Irene Tramacere
- Scientific Directorate, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Giuseppe Lauria
- 3rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy.,Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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31
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Luna J, Couratier P, Lahmadi S, Lautrette G, Fontana A, Tortelli R, Logroscino G, Preux PM, Copetti M, Benoit M. Comparison of the ability of the King's and MiToS staging systems to predict disease progression and survival in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:478-485. [PMID: 33829938 DOI: 10.1080/21678421.2021.1903506] [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] [Indexed: 10/21/2022]
Abstract
Background: Assessing clinical progression in amyotrophic lateral sclerosis (ALS) remains a challenge. We evaluated the validity and predictive capabilities of the King's and Milano-Torino Staging (MiToS) systems in a cohort of patients with ALS to demonstrate their benefit in clinical practice.Methodology: A cohort study was performed by including ALS incident cases in a referral center from 2007 to 2016. The staging systems were determined at time of diagnosis and follow-up. The standardized median times to reach each stage were computed. A multi-state model in the framework of the Cox model evaluated the predictive value of measurements. The survival C-statistic was reported as a measure of prediction ability.Results: Overall, 298 incident cases were included. The King's and MiToS systems described a progressive increase in the risk of dying with each elapsed stage. However, a lower resolution for late disease description for the King's system was observed, and late stages overlapped for the MiToS system. Slight variations in the staging systems appeared to improve performance based on validity and prediction abilities: (i) in the King's (C-statistic = 0.783), by adding a new stage involving the need for both gastrostomy and NIV: (ii) in the MiToS (C-statistic = 0.792), by merging stage 3 and stage 4 into a single stage 3.Conclusion: Both King's and MiToS are valid systems but have certain limitations. Variations in the staging systems may provide a more suitable framework for describing progression and survival. Further research is needed to evaluate the variations in the staging systems.
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Affiliation(s)
- Jaime Luna
- INSERM, University of Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST,Limoges, France.,Department of Neurology, ALS expert centre, CHU Limoges,Limoges, France
| | - Philippe Couratier
- INSERM, University of Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST,Limoges, France.,Department of Neurology, ALS expert centre, CHU Limoges,Limoges, France
| | - Sanae Lahmadi
- Department of Neurology, ALS expert centre, CHU Limoges,Limoges, France
| | | | - Andrea Fontana
- Unit of Biostatistics, IRCCS ''Casa Sollievo della Sofferenza'', San Giovanni Rotondo, Italy
| | - Rosanna Tortelli
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari ''Aldo Moro'', at ''Pia Fondazione Cardinale G. Panico'', Lecce, Italy.,Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Giancarlo Logroscino
- Unit of Neurodegenerative Diseases, Department of Clinical Research in Neurology, University of Bari ''Aldo Moro'', at ''Pia Fondazione Cardinale G. Panico'', Lecce, Italy.,Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari ''Aldo Moro'', Bari, Italy
| | - Pierre-Marie Preux
- INSERM, University of Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST,Limoges, France.,Centre d'Epidémiologie, de Biostatistique et de Méthodologie de la Recherche, CHU Limoges, Limoges, France
| | - Massimilano Copetti
- Unit of Biostatistics, IRCCS ''Casa Sollievo della Sofferenza'', San Giovanni Rotondo, Italy
| | - Marin Benoit
- INSERM, University of Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST,Limoges, France
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Al Khleifat A, Balendra R, Fang T, Al-Chalabi A. Intuitive Staging Correlates With King's Clinical Stage. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:336-340. [PMID: 33821690 DOI: 10.1080/21678421.2020.1867181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Clinical stage in amyotrophic lateral sclerosis (ALS) can be assigned using King's staging with a simple protocol based on the number of CNS regions involved and the presence of significant nutritional or respiratory failure. It is important that the assigned clinical stage matches expectations, and generally corresponds with how a health care professional would intuitively stage the patient. We therefore investigated the relationship between King's clinical ALS stage and ALS stage as intuitively assigned by health care professionals. Methods: We wrote 17 case vignettes describing people with ALS at different disease stages from very early limited disease involvement through to severe, multi-domain disease. During two workshops, we asked health care professionals to intuitively stage the vignettes and compared the answers with the actual King's clinical ALS stage. Results: There was a good correlation between King's clinical ALS stage and intuitively assigned stage, with a Spearman's Rank correlation coefficient of 0.64 (p < 0.001). There was no difference in the intuitive stages assigned by practitioners of different types or at different levels of experience. Conclusions: Across a spectrum of ALS scenarios, King's clinical ALS stage corresponds to intuitive ALS stage as assigned by a range of health care professionals.
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Affiliation(s)
- Ahmad Al Khleifat
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Rubika Balendra
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,Department of Genetics, Evolution and Environment, Institute of Healthy Ageing, University College London, London, UK
| | - Ton Fang
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
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33
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Abdul Aziz NA, Toh TH, Loh EC, Capelle DP, Goh KJ, Abdul Latif L, Chung TY, Shahrizaila N. The utility of ALS staging systems in a multi-ethnic patient cohort. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:341-349. [PMID: 33726578 DOI: 10.1080/21678421.2021.1893336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: To compare two ALS staging systems, King's clinical staging and Milano-Torino (MiToS) functional staging, using prospective data from a multi-ethnic cohort of ALS patients. Methods: The stages of disease were determined prospectively based on existing definitions. The two systems were compared for timing of stages using box plots, correspondence using chi-square tests and association using Spearman's rank correlation. Results: The distribution of stages differed between the two systems. The proportions of disease stages of the King's staging system were more evenly distributed whereas in MiToS, there was greater weight seen at the later stages of disease. At the early stages, patients moved consecutively in the MiToS staging system but not in the King's staging system where patients tended to skip stages to reach later stages. Both systems had good correlation (Spearman's rho = 0.869) and the King's stage 4 most frequently corresponded to MiToS stage 2. Conclusion: We found the King's staging was helpful in determining the stages of disease burden, whereas both were helpful in determining the time to functional dependence with MiToS further refining the levels of dependence.
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Affiliation(s)
- Nur Adilah Abdul Aziz
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tsun-Haw Toh
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ee-Chin Loh
- Palliative Care Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia and
| | - David Paul Capelle
- Palliative Care Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia and
| | - Khean-Jin Goh
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lydia Abdul Latif
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tze-Yang Chung
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Neurology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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34
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Poluyi E, Morgan E, Poluyi C, Ikwuegbuenyi C, Imaguezegie G. Examining the Relationship between Concussion and Neurodegenerative Disorders: A Review on Amyotrophic Lateral Sclerosis (ALS) and Alzheimer’s Disease (AD). INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1725571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abstract
Background Current epidemiological studies have examined the associations between moderate and severe traumatic brain injury (TBI) and their risks of developing neurodegenerative diseases. Concussion, also known as mild TBI (mTBI), is however quite distinct from moderate or severe TBIs. Only few studies in this burgeoning area have examined concussion—especially repetitive episodes—and neurodegenerative diseases. Thus, no definite relationship has been established between them.
Objectives This review will discuss the available literatures linking concussion and amyotrophic lateral sclerosis (ALS) and Alzheimer’s disease (AD).
Materials and Methods Given the complexity of this subject, a realist review methodology was selected which includes clarifying the scope and developing a theoretical framework, developing a search strategy, selection and appraisal, data extraction, and synthesis. A detailed literature matrix was set out in order to get relevant and recent findings on this topic.
Results Presently, there is no objective clinical test for the diagnosis of concussion because the features are less obvious on physical examination. Absence of an objective test in diagnosing concussion sometimes leads to skepticism when confirming the presence or absence of concussion. Intriguingly, several possible explanations have been proposed in the pathological mechanisms that lead to the development of some neurodegenerative disorders (such as ALS and AD) and concussion but the two major events are deposition of tau proteins (abnormal microtubule proteins) and neuroinflammation, which ranges from glutamate excitotoxicity pathways and inflammatory pathways (which leads to a rise in the metabolic demands of microglia cells and neurons), to mitochondrial function via the oxidative pathways.
Conclusion mTBI constitutes majority of brain injuries. However, studies have focused mostly on moderate-to-severe TBI as highlighted above with inconclusive and paucity of studies linking concussion and neurodegenerative disorders. Although, it is highly probable that repetitive concussion (mTBI) and subconcussive head injuries may be risk factors for ALS) and AD from this review. It will be imperative therefore to conduct more research with a focus on mTBI and its association with ALS and AD.
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Affiliation(s)
- Edward Poluyi
- Department of Clinical Neuroscience, University of Roehampton, London, United Kingdom
| | - Eghosa Morgan
- Department of Neurosurgery, Irrua Specialist Teaching Hospital, Irrua, Nigeria
| | - Charles Poluyi
- MPH Program, University of Buffalo, New York, United States
| | | | - Grace Imaguezegie
- Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
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Ranieri F, Mariotto S, Dubbioso R, Di Lazzaro V. Brain Stimulation as a Therapeutic Tool in Amyotrophic Lateral Sclerosis: Current Status and Interaction With Mechanisms of Altered Cortical Excitability. Front Neurol 2021; 11:605335. [PMID: 33613416 PMCID: PMC7892772 DOI: 10.3389/fneur.2020.605335] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
In the last 20 years, several modalities of neuromodulation, mainly based on non-invasive brain stimulation (NIBS) techniques, have been tested as a non-pharmacological therapeutic approach to slow disease progression in amyotrophic lateral sclerosis (ALS). In both sporadic and familial ALS cases, neurophysiological studies point to motor cortical hyperexcitability as a possible priming factor in neurodegeneration, likely related to dysfunction of both excitatory and inhibitory mechanisms. A trans-synaptic anterograde mechanism of excitotoxicity is thus postulated, causing upper and lower motor neuron degeneration. Specifically, motor neuron hyperexcitability and hyperactivity are attributed to intrinsic cell abnormalities related to altered ion homeostasis and to impaired glutamate and gamma aminobutyric acid gamma-aminobutyric acid (GABA) signaling. Several neuropathological mechanisms support excitatory and synaptic dysfunction in ALS; additionally, hyperexcitability seems to drive DNA-binding protein 43-kDA (TDP-43) pathology, through the upregulation of unusual isoforms directly contributing to ASL pathophysiology. Corticospinal excitability can be suppressed or enhanced using NIBS techniques, namely, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), as well as invasive brain and spinal stimulation. Experimental evidence supports the hypothesis that the after-effects of NIBS are mediated by long-term potentiation (LTP)-/long-term depression (LTD)-like mechanisms of modulation of synaptic activity, with different biological and physiological mechanisms underlying the effects of tDCS and rTMS and, possibly, of different rTMS protocols. This potential has led to several small trials testing different stimulation interventions to antagonize excitotoxicity in ALS. Overall, these studies suggest a possible efficacy of neuromodulation in determining a slight reduction of disease progression, related to the type, duration, and frequency of treatment, but current evidence remains preliminary. Main limitations are the small number and heterogeneity of recruited patients, the limited "dosage" of brain stimulation that can be delivered in the hospital setting, the lack of a sufficient knowledge on the excitatory and inhibitory mechanisms targeted by specific stimulation interventions, and the persistent uncertainty on the key pathophysiological processes leading to motor neuron loss. The present review article provides an update on the state of the art of neuromodulation in ALS and a critical appraisal of the rationale for the application/optimization of brain stimulation interventions, in the light of their interaction with ALS pathophysiological mechanisms.
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Affiliation(s)
- Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, Rome, Italy
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Al-Chalabi A, Chiò A, Merrill C, Oster G, Bornheimer R, Agnese W, Apple S. Clinical staging in amyotrophic lateral sclerosis: analysis of Edaravone Study 19. J Neurol Neurosurg Psychiatry 2021; 92:165-171. [PMID: 33109706 PMCID: PMC7841496 DOI: 10.1136/jnnp-2020-323271] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This was a post hoc analysis of the Edaravone Phase III Study MCI186-19 ('Study 19') to examine the utility of clinical staging systems as end points in clinical trials in amyotrophic lateral sclerosis (ALS). METHODS Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised item scores from Study 19 were retrospectively mapped to King's stage and Milano-Torino staging (MiToS) stage. We assessed the percentage of patients who experienced progression in King's and MiToS stages during Study 19. We also assessed disease progression in subgroups of patients according to baseline King's stage. RESULTS During double-blind treatment, the percentage of patients who experienced a progression in King's stage was lower for edaravone (42.0%, 95% CI 30.4% to 53.6%) than placebo (55.9%, 95% CI 44.1% to 67.6%). The most pronounced effect was noted among patients who were in stage 1 and was maintained throughout open-label treatment. An analysis of a ≥2-stage progression in MiToS stage showed no difference between treatment arms during double-blind treatment, but during the open-label period, more rapid progression was noted among patients in the placebo-edaravone arm than among those in the edaravone-edaravone arm (log-rank test, p<0.001). CONCLUSIONS The King's and MiToS staging systems provided utility in assessing clinical progression in Edaravone Study 19. These findings may support the use of staging systems as end points in ALS clinical trials and to understand the timing of benefit as measured by these scales.
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Affiliation(s)
- Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Adriano Chiò
- "Rita Levi Montalcini" Department of Neurosciences, ALS Centre, University of Turin and Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Turin, Italy
| | | | - Gerry Oster
- Policy Analysis Inc, Brookline, Massachusetts, USA
| | | | - Wendy Agnese
- Mitsubishi Tanabe Pharma America, Inc, Jersey City, New Jersey, USA
| | - Stephen Apple
- Mitsubishi Tanabe Pharma America, Inc, Jersey City, New Jersey, USA
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Kiernan MC, Vucic S, Talbot K, McDermott CJ, Hardiman O, Shefner JM, Al-Chalabi A, Huynh W, Cudkowicz M, Talman P, Van den Berg LH, Dharmadasa T, Wicks P, Reilly C, Turner MR. Improving clinical trial outcomes in amyotrophic lateral sclerosis. Nat Rev Neurol 2021; 17:104-118. [PMID: 33340024 PMCID: PMC7747476 DOI: 10.1038/s41582-020-00434-z] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
Individuals who are diagnosed with amyotrophic lateral sclerosis (ALS) today face the same historically intransigent problem that has existed since the initial description of the disease in the 1860s - a lack of effective therapies. In part, the development of new treatments has been hampered by an imperfect understanding of the biological processes that trigger ALS and promote disease progression. Advances in our understanding of these biological processes, including the causative genetic mutations, and of the influence of environmental factors have deepened our appreciation of disease pathophysiology. The consequent identification of pathogenic targets means that the introduction of effective therapies is becoming a realistic prospect. Progress in precision medicine, including genetically targeted therapies, will undoubtedly change the natural history of ALS. The evolution of clinical trial designs combined with improved methods for patient stratification will facilitate the translation of novel therapies into the clinic. In addition, the refinement of emerging biomarkers of therapeutic benefits is critical to the streamlining of care for individuals. In this Review, we synthesize these developments in ALS and discuss the further developments and refinements needed to accelerate the introduction of effective therapeutic approaches.
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Affiliation(s)
- Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
| | - Steve Vucic
- Sydney Medical School Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield, UK
| | - Orla Hardiman
- Academic Neurology Unit, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- National Neuroscience Centre, Beaumont Hospital, Dublin, Ireland
| | - Jeremy M Shefner
- Department of Neurology, Barrow Neurological Institute, University of Arizona College of Medicine Phoenix, Creighton University, Phoenix, AZ, USA
| | - Ammar Al-Chalabi
- King's College London, Maurice Wohl Clinical Neuroscience Institute, Department of Basic and Clinical Neuroscience, London, UK
| | - William Huynh
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Merit Cudkowicz
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul Talman
- Neurosciences Department, Barwon Health District, Melbourne, Victoria, Australia
| | - Leonard H Van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thanuja Dharmadasa
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Paul Wicks
- Wicks Digital Health, Lichfield, United Kingdom
| | - Claire Reilly
- The Motor Neurone Disease Association of New Zealand, Auckland, New Zealand
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Thakore NJ, Pioro EP, Udeh BL, Lapin BR, Katzan IL. A Cost-Effectiveness Framework for Amyotrophic Lateral Sclerosis, Applied to Riluzole. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1543-1551. [PMID: 33248509 DOI: 10.1016/j.jval.2020.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/18/2020] [Accepted: 06/21/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Reexamine cost-effectiveness of riluzole in the treatment of amyotrophic lateral sclerosis (ALS) in light of recent advances in disease staging and understanding of stage-specific drug effect. METHODS ALS was staged according to the "fine'til 9" (FT9) staging method. Stage-specific health utilities (EQ-5D, US valuation) were estimated from an institutional cohort, whereas literature informed costs and transition probabilities. Costs at 2018 prices were disaggregated into recurring costs (RCs) and "one-off" transition/"tollgate" costs (TCs). Five- and 10-year horizons starting in stage 1 disease were examined from healthcare sector and societal perspectives using Markov models to evaluate riluzole use, at a threshold of $100 000/quality-adjusted life year (QALY). Probabilistic and deterministic sensitivity analyses were conducted. RESULTS Mean EQ-5D utilities for stages 0 to 4 were 0.79, 0.74, 0.63, 0.54, and 0.46, respectively. From the healthcare sector perspective at the 5-year horizon, riluzole use contributed to 0.182 QALY gained at the cost difference of $12 348 ($5403 riluzole cost, $8870 RC and -$1925 TC differences), translating to an incremental cost-effectiveness ratio (ICER) of $67 658/QALY. Transition probability variation contributed considerably to ICER uncertainty (-30.2% to +90.0%). ICER was sensitive to drug price and RCs, whereas higher TCs modestly reduced ICER due to delayed tollgates. CONCLUSION This study provides a framework for health economic studies of ALS treatments using FT9 staging. Prospective stage-specific and disaggregated cost measurement is warranted for accurate future cost-effectiveness analyses. Appropriate separation of TCs from RCs substantially mitigates the high burden of background cost of care on the ICER.
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Affiliation(s)
| | - Erik P Pioro
- Neurology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Belinda L Udeh
- Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic, Cleveland, OH, USA
| | - Brittany R Lapin
- Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic, Cleveland, OH, USA
| | - Irene L Katzan
- Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic, Cleveland, OH, USA
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Abstract
PURPOSE OF REVIEW The current review will provide recent updates in the clinical management of amyotrophic lateral sclerosis (ALS). RECENT FINDINGS Although there is no cure for ALS, there are new treatments, growing knowledge of genetics, development of clinical staging systems, and the recent coronavirus disease 2019 pandemic that have recently impacted the clinical management of ALS. Increased understanding of genetics has helped provide insights into pathophysiology, the staging systems and clinical measures help to provide tools for monitoring disease clinically, and the recent coronavirus disease 2019 pandemic has provided opportunities to develop telemedicine and remote monitoring of disease thereby increasing accessibility to care and reducing burden of travel to centers for people living with the disease and their caregivers. SUMMARY ALS is a progressive neurodegenerative disease that causes degeneration of the motor neurons which leads to paralysis and respiratory failure. Despite the lack of a cure, multidisciplinary care, proactive respiratory management, nutritional care and management of symptoms as well as pharmacological interventions that can improve quality of life and survival.
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Manifold learning for amyotrophic lateral sclerosis functional loss assessment : Development and validation of a prognosis model. J Neurol 2020; 268:825-850. [PMID: 32886252 DOI: 10.1007/s00415-020-10181-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is an inexorably progressive neurodegenerative condition with no effective disease-modifying therapy at present. Given the striking clinical heterogeneity of the condition, the development and validation of reliable prognostic models is a recognised research priority. We present a prognostic model for functional decline in ALS where outcome uncertainty is taken into account. Patient data were reduced and projected onto a 2D space using Uniform Manifold Approximation and Projection (UMAP), a novel non-linear dimension reduction technique. Information from 3756 patients was included. Development data were sourced from past clinical trials. Real-world population data were used as validation data. Predictors included age, gender, region of onset, symptom duration, weight at baseline, functional impairment, and estimated rate of functional loss. UMAP projection of patients showed an informative 2D data distribution. As limited data availability precluded complex model designs, the projection was divided into three zones defined by a functional impairment range probability. Zone membership allowed individual patient prediction. Patients belonging to the first zone had a probability of [Formula: see text] (± [Formula: see text]) to have an ALSFRS score over 20 at 1-year follow-up. Patients within the second zone had a probability of [Formula: see text] (± [Formula: see text]) to have an ALSFRS score between 10 and 30 at 1 year follow-up. Finally, patients within the third zone had a probability of [Formula: see text] (± [Formula: see text]) to have an ALSFRS score lower than 20 at 1 year follow-up. This approach requires a limited set of features, is easily updated, improves with additional patient data, and accounts for results uncertainty. This method could therefore be used in a clinical setting for patient stratification and outcome projection.
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Manera U, Calvo A, Daviddi M, Canosa A, Vasta R, Torrieri MC, Grassano M, Brunetti M, D'Alfonso S, Corrado L, De Marchi F, Moglia C, D'Ovidio F, Mora G, Mazzini L, Chiò A. Regional spreading of symptoms at diagnosis as a prognostic marker in amyotrophic lateral sclerosis: a population-based study. J Neurol Neurosurg Psychiatry 2020; 91:291-297. [PMID: 31871138 DOI: 10.1136/jnnp-2019-321153] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/03/2019] [Accepted: 12/04/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The lack of prognostic biomarkers in patients with amyotrophic lateral sclerosis (ALS) induced researchers to develop clinical evaluation tools for stratification and survival prediction. We assessed the correlation between patterns of functional involvement, considered as a cumulative number of body regions involved, and overall survival in a population-based series of patients with ALS (PARALS). METHODS We derived the functional involvement of four body regions at diagnosis using ALSFRS-R subscores for bulbar, upper limbs, lower limbs and respiratory/thoracic regions. We analysed the effect of number of body regions involved (NBRI) at diagnosis on overall survival, adjusting for age at onset, sex, site of onset, diagnostic delay, forced vital capacity, body mass index, mutational status, cognition and comparing it with King's staging system. RESULTS The NBRI was strongly related to survival, with a progressive increase of death/tracheostomy risk among groups (two body regions HR=1.24, 95% CI 1.06 to 1.45, p=0007; three body regions HR=1.65, 95% CI 1.38 to 1.98, p<0.001; four body regions HR=2.68, 95% CI 2.11 to 3.39, p<0.001). Using ALSFRS-R score, the consistency between the number of regions involved and King's clinical stage at diagnosis was very high (81%). The evaluation of respiratory/thoracic region and cognition allowed to subdivide patients into different prognostic categories. Regional spreading of the disease is associated with survival, independently from the initial region involved. CONCLUSIONS The evaluation of NBRI, with the inclusion of initial respiratory/thoracic involvement and cognition, can be useful in many research fields, improving the stratification of patients. Our findings highlight the importance of the spatial spreading of functional impairment in the prediction of ALS outcome.
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Affiliation(s)
- Umberto Manera
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Andrea Calvo
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Margherita Daviddi
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Antonio Canosa
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Rosario Vasta
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Maria Claudia Torrieri
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Maurizio Grassano
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Maura Brunetti
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Sandra D'Alfonso
- Department of Health Sciences, Interdisciplinary Research Center of Autoimmune Diseases, University of Eastern Piedmont Amedeo Avogadro School of Medicine, Novara, Piemonte, Italy
| | - Lucia Corrado
- Department of Health Sciences, Interdisciplinary Research Center of Autoimmune Diseases, University of Eastern Piedmont Amedeo Avogadro School of Medicine, Novara, Piemonte, Italy
| | - Fabiola De Marchi
- Department of Neurology, ALS Centre, Azienda Ospedaliero-Universitaria Maggiore della Carita, Novara, Piemonte, Italy
| | - Cristina Moglia
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Fabrizio D'Ovidio
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy
| | - Gabriele Mora
- ALS Centre, Fondazione Salvatore Maugeri Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Lombardia, Italy
| | - Letizia Mazzini
- Department of Neurology, ALS Centre, Azienda Ospedaliero-Universitaria Maggiore della Carita, Novara, Piemonte, Italy
| | - Adriano Chiò
- Department of Neuroscience 'Rita Levi Montalcini', ALS Centre, University of Turin, Torino, Piemonte, Italy.,Neuroscience Institute of Torino (NIT), University of Torino, Torino, Piemonte, Italy
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Steinbach R, Batyrbekova M, Gaur N, Voss A, Stubendorff B, Mayer TE, Gaser C, Witte OW, Prell T, Grosskreutz J. Applying the D50 disease progression model to gray and white matter pathology in amyotrophic lateral sclerosis. NEUROIMAGE-CLINICAL 2019; 25:102094. [PMID: 31896467 PMCID: PMC6940701 DOI: 10.1016/j.nicl.2019.102094] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/07/2019] [Accepted: 11/15/2019] [Indexed: 12/11/2022]
Abstract
The D50 disease progression model well characterized a cross-sectional ALS cohort. VBM reveled ALS-related widespread gray and white matter density decreases. A spread of structural alterations occurs along with D50 model derived disease phases. White-matter alterations were associated with higher disease aggressiveness.
Therapeutic management and research in Amyotrophic Laterals Sclerosis (ALS) have been limited by the substantial heterogeneity in progression and anatomical spread that are endemic of the disease. Neuroimaging biomarkers represent powerful additions to the current monitoring repertoire but have yielded inconsistent associations with clinical scores like the ALS functional rating scale. The D50 disease progression model was developed to address limitations with clinical indices and the difficulty obtaining longitudinal data in ALS. It yields overall disease aggressiveness as time taken to reach halved functionality (D50); individual disease covered in distinct phases; and calculated functional state and calculated functional loss as acute descriptors of local disease activity. It greatly reduces the noise of the ALS functional rating scale and allows the comparison of highly heterogeneous disease and progression subtypes. In this study, we performed Voxel-Based Morphometry for 85 patients with ALS (60.1 ± 11.5 years, 36 female) and 62 healthy controls. Group-wise comparisons were performed separately for gray matter and white matter using ANCOVA testing with threshold-free cluster enhancement. ALS-related widespread gray and white matter density decreases were observed in the bilateral frontal and temporal lobes (p < 0.001, family-wise error corrected). We observed a progressive spread of structural alterations along the D50-derived phases, that were primarily located in frontal, temporal and occipital gray matter areas, as well as in supratentorial neuronal projections (p < 0.001 family-wise error corrected). ALS patients with higher overall disease aggressiveness (D50 < 30 months) showed a distinct pattern of supratentorial white matter density decreases relative to patients with lower aggressiveness; no significant differences were observed for gray matter density (p < 0.001 family-wise error corrected). The application of the D50 disease progression model separates measures of disease aggressiveness from disease accumulation. It revealed a strong correlation between disease phases and in-vivo measures of cerebral structural integrity. This study underscores the proposed corticofugal spread of cerebral pathology in ALS. We recommend application of the D50 model in studies linking clinical data with neuroimaging correlates.
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Affiliation(s)
- Robert Steinbach
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Meerim Batyrbekova
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Nayana Gaur
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Annika Voss
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital, Jena, Germany
| | - Christian Gaser
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Tino Prell
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Julian Grosskreutz
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany; Center for Healthy Ageing, Jena University Hospital, Jena, Germany
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Moore A, Young CA, Hughes DA. Health Utilities and Costs for Motor Neurone Disease. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1257-1265. [PMID: 31708062 DOI: 10.1016/j.jval.2019.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/19/2019] [Accepted: 05/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Motor neurone disease (MND) places a significant burden on patients, their carers, and healthcare systems. OBJECTIVES To estimate health utilities and costs of MND within the UK setting. METHODS Patients with MND, recruited via 22 regional clinics, completed a postal questionnaire of a cost and quality-of-life survey. Health outcome assessment included the EuroQoL (EQ)-5D-5L, EQ-5D-visual analogue scale, Amyotrophic Lateral Sclerosis Utility Index, and the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised. Clinical staging was based on the Kings and Milano-Torino (MiToS) systems. The questionnaire asked about patients' use of primary, secondary, and community care services in the previous 3 months. Variability in total costs was examined using regression models. RESULTS 595 patients were included in the health utility analysis, of whom 584 patients also completed a resource use questionnaire. Mean health utility decreased and costs increased between consecutive Kings stages, from 0.76 (95% CI 0.71-0.80) and £1096 (£757-£1240) in Kings stage 1, to 0.50 (0.45-0.54) and £3311 (£2666-£4151) in stage 4, respectively. The changes by MiToS stages were from 0.71 (0.69-0.73) and £1115 (£937-£1130) in MiToS stage 0, to 0.25 (0.07-0.42) and £2899 (£2190-£3840) in stage 2. Kings stages 3 and 4 and MiToS stages 1 and 2, respectively, were significant in explaining variability in total costs. CONCLUSIONS The impact of MND on health utilities and costs differs by disease severity. The data provided here can be used in cost-effectiveness analyses and to inform decision-making regarding healthcare provision for people with MND.
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Affiliation(s)
- Alan Moore
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, England, UK
| | | | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, England, UK.
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Chipika RH, Finegan E, Li Hi Shing S, Hardiman O, Bede P. Tracking a Fast-Moving Disease: Longitudinal Markers, Monitoring, and Clinical Trial Endpoints in ALS. Front Neurol 2019; 10:229. [PMID: 30941088 PMCID: PMC6433752 DOI: 10.3389/fneur.2019.00229] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) encompasses a heterogeneous group of phenotypes with different progression rates, varying degree of extra-motor involvement and divergent progression patterns. The natural history of ALS is increasingly evaluated by large, multi-time point longitudinal studies, many of which now incorporate presymptomatic and post-mortem assessments. These studies not only have the potential to characterize patterns of anatomical propagation, molecular mechanisms of disease spread, but also to identify pragmatic monitoring markers. Sensitive markers of progressive neurodegenerative change are indispensable for clinical trials and individualized patient care. Biofluid markers, neuroimaging indices, electrophysiological markers, rating scales, questionnaires, and other disease-specific instruments have divergent sensitivity profiles. The discussion of candidate monitoring markers in ALS has a dual academic and clinical relevance, and is particularly timely given the increasing number of pharmacological trials. The objective of this paper is to provide a comprehensive and critical review of longitudinal studies in ALS, focusing on the sensitivity profile of established and emerging monitoring markers.
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Affiliation(s)
| | - Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Kukulka K, Washington KT, Govindarajan R, Mehr DR. Stakeholder Perspectives on the Biopsychosocial and Spiritual Realities of Living With ALS: Implications for Palliative Care Teams. Am J Hosp Palliat Care 2019; 36:851-857. [PMID: 30827121 DOI: 10.1177/1049909119834493] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
CONTEXT Amyotrophic lateral sclerosis (ALS) is an all-encompassing, life-limiting disease, resulting in the eventual paralysis of all voluntary muscles and concurrent loss of independence. As the disease advances, both patients and their family caregivers develop complex biological, psychological, and social needs, leading to increasing calls for the involvement of palliative care teams in the management of ALS. OBJECTIVE The purpose of this study was to generate a rich description of the realities of living with ALS, equipping palliative care teams with an in-depth understanding of the experiences and needs of patients with ALS and their family caregivers. METHODS This study employed a mixed-methods design, with quantitative data supplementing a larger body of qualitative data. Semi-structured interviews with 42 key stakeholders, including patients, family caregivers, and health-care providers, were analyzed for themes essential for effective understanding of ALS. RESULTS Identified themes were organized into 2 broad categories: (1) biopsychosocial needs of patients with ALS and family caregivers and (2) the impact of ALS on spiritual and emotional well-being. Quantitative data supported the recognized themes, particularly with regard to challenges associated with preserving independence, securing sufficient social support, and managing the emotional complexities of the disease. CONCLUSION Study findings illustrate the intricacies of living with ALS and the importance of eliciting individualized values when caring for patients with ALS and their families. The complex biopsychosocial needs experienced by patients and family caregivers suggest numerous opportunities for meaningful palliative care involvement.
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Affiliation(s)
- Klaudia Kukulka
- 1 Deparment of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - Karla T Washington
- 1 Deparment of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - Raghav Govindarajan
- 2 Department of Neurology, School of Medicine, University of Missouri, Columbia, Missouri
| | - David R Mehr
- 1 Deparment of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri
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Yunusova Y, Plowman EK, Green JR, Barnett C, Bede P. Clinical Measures of Bulbar Dysfunction in ALS. Front Neurol 2019; 10:106. [PMID: 30837936 PMCID: PMC6389633 DOI: 10.3389/fneur.2019.00106] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/28/2019] [Indexed: 12/31/2022] Open
Abstract
Bulbar impairment represents a hallmark feature of Amyotrophic Lateral Sclerosis (ALS) that significantly impacts survival and quality of life. Speech and swallowing dysfunction are key contributors to the clinical heterogeneity of ALS and require well-timed and carefully coordinated interventions. The accurate clinical, radiological and electrophysiological assessment of bulbar dysfunction in ALS is one of the most multidisciplinary aspects of ALS care, requiring expert input from speech-language pathologists (SLPs), neurologists, otolaryngologists, augmentative alternative communication (AAC) specialists, dieticians, and electrophysiologists—each with their own evaluation strategies and assessment tools. The need to systematically evaluate the comparative advantages and drawbacks of various bulbar assessment instruments and to develop integrated assessment protocols is increasingly recognized. In this review, we provide a comprehensive appraisal of the most commonly utilized clinical tools for assessing and monitoring bulbar dysfunction in ALS based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) evaluation framework. Despite a plethora of assessment tools, considerable geographical differences exist in bulbar assessment practices and individual instruments exhibit considerable limitations. The gaps identified in the literature offer unique opportunities for the optimization of existing and development of new tools both for clinical and research applications. The multicenter validation and standardization of these instruments will be essential for guideline development and best practice recommendations.
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Affiliation(s)
- Yana Yunusova
- Department of Speech Language Pathology, University of Toronto, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Volcal Tract Visualization Lab, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Emily K Plowman
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, United States
| | - Jordan R Green
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA, United States.,Speech and Hearing Biosciences and Technology Program, Harvard University, Cambridge, MA, United States
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Peter Bede
- Computational Neuroimaging Group, Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
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Balendra R, Al Khleifat A, Fang T, Al-Chalabi A. A standard operating procedure for King's ALS clinical staging. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:159-164. [PMID: 30773950 PMCID: PMC6558284 DOI: 10.1080/21678421.2018.1556696] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: Clinical stages in amyotrophic lateral sclerosis (ALS) can be measured using a simple system based on the number of CNS regions involved and requirement for gastrostomy or noninvasive ventilation (NIV). We aimed to design a standard operating procedure (SOP) to define the standardized use and application of the King’s staging system. Methods: We designed a SOP for the King’s staging system. We wrote case vignettes representative of ALS patients at different disease stages. During two workshops, we taught health care professionals how to use the SOP, then asked them to stage the vignettes using the SOP. We measured the extent to which SOP staging corresponded with correct clinical stage. Results: The reliability of staging using the SOP was excellent, with a Spearman’s Rank coefficient of 0.95 (p < 0.001), and was high for different groups of health care professionals, and for those with different levels of experience in ALS. The limits of agreement between SOP staging and actual clinical stage lie within a single stage, confirming that there is a clinically acceptable level of agreement between staging using the SOP and actual King’s clinical stage. There were also no systematic biases of the SOP over the range of stages, either for over-staging or under-staging. Conclusions: We have demonstrated that the staging SOP provides a reliable method of calculating clinical stages in ALS patients and can be used prospectively by a range of health care professionals with different levels of experience, as for example may be the case in multicentre clinical trials.
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Affiliation(s)
- Rubika Balendra
- a Department of Neurodegenerative Disease , UCL Institute of Neurology , London , UK.,b Department of Genetics, Evolution and Environment , Institute of Healthy Ageing, University College London , London , UK , and
| | - Ahmad Al Khleifat
- c Department of Basic and Clinical Neuroscience , Maurice Wohl Clinical Neuroscience Institute, King's College London , London , UK
| | - Ton Fang
- c Department of Basic and Clinical Neuroscience , Maurice Wohl Clinical Neuroscience Institute, King's College London , London , UK
| | - Ammar Al-Chalabi
- c Department of Basic and Clinical Neuroscience , Maurice Wohl Clinical Neuroscience Institute, King's College London , London , UK
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Corcia P, Beltran S, Lautrette G, Bakkouche S, Couratier P. Staging amyotrophic lateral sclerosis: A new focus on progression. Rev Neurol (Paris) 2018; 175:277-282. [PMID: 30606512 DOI: 10.1016/j.neurol.2018.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a heterogenous motoneuronal neurodegenerative condition with a panel of phenotypes exhibiting different clinical patterns. Two compounds are currently available for the treatment of ALS but the majority of trials have failed to show a positive effect on prognosis. One of the explanations which could be put forward involves the way efficacy is evaluated: clinicians agree that the ALSFRS-revised scale used in all trials does not fit with highlighting a positive effect. So, the development and validation of new tools allowing a reliable assessment of ALS has become a key issue in clinical research. Over the last three years, two functional scales (the King's College and MiToS staging systems) have been proposed. These scales rely on two different approaches to ALS: an anatomical and prognostic concept, and loss of autonomy. Both scales propose five stages. We will discuss below the contribution of these two scales to clinical evaluation and the questions which remain to be resolved in the future.
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Affiliation(s)
- P Corcia
- Centre Constitutif SLA, CHU Tours, 2, boulevard Tonnellé, 37044 Tours cedex 1, France; Fédération des centres SLA de Tours et Limoges, Litorals, France.
| | - S Beltran
- Centre Constitutif SLA, CHU Tours, 2, boulevard Tonnellé, 37044 Tours cedex 1, France; Fédération des centres SLA de Tours et Limoges, Litorals, France
| | - G Lautrette
- Centre Constitutif SLA, CHU Tours, 2, boulevard Tonnellé, 37044 Tours cedex 1, France; Centre de coordination de la filière FILSLAN, CHU Limoges, France
| | - S Bakkouche
- Centre Constitutif SLA, CHU Tours, 2, boulevard Tonnellé, 37044 Tours cedex 1, France
| | - P Couratier
- Fédération des centres SLA de Tours et Limoges, Litorals, France; Centre de coordination de la filière FILSLAN, CHU Limoges, France
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Crockford C, Newton J, Lonergan K, Chiwera T, Booth T, Chandran S, Colville S, Heverin M, Mays I, Pal S, Pender N, Pinto-Grau M, Radakovic R, Shaw CE, Stephenson L, Swingler R, Vajda A, Al-Chalabi A, Hardiman O, Abrahams S. ALS-specific cognitive and behavior changes associated with advancing disease stage in ALS. Neurology 2018; 91:e1370-e1380. [PMID: 30209236 PMCID: PMC6177274 DOI: 10.1212/wnl.0000000000006317] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/28/2018] [Indexed: 11/25/2022] Open
Abstract
Objective To elucidate the relationship between disease stage in amyotrophic lateral sclerosis (ALS), as measured with the King's Clinical Staging System, and cognitive and behavioral change, measured with the Edinburgh Cognitive and Behavioural ALS Screen (ECAS). Methods A large multicenter observational cohort of 161 cross-sectional patients with ALS and 80 healthy matched controls were recruited across 3 research sites (Dublin, Edinburgh, and London). Participants were administered the ECAS and categorized into independent groups based on their King's clinical disease stage at time of testing. Results Significant differences were observed between patients and controls on all subtests of the ECAS except for visuospatial functioning. A significant cross-sectional effect was observed across disease stages for ALS-specific functions (executive, language, letter fluency) and ECAS total score but not for ALS-nonspecific functions (memory, visuospatial). Rates of ALS-specific impairment and behavioral change were also related to disease stage. The relationship between cognitive function and disease stage may be due to letter fluency impairment, whereas higher rates of all behavioral domains were seen in later King's stage. The presence of bulbar signs, but not site of onset, was significantly related to ALS-specific, ECAS total, and behavioral scores. Conclusion ALS-specific cognitive deficits and behavioral impairment are more frequent with more severe disease stage. By end-stage disease, only a small percentage of patients are free of neuropsychological impairment. The presence of bulbar symptoms exaggerates the differences observed between disease stages. These findings suggest that cognitive and behavioral change should be incorporated into ALS diagnostic criteria and should be included in future staging systems.
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Affiliation(s)
- Christopher Crockford
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Judith Newton
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Katie Lonergan
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Theresa Chiwera
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Tom Booth
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Siddharthan Chandran
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Shuna Colville
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Mark Heverin
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Iain Mays
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Suvankar Pal
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Niall Pender
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Marta Pinto-Grau
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Ratko Radakovic
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Christopher E Shaw
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Laura Stephenson
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Robert Swingler
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Alice Vajda
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Ammar Al-Chalabi
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Orla Hardiman
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Sharon Abrahams
- From Human Cognitive Neuroscience (C.C., J.N., T.B., R.R., S.A.), Psychology, Philosophy, Psychology and Language Sciences, Euan MacDonald Centre for Motor Neurone Disease Research (C.C., S.A.), and Alzheimer Scotland Dementia Research Centre (R.R.), University of Edinburgh; Anne Rowling Regenerative Neurology Clinic (J.N., S.C., S.P., R.R., L.S., R.S., S.A.), Royal Infirmary of Edinburgh, UK; Academic Unit of Neurology (K.L., M.H., I.M., M.P.-G., A.V., O.H.), Trinity College Dublin; Departments of Psychology (K.L., I.M., N.P., M.P.-G.) and Neurology (O.H.), Beaumont Hospital, Dublin, Ireland; and Maurice Wohl Clinical Neuroscience Institute (T.C., C.E.S., A.A.-C.), Department of Basic and Clinical Neuroscience, King's College London, UK.
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Thakore NJ, Lapin BR, Kinzy TG, Pioro EP. Deconstructing progression of amyotrophic lateral sclerosis in stages: a Markov modeling approach. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:483-494. [PMID: 30001159 DOI: 10.1080/21678421.2018.1484925] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Propose an empirical amyotrophic lateral sclerosis (ALS) staging approach called Fine'til 9 (FT9) based on how many of the patient's ALS functional rating scale (ALSFRS-R) subscores are 9 or less (of normal 12). Gain insights into progression of ALS by applying Markov models to ALS stages by multiple systems (King's, Milan-Torino system (MITOS) and FT9). METHODS Patients from the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) dataset were staged using ALSFRS-R responses. Risks of progression through stages and death were estimated, as were effects of prognostic variables on these risks. RESULTS A total of 29,947 time points in 3199 patients from the PRO-ACT dataset were assigned stages. Although the three systems were moderately correlated, MITOS stages were heavily skewed toward advanced disease, whereas King's and FT9 stages were more balanced. Non-sequential progression was observed with King's system. Markov models adequately described transitions from stage to stage in the first year of observation, but underestimated risks beyond that point. Regardless of staging method, initial rate of ALSFRS-R decline had a powerful effect on rate of progression through sequential stages, whereas age predominantly influenced stage-specific mortality. CONCLUSION King's and FT9 are more sensitive to observed progression of disease in clinical trials than MITOS. FT9 can partition the course similar to King's, and may have advantages of sequential progression and easy applicability to retrospective data. Markov transition intensity estimates may be of value for counseling, health economic studies, and research design. In particular, this framework permits estimation of multidimensional effects of variables (including treatment) on outcome.
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Affiliation(s)
- Nimish J Thakore
- a Department of Neurology/Neuromuscular Center, Cleveland Clinic , Cleveland , OH , USA
| | - Brittany R Lapin
- b Quantitative Health Sciences/Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic , Cleveland , OH , USA , and
| | - Tyler G Kinzy
- b Quantitative Health Sciences/Neurological Institute Center for Outcomes Research and Evaluation (NICORE), Cleveland Clinic , Cleveland , OH , USA , and
| | - Erik P Pioro
- a Department of Neurology/Neuromuscular Center, Cleveland Clinic , Cleveland , OH , USA.,c Department of Neurosciences , Lerner Research Institute, Cleveland Clinic , Cleveland , OH , USA
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