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Berger TD, Fogel Berger C, Gara S, Ben-Zeev B, Weiss B. Nutritional and gastrointestinal manifestations in Rett syndrome: long-term follow-up. Eur J Pediatr 2024:10.1007/s00431-024-05668-3. [PMID: 38960904 DOI: 10.1007/s00431-024-05668-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Rett syndrome is a rare neurodevelopmental disorder associated with methyl CpG binding protein 2 (MECP2) gene mutations. We aimed to characterize the long-term nutritional and gastrointestinal course of Rett syndrome in a large national patient population. METHODS We conducted a retrospective cohort study of patients followed during 1991-2021 at a national center for Rett syndrome. The data retrieved included clinical features, laboratory and genetic analyses. Continuous anthropometric measurements were calculated for the closest visit to the median ages: 2.5, 7.5, 12.5 and 17.5 years. Kaplan Meier curves were used to describe the appearance of clinical manifestations during the follow up period. Generalized estimating equation models were used to compare repeated measurements. RESULTS Included were 141 patients (139 females), the median age at the first visit was 3.2 years (interquartile range [IQR] 2.3-5.7), and the median length of follow-up was 94.5 months (IQR 28.6-153.3). Mean weight, height and BMI Z-scores were -1.09, -1.03 and -0.56, respectively, at median age 2.5 years; and deteriorated to -3.95, -3.01 and -1.19, respectively, at median age 17.5 years (P < 0.001). Gastrointestinal features included constipation (47.5%, 67/141) and chewing/feeding difficulties (20%, 28/141) at presentation; and an additional 47 (33.3%) and 24 (17.0%), respectively, during follow up. Twenty-eight patients (20%) developed aerophagia and 44 (31.2%) gastroesophageal reflux. No relation was found between genetic mutation types and clinical manifestations. GI manifestations were more prevalent in patients with typical form of Rett syndrome. CONCLUSIONS Anthropometric parameters were shown to deteriorate with age, regardless of the specific genetic mutation. Chewing/feeding difficulties, constipation and gastroesophageal reflux are common in Rett patients.
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Affiliation(s)
- Tal David Berger
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel.
| | - Chen Fogel Berger
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
| | - Sewar Gara
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
| | - Bruria Ben-Zeev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Neurology, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond & Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, 52621, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Allison K, Maletic-Savatic M, Pehlivan D. MECP2-related disorders while gene-based therapies are on the horizon. Front Genet 2024; 15:1332469. [PMID: 38410154 PMCID: PMC10895005 DOI: 10.3389/fgene.2024.1332469] [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: 11/03/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
The emergence of new genetic tools has led to the discovery of the genetic bases of many intellectual and developmental disabilities. This creates exciting opportunities for research and treatment development, and a few genetic disorders (e.g., spinal muscular atrophy) have recently been treated with gene-based therapies. MECP2 is found on the X chromosome and regulates the transcription of thousands of genes. Loss of MECP2 gene product leads to Rett Syndrome, a disease found primarily in females, and is characterized by developmental regression, motor dysfunction, midline hand stereotypies, autonomic nervous system dysfunction, epilepsy, scoliosis, and autistic-like behavior. Duplication of MECP2 causes MECP2 Duplication Syndrome (MDS). MDS is found mostly in males and presents with developmental delay, hypotonia, autistic features, refractory epilepsy, and recurrent respiratory infections. While these two disorders share several characteristics, their differences (e.g., affected sex, age of onset, genotype/phenotype correlations) are important to distinguish in the light of gene-based therapy because they require opposite solutions. This review explores the clinical features of both disorders and highlights these important clinical differences.
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Affiliation(s)
- Katherine Allison
- Royal College of Surgeons in Ireland, School of Medicine, Dublin, Ireland
| | - Mirjana Maletic-Savatic
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, United States
| | - Davut Pehlivan
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, United States
- Blue Bird Circle Rett Center, Texas Children's Hospital, Houston, TX, United States
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3
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Zade K, Campbell C, Bach S, Fernandes H, Tropea D. Rett syndrome in Ireland: a demographic study. Orphanet J Rare Dis 2024; 19:34. [PMID: 38291497 PMCID: PMC10829226 DOI: 10.1186/s13023-024-03046-8] [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: 09/04/2023] [Accepted: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Rett syndrome (RTT) is a rare neurodevelopmental condition associated with mutations in the gene coding for the methyl-CpG-binding protein 2 (MECP2). It is primarily observed in girls and affects individuals globally. The understanding of the neurobiology of RTT and patient management has been improved by studies that describe the demographic and clinical presentation of individuals with RTT. However, in Ireland, there is a scarcity of data regarding individuals with RTT, which impedes the ability to fully characterize the Irish RTT population. Together with the Rett Syndrome Association of Ireland (RSAI), we prepared a questionnaire to determine the characteristics of RTT individuals in Ireland. Twenty-five families have participated in the study to date, providing information about demographics, genetics, familial history, clinical features, and regression. RESULTS The results show that Irish individuals with RTT have comparable presentation with respect to individuals in other countries; however, they had a better response to anti-epileptic drugs, and fewer skeletal deformities were reported. Nonetheless, seizures, involuntary movements and regression were more frequently observed in Irish individuals. One of the main findings of this study is the limited genetic information available to individuals to support the clinical diagnosis of RTT. CONCLUSIONS Despite the limited sample size, this study is the first to characterize the RTT population in Ireland and highlights the importance of having a swift access to genetic testing to sharpen the characterization of the phenotype and increase the visibility of Irish individuals in the international RTT community.
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Affiliation(s)
- Komal Zade
- Department of Psychiatry, School of Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, St James Hospital, Dublin, D08 W9RT, Ireland
| | - Ciara Campbell
- Department of Psychiatry, School of Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, St James Hospital, Dublin, D08 W9RT, Ireland
| | - Snow Bach
- Department of Psychiatry, School of Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, St James Hospital, Dublin, D08 W9RT, Ireland
| | - Hazel Fernandes
- Consultant Child and Adolescent Psychiatrist, Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
| | - Daniela Tropea
- Department of Psychiatry, School of Medicine, Trinity Centre for Health Sciences, Trinity College Dublin, St James Hospital, Dublin, D08 W9RT, Ireland.
- Neuropsychiatric Genetics, Department of Psychiatry, School of Medicine, Trinity College Dublin, Trinity Translational Medicine Institute, St James's Hospital, Dublin, Ireland.
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.
- FutureNeuro, The SFI Research Centre for Chronic and Rare Neurological Diseases, Dublin, Ireland.
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4
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Davidson EA, Holingue C, Jimenez-Gomez A, Dallman JE, Moshiree B. Gastrointestinal Dysfunction in Genetically Defined Neurodevelopmental Disorders. Semin Neurol 2023; 43:645-660. [PMID: 37586397 PMCID: PMC10895389 DOI: 10.1055/s-0043-1771460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Gastrointestinal symptoms are common in most forms of neurodevelopment disorders (NDDs) such as in autism spectrum disorders (ASD). The current patient-reported outcome measures with validated questionnaires used in the general population of children without NDDS cannot be used in the autistic individuals. We explore here the multifactorial pathophysiology of ASD and the role of genetics and the environment in this disease spectrum and focus instead on possible diagnostics that could provide future objective insight into the connection of the gut-brain-microbiome in this disease entity. We provide our own data from both humans and a zebrafish model of ASD called Phelan-McDermid Syndrome. We hope that this review highlights the gaps in our current knowledge on many of these profound NDDs and that it provides a future framework upon which clinicians and researchers can build and network with other interested multidisciplinary specialties.
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Affiliation(s)
| | - Calliope Holingue
- Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andres Jimenez-Gomez
- Neuroscience Center, Joe DiMaggio Children’s Hospital, Hollywood, Florida
- Department of Child Neurology, Florida Atlantic University Stiles - Nicholson Brain Institute, Jupiter, Florida
| | - Julia E. Dallman
- Department of Biology, University of Miami, Coral Gables, Miami, Florida
| | - Baharak Moshiree
- Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
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5
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Wong LC, Chen YT, Tsai SM, Lin YJ, Hsu CJ, Wang HP, Hu SC, Shen HY, Tsai WC, Lee WT. Dietary intake and growth deficits in Rett syndrome-A cross-section study. Autism Res 2021; 14:1512-1521. [PMID: 33788416 DOI: 10.1002/aur.2508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/10/2022]
Abstract
Growth deficit is a common comorbidity and one of the supportive criteria in Rett syndrome (RTT). This study aimed to investigate the impact of dystonia, dietary intakes, and clinical severities on growth patterns in a Taiwanese cohort of RTT. We recruited 44 RTT patients with MECP2 mutation for analysis. For individuals ≤18 years of age, in comparison to the RTT-specific growth chart which comprised American RTT cohort, the body height was right-shifted to a higher percentile, whereas the body weight was left-shifted to a lower percentile. Furthermore, the body mass index was significantly decreased when compared to RTT-specific growth chart (p = 0.01). Higher degree of overall disease severity (odd ratio = 1.159; 95% CI = 1.063-1.264; p = 0.001) and hand use impairment (odd ratio = 2.017; 95% CI = 1.037, 3.921; p = 0.039) were associated with more severe growth patterns. All individuals had dystonia at certain variable degrees. The dystonia worsened with age (p < 0.001) but did not have significant impact on growth deficit. Most of our cohort had adequate protein (97.37%) and energy (58.97%) intakes. The fiber intakes were generally low, with about 38 (97.4%) individuals did not meet the daily reference intakes of fiber. The protein intake was significantly lower in individuals with severe growth deficit (p = 0.04). Our study shows that ethnicity should be considered when comparing RTT individuals' growth pattern to the RTT-specific growth chart. Further, disease severity, genotypes, and nutrition exert important impacts on RTT-growth pattern. LAY SUMMARY: Growth impairment is an important issue in Rett syndrome and the underlying patho-mechanism is multifactorial. Higher degree of overall disease severity and hand use impairment were associated with more severe growth pattern deficits. Although all individuals had dystonia at certain variable degrees and the dystonia worsened with age, but it did not have significant impact on growth deficit. Nutritional intakes may partially affect growth. Furthermore, ethnicity should be considered when comparing RTT individuals' growth pattern to the RTT-specific growth chart.
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Affiliation(s)
- Lee Chin Wong
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Tsz Chen
- Department of Dietetics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Shu-Mei Tsai
- Department of Dietetics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yen-Ju Lin
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Chia-Jui Hsu
- Department of Pediatrics, National Taiwan University Hospital HsinChu Branch, HsinChu, Taiwan
| | - Hsin-Pei Wang
- Department of Pediatrics, National Taiwan University Hospital YunLin Branch, YunLin, Taiwan
| | - Su-Ching Hu
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Hsiu-Yu Shen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Che Tsai
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Tso Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei, Taiwan
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6
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Fu C, Armstrong D, Marsh E, Lieberman D, Motil K, Witt R, Standridge S, Nues P, Lane J, Dinkel T, Coenraads M, von Hehn J, Jones M, Hale K, Suter B, Glaze D, Neul J, Percy A, Benke T. Consensus guidelines on managing Rett syndrome across the lifespan. BMJ Paediatr Open 2020; 4:e000717. [PMID: 32984552 PMCID: PMC7488790 DOI: 10.1136/bmjpo-2020-000717] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Rett syndrome (RTT) is a severe neurodevelopmental disorder with complex medical comorbidities extending beyond the nervous system requiring the attention of health professionals. There is no peer-reviewed, consensus-based therapeutic guidance to care in RTT. The objective was to provide consensus on guidance of best practice for addressing these concerns. METHODS Informed by the literature and using a modified Delphi approach, a consensus process was used to develop guidance for care in RTT by health professionals. RESULTS Typical RTT presents early in childhood in a clinically recognisable fashion. Multisystem comorbidities evolve throughout the lifespan requiring coordination of care between primary care and often multiple subspecialty providers. To assist health professionals and families in seeking best practice, a checklist and detailed references for guidance were developed by consensus. CONCLUSIONS The overall multisystem issues of RTT require primary care providers and other health professionals to manage complex medical comorbidities within the context of the whole individual and family. Given the median life expectancy well into the sixth decade, guidance is provided to health professionals to achieve current best possible outcomes for these special-needs individuals.
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Affiliation(s)
- Cary Fu
- Pediatrics and Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dallas Armstrong
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Marsh
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lieberman
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen Motil
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Children's Nutrition Research Center, USDA ARS, Houston, Texas, USA
| | - Rochelle Witt
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shannon Standridge
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paige Nues
- International Rett Syndrome Foundation, Cincinnati, Ohio, USA
| | - Jane Lane
- Civitan International Research Center, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Tristen Dinkel
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Jana von Hehn
- Rett Syndrome Research Trust, New York, New York, USA
| | - Mary Jones
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Katie Hale
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Bernhard Suter
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel Glaze
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey Neul
- Vanderbilt Kennedy Center, Nashville, Tennessee, USA.,Pediatrics, Pharmacology, and Special Education, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alan Percy
- Pediatrics, Neurology, Neurobiology, Genetics, and Psychology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy Benke
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, Pharmacology, Neurology, Otolaryngology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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7
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Fu C, Armstrong D, Marsh E, Lieberman D, Motil K, Witt R, Standridge S, Lane J, Dinkel T, Jones M, Hale K, Suter B, Glaze D, Neul J, Percy A, Benke T. Multisystem comorbidities in classic Rett syndrome: a scoping review. BMJ Paediatr Open 2020; 4:e000731. [PMID: 33024833 PMCID: PMC7509967 DOI: 10.1136/bmjpo-2020-000731] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/22/2020] [Accepted: 08/17/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Rett syndrome (RTT) is a severe, progressive neurodevelopmental disorder with multisystem comorbidities that evolve across a patient's lifespan requiring attentive coordination of subspecialty care by primary care providers. A comprehensive, up-to-date synthesis of medical comorbidities in RTT would aid care coordination and anticipatory guidance efforts by healthcare providers. Our objective was to review and summarise published evidence regarding prevalence of RTT medical comorbidities across all relevant organ systems. METHODS Search of PubMed from January 2000 to July 2019 was performed using the search terms (Rett and MECP2 AND patient) OR (Rett and MECP2 AND cohort). Articles reporting the prevalence of clinical findings in RTT were assessed with respect to the size and nature of the cohorts interrogated and their relevance to clinical care. RESULTS After review of over 800 records, the multisystem comorbidities of RTT were summarised quantitatively from 18 records comprising both retrospective and prospective cohorts (31-983 subjects). Neurological comorbidities had the highest prevalence, occurring in nearly all individuals with gastrointestinal and orthopaedic concerns almost as prevalent as neurological. With the exception of low bone mineral content which was relatively common, endocrine comorbidities were seen in only around one-third of patients. Although more prevalent compared with the general population, cardiac conduction abnormalities were the least common comorbidity in RTT. CONCLUSIONS Effective care coordination for RTT requires knowledge of and attention to multiple comorbidities across multiple unrelated organ systems. Many issues common to RTT can potentially be managed by a primary care provider but the need for sub-specialist referral can be anticipated. Since the median life expectancy extends into the sixth decade with evolving subspecialty requirements throughout this time, paediatric providers may be tasked with continued coordination of these comorbidities or transitioning to adult medicine and specialists with experience managing individuals with complex medical needs.
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Affiliation(s)
- Cary Fu
- Pediatrics and Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dallas Armstrong
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Eric Marsh
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Lieberman
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen Motil
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Children's Nutrition Research Center, USDA ARS, Houston, Texas, USA
| | - Rochelle Witt
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shannon Standridge
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jane Lane
- University of Alabama at Birmingham, School of Medicine, Civitan International Research Center, Birmingham, Alabama, USA.,UAB Civitan International Research Center, Birmingham, Alabama, USA
| | - Tristen Dinkel
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Mary Jones
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Katie Hale
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Bernhard Suter
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel Glaze
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey Neul
- Vanderbilt Kennedy Center, Nashville, Tennessee, USA.,Pediatrics, Pharmacology and Special Education, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alan Percy
- Pediatrics, Neurology, Neurobiology, Genetics, and Psychology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy Benke
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, Pharmacology, Neurology, Otolaryngology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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8
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Wong K, Downs J, Ellaway C, Baikie G, Ravikumara M, Jacoby P, Christodoulou J, Elliott EJ, Leonard H. Impact of Gastrostomy Placement on Nutritional Status, Physical Health, and Parental Well-Being of Females with Rett Syndrome: A Longitudinal Study of an Australian Population. J Pediatr 2018; 200:188-195.e1. [PMID: 29941161 DOI: 10.1016/j.jpeds.2018.04.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/11/2018] [Accepted: 04/20/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate how age-related trends in nutritional status, physical health, and parental well-being in females with Rett syndrome may be related to gastrostomy placement and to examine the impact of the procedure on mortality. STUDY DESIGN We included 323 females from the Australian Rett Syndrome Study and analyzed their demographic, genetic, and child and parental health data collected from over 6 waves of follow-up questionnaire between 2000 and 2011. We used mixed-effects models to estimate the association between repeated measures of outcomes and age, gastrostomy placement and their interaction and Cox proportional hazards regression models to estimate relative risks of mortality for individuals with gastrostomy. RESULTS Nearly one-third (30.3%) of the cases underwent gastrostomy placement. Nutritional status based on weight, height, and body mass index (BMI) improved over time, and BMI was greater in individuals with gastrostomy placement than in those without (adjusted β = 0.87, 95% CI 0.02-1.73). There was no association between gastrostomy placement and individual's physical health outcomes or parental physical and mental health, nor did the age trend of these outcomes vary by gastrostomy insertion status. Nevertheless, among those at risk of suboptimal weight, the all-cause mortality rate was greater in those who had gastrostomy placement compared with those who had not (hazard ratio 4.07, 95% CI 1.96-8.45). CONCLUSION Gastrostomy placement was associated with improvement in BMI in females with Rett syndrome, but its long-term impact on individuals and their families is unclear.
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Affiliation(s)
- Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia; School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Carolyn Ellaway
- Disciplines of Genetic Medicine and Paediatrics and Child Health, The University of Sydney, Western Sydney Genetics Program, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Gordon Baikie
- Department of Developmental Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Peter Jacoby
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - John Christodoulou
- Disciplines of Genetic Medicine and Paediatrics and Child Health, The University of Sydney, Western Sydney Genetics Program, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Elizabeth J Elliott
- Discipline of Paediatrics and Child Health, The University of Sydney, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.
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9
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Tarquinio DC, Hou W, Berg A, Kaufmann WE, Lane JB, Skinner SA, Motil KJ, Neul JL, Percy AK, Glaze DG. Longitudinal course of epilepsy in Rett syndrome and related disorders. Brain 2016; 140:306-318. [PMID: 28007990 DOI: 10.1093/brain/aww302] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/22/2016] [Accepted: 10/10/2016] [Indexed: 01/05/2023] Open
Abstract
Epilepsy is common in Rett syndrome, an X-linked dominant disorder caused by mutations in the MECP2 gene, and in Rett-related disorders, such as MECP2 duplication. However, neither the longitudinal course of epilepsy nor the patterns of seizure onset and remission have been described in Rett syndrome and related conditions. The present study summarizes the findings of the Rett syndrome Natural History study. Participants with clinical Rett syndrome and those with MECP2 mutations without the clinical syndrome were recruited through the Rett Natural History study from 2006 to 2015. Clinical details were collected, and cumulative lifetime prevalence of epilepsy was determined using the Kaplan-Meier estimator. Risk factors for epilepsy were assessed using Cox proportional hazards models. Of 1205 participants enrolled in the study, 922 had classic Rett syndrome, and 778 of these were followed longitudinally for 3939 person-years. The diagnosis of atypical Rett syndrome with a severe clinical phenotype was associated with higher prevalence of epilepsy than those with classic Rett syndrome. While point prevalence of active seizures ranged from 30% to 44%, the estimated cumulative lifetime prevalence of epilepsy using Kaplan-Meier approached 90%. Specific MECP2 mutations were not significantly associated with either seizure prevalence or seizure severity. In contrast, many clinical features were associated with seizure prevalence; frequency of hospitalizations, inability to walk, bradykinesia, scoliosis, gastrostomy feeding, age of seizure onset, and late age of diagnosis were independently associated with higher odds of an individual having epilepsy. Aggressive behaviour was associated with lower odds. Three distinct patterns of seizure prevalence emerged in classic Rett syndrome, including those who did not have seizures throughout the study, those who had frequent relapse and remission, and those who had relentless seizures. Although 248 of those with classic Rett syndrome and a history of seizures were in terminal remission at last contact, only 74 (12% of those with a history of epilepsy) were seizure free and off anti-seizure medication. When studied longitudinally, point prevalence of active seizures is relatively low in Rett syndrome, although lifetime risk of epilepsy is higher than previously reported. While daily seizures are uncommon in Rett syndrome, prolonged remission is less common than in other causes of childhood onset epilepsy. Complete remission off anti-seizure medications is possible, but future efforts should be directed at determining what factors predict when withdrawal of medications in those who are seizure free is propitious.
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Affiliation(s)
| | - Wei Hou
- Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Anne Berg
- Ann and Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | | | - Jane B Lane
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Progress in Rett Syndrome: from discovery to clinical trials. Wien Med Wochenschr 2016; 166:325-32. [PMID: 27491553 PMCID: PMC5005392 DOI: 10.1007/s10354-016-0491-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/04/2016] [Indexed: 12/27/2022]
Abstract
Fifty years ago, Andreas Rett described a disorder in 22 females featuring prominent regression of fine motor and communication skills, cognitive impairment, stereotypic movements, periodic breathing, and gait abnormalities. This disorder became known as Rett syndrome (RTT) following the report of Hagberg et al. in 1983. Although RTT was scarcely recognized at that time in the United States, here the efforts of Rett and Hagberg led to rapid progress in recognition and diagnosis, a clearer understanding of its clinical and pathological underpinnings, and, ultimately, identification of mutations in the methyl-CpG-binding protein 2 (MECP2) gene as the primary cause of this unique and challenging neurodevelopmental disorder. Thereafter, a natural history study and critical translational research in animal models paved the way for potential disease-modifying agents to be assessed in human clinical trials. To be successful, the energies of the international community at all levels, including researchers in clinical and basic science, funding agencies, pharmaceutical companies, patient advocates, and, above all, parents and their children are essential. Otherwise, hopes for effective treatment, if not, a cure, will remain unfulfilled.
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Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics 2016; 138:peds.2015-3967. [PMID: 27365302 DOI: 10.1542/peds.2015-3967] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Uncertainty exists about the impacts of feeding tubes on neurologically impaired children. Core outcome sets (COS) standardize outcome selection, definition, measurement, and reporting. OBJECTIVE To synthesize an evidence base of qualitative data on all outcomes selected and/or reported for neurologically impaired children 0 to 18 years living with gastrostomy/gastrojejunostomy tubes. DATA SOURCES Medline, Embase, and Cochrane Register databases searched from inception to March 2014. STUDY SELECTION Articles examining health outcomes of neurologically impaired children living with feeding tubes. DATA EXTRACTION Outcomes were extracted and assigned to modified Outcome Measures in Rheumatology 2.0 Filter core areas; death, life impact, resource use, pathophysiological manifestations, growth and development. RESULTS We identified 120 unique outcomes with substantial heterogeneity in definition, measurement, and frequency of selection and/or reporting: "pathophysiological manifestation" outcomes (n = 83) in 79% of articles; "growth and development" outcomes (n = 13) in 55% of articles; "death" outcomes (n = 3) and "life impact" outcomes (n = 17) in 39% and 37% of articles, respectively; "resource use" outcomes (n = 4) in 14%. Weight (50%), gastroesophageal reflux (35%), and site infection (25%) were the most frequently reported outcomes. LIMITATIONS We were unable to investigate effect size of outcomes because quantitative data were not collected. CONCLUSIONS The paucity of outcomes assessed for life impact, resource use and death hinders meaningful evidence synthesis. A COS could help overcome the current wide heterogeneity in selection and definition. These results will form the basis of a consensus process to produce a final COS.
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Affiliation(s)
- Mufiza Z Kapadia
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences,
| | - Kariym C Joachim
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Chrinna Balasingham
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
| | - Eyal Cohen
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Sanjay Mahant
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, Ontario, Canada; and
| | - Katherine Nelson
- Division of Paediatric Medicine, Institute of Health Policy, Management and Evaluation, and Paediatric Advanced Care Team, Department of Paediatrics, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jonathon L Maguire
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, and Department of Paediatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Division of Paediatric Medicine, Paediatrics Outcomes Research Team, and Institute of Health Policy, Management and Evaluation, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Martin Offringa
- Toronto Outcomes Research in Child Health (TORCH), Child Health Evaluative Sciences
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Tarquinio DC, Hou W, Neul JL, Kaufmann WE, Glaze DG, Motil KJ, Skinner SA, Lee HS, Percy AK. The Changing Face of Survival in Rett Syndrome and MECP2-Related Disorders. Pediatr Neurol 2015; 53:402-11. [PMID: 26278631 PMCID: PMC4609589 DOI: 10.1016/j.pediatrneurol.2015.06.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Survival in Rett syndrome remains unclear. Although early estimates were grim, more recent data suggest that survival into adulthood is typical. We aimed to define survival in Rett syndrome more clearly and identify risk factors for early death. METHODS Participants with clinical Rett Syndrome or methyl-CpG-binding protein 2 mutations without clinical RTT were recruited through the Rett Syndrome Natural History study from 2006 to 2015. Clinical details were collected, and survival was determined using the Kaplan-Meier estimator. Risk factors were assessed using Cox proportional hazards models. RESULTS Among 1189 valid participants, 51 died (range 3.9-66.6 years) during the 9-year follow-up period. Those who died included 36 (3.9%) classic Rett syndrome females, 5 (5.9%) atypical severe Rett syndrome females, 1 (2.4%) non-Rett syndrome female, the single atypical severe male, 6 (30%) non-Rett syndrome males, and 2 (7.1%) methyl-CpG-binding protein 2 duplication syndrome males. All atypical mild Rett syndrome females, methyl-CpG-binding protein 2 duplication syndrome females, and the single classic Rett syndrome male remain alive. Most deaths were due to cardiorespiratory issues. Only one died from severe malnutrition, scoliosis, and extreme frailty. Survival for classic and atypical Rett syndrome was greater than 70% at 45 years. Overall severity and several modifiable risk factors, including ambulation, weight, and seizures, were associated with mortality in classic Rett syndrome. CONCLUSIONS Survival into the fifth decade is typical in Rett syndrome, and death due to extreme frailty has become rare. Although the leading cause of death remains cardiorespiratory compromise, many risk factors for early death are modifiable. Intense therapeutic interventions could further improve the prognosis for individuals with Rett syndrome.
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Affiliation(s)
| | - Wei Hou
- Stony Brook University Medical Center, Stony Brook, NY
| | - Jeffrey L. Neul
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Daniel G. Glaze
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | | | - Hye-Seung Lee
- Pediatrics Epidemiology Center, University of South Florida, Tampa, FL
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13
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Abstract
Rett syndrome (RTT) is a syndromic autism spectrum disorder caused by loss-of-function mutations in MECP2. The methyl CpG binding protein 2 binds methylcytosine and 5-hydroxymethycytosine at CpG sites in promoter regions of target genes, controlling their transcription by recruiting co-repressors and co-activators. Several preclinical studies in mouse models have identified rational molecular targets for drug therapies aimed at correcting the underlying neural dysfunction. These targeted therapies are increasingly translating into human clinical trials. In this review, we present an overview of RTT and describe the current state of preclinical studies in methyl CpG binding protein 2-based mouse models, as well as current clinical trials in individuals with RTT.
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Affiliation(s)
- Lucas Pozzo-Miller
- />Department of Neurobiology, Civitan International Research Center, The University of Alabama at Birmingham, Birmingham, AL USA
| | - Sandipan Pati
- />Department of Neurology, Epilepsy Division, Civitan International Research Center, The University of Alabama at Birmingham, Birmingham, AL USA
| | - Alan K. Percy
- />Department of Pediatrics, Civitan International Research Center, The University of Alabama at Birmingham, Birmingham, AL USA
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14
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Tarquinio DC, Hou W, Neul JL, Lane JB, Barnes KV, O’Leary HM, Bruck NM, Kaufmann WE, Motil KJ, Glaze DG, Skinner SA, Annese F, Baggett L, Barrish JO, Geerts SP, Percy AK. Age of diagnosis in Rett syndrome: patterns of recognition among diagnosticians and risk factors for late diagnosis. Pediatr Neurol 2015; 52:585-91.e2. [PMID: 25801175 PMCID: PMC4442062 DOI: 10.1016/j.pediatrneurol.2015.02.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/06/2015] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE Diagnosis of Rett syndrome (RTT) is often delayed. We sought to determine the type of physician who typically makes the RTT diagnosis and to identify risk factors for delayed diagnosis. METHODS A total of 1085 participants from the multicenter longitudinal RTT natural history study with classic and atypical RTT were recruited between 2006 and 2014. Age of diagnosis, diagnostician, diagnostic criteria, and clinical and developmental data were collected. RESULTS Among 919 classic and 166 atypical RTT participants, the median diagnosis age was 2.7 years (interquartile range 2.0-4.1) in classic and 3.8 years (interquartile range 2.3-6.9) in atypical RTT. Pediatricians made the diagnosis of classic RTT rarely (5.2%); however, the proportion diagnosed by pediatricians has increased since 2006. Since the first diagnostic criteria, the age of diagnosis decreased among subspecialists but not pediatricians. Odds of a pediatrician making the diagnosis of classic RTT were higher if a child stopped responding to parental interaction, and lower if they possessed gastroesophageal reflux, specific stereotypies, lost babbling, or the ability to follow commands. Delayed acquisition of basic gross motor skills or finger feeding was associated with younger diagnosis; delayed acquisition of higher level fine motor skills, later onset of supportive features, and normal head circumference were associated with late diagnosis. Thirty-three percent with microcephaly before 2.5 years were diagnosed after the median age of 2.7 years. CONCLUSIONS Age of RTT diagnosis has improved among subspecialists, and pediatricians have made the diagnosis of classic RTT more frequently since 2006. Strategies for educating diagnosticians should incorporate specific risk factors for delayed diagnosis.
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Affiliation(s)
| | - Wei Hou
- Stony Brook University Medical Center, Stony Brook, NY
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Jefferson A, Fyfe S, Downs J, Woodhead H, Jacoby P, Leonard H. Longitudinal bone mineral content and density in Rett syndrome and their contributing factors. Bone 2015; 74:191-8. [PMID: 25659951 DOI: 10.1016/j.bone.2015.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/24/2014] [Accepted: 01/30/2015] [Indexed: 11/29/2022]
Abstract
Bone mass and density are low in females with Rett syndrome. This study used Dual energy x-ray absorptiometry to measure annual changes in z-scores for areal bone mineral density (aBMD) and bone mineral content (BMC) in the lumbar spine and total body in an Australian Rett syndrome cohort at baseline and then after three to four years. Bone mineral apparent density (BMAD) was calculated in the lumbar spine. Annual changes in lean tissue mass (LTM) and bone area (BA) were also assessed. The effects of age, genotype, mobility, menstrual status and epilepsy diagnosis on these parameters were also investigated. The baseline sample included 97 individuals who were representative of the total live Australian Rett syndrome population under 30years in 2005 (n=274). Of these 74 had a follow-up scan. Less than a quarter of females were able to walk on their own at follow-up. Bone area and LTM z-scores declined over the time between the baseline and follow-up scans. Mean height-standardised z-scores for the bone outcomes were obtained from multiple regression models. The lumbar spine showed a positive mean annual BMAD z-score change (0.08) and a marginal decrease in aBMD (-0.04). The mean z-score change per annum for those 'who could walk unaided' was more positive for LS BMAD (p=0.040). Total body BMD mean annual z-score change from baseline to follow-up was negative (-0.03). However this change was positive in those who had achieved menses prior to the study (0.03, p=0,040). Total body BMC showed the most negative change (-0.60), representing a decrease in bone mineral content over time. This normalised to a z-score change of 0.21 once adjusted for the reduced lean tissue mass mean z-score change (-0.21) and bone area mean z-score change (-0.14). Overall, the bone mineral content, bone mineral density, bone area and lean tissue mass z-scores for all outcome measures declined, with the TB BMC showing significant decreases. Weight, height and muscle mass appear to have impacts on bone formation and we recommend that nutritional intake should be closely monitored and a physical activity plan developed to optimise bone health. Pubertal progression should also be assessed in conjunction with serial densitometry assessments to track bone mass and density changes over time.
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Affiliation(s)
- Amanda Jefferson
- School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Sue Fyfe
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia; School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Helen Woodhead
- Department of Paediatric Endocrinology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Peter Jacoby
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.
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Downs J, Wong K, Ravikumara M, Ellaway C, Elliott EJ, Christodoulou J, Jacoby P, Leonard H. Experience of gastrostomy using a quality care framework: the example of rett syndrome. Medicine (Baltimore) 2014; 93:e328. [PMID: 25526491 PMCID: PMC4603139 DOI: 10.1097/md.0000000000000328] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Rett syndrome is one of many severe neurodevelopmental disorders with feeding difficulties. In this study, associations between feeding difficulties, age, MECP2 genotype, and utilization of gastrostomy were investigated. Weight change and family satisfaction following gastrostomy were explored. Data from the longitudinal Australian Rett Syndrome Database whose parents provided data in the 2011 family questionnaire (n=229) were interrogated. We used logistic regression to model relationships between feeding difficulties, age group, and genotype. Content analysis was used to analyze data on satisfaction following gastrostomy. In those who had never had gastrostomy and who fed orally (n=166/229), parents of girls<7 years were more concerned about food intake compared with their adult peers (odds ratio [OR] 4.26; 95% confidence interval [CI] 1.29, 14.10). Those with a p.Arg168 mutation were often perceived as eating poorly with nearly a 6-fold increased odds of choking compared to the p.Arg133Cys mutation (OR 5.88; 95% CI 1.27, 27.24). Coughing, choking, or gagging during meals was associated with increased likelihood of later gastrostomy. Sixty-six females (28.8%) had a gastrostomy, and in those, large MECP2 deletions and p.Arg168 mutations were common. Weight-for-age z-scores increased by 0.86 (95% CI 0.41, 1.31) approximately 2 years after surgery. Families were satisfied with gastrostomy and felt less anxious about the care of their child. Mutation type provided some explanation for feeding difficulties. Gastrostomy assisted the management of feeding difficulties and poor weight gain, and was acceptable to families. Our findings are likely applicable to the broader community of children with severe disability.
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Affiliation(s)
- Jenny Downs
- From the Telethon Kids Institute (JD, KW, PJ, HL), The University of Western Australia; School of Physiotherapy and Exercise Science (JD), Curtin University, Perth, Australia; Department of Gastroenterology (MR), Princess Margaret Hospital, Perth, Australia; Discipline of Genetic Medicine (CE, JC); Discipline of Paediatrics and Child Health (CE, EJE, JC), The University of Sydney, The Children's Hospital at Westmead; and The Sydney Children's Hospitals Network (Westmead) (CE, EJE, JC), Sydney, Australia
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Lalanne A, Gottrand F, Salleron J, Puybasset-Jonquez AL, Guimber D, Turck D, Michaud L. Long-term outcome of children receiving percutaneous endoscopic gastrostomy feeding. J Pediatr Gastroenterol Nutr 2014; 59:172-6. [PMID: 24709828 DOI: 10.1097/mpg.0000000000000393] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of the present study was to analyze the long-term follow-up of children receiving percutaneous endoscopic gastrostomy (PEG) in terms of survival, nutritional outcome, and weaning from enteral nutrition. The secondary objectives were to evaluate the complications related to PEG and the outcome of patients with neurological disability. METHODS The present study was a single-center retrospective study including all of the 368 patients who underwent PEG from 1990 to 2003 in our tertiary hospital. RESULTS A total of 368 patients received PEG during the study period. After a median follow-up of 2.4 years (interquartile range 1.4-4.2 years), PEG was in place in 36% and was removed in 27%; 26% of patients were deceased. Two deaths could be directly related to PEG. A statistically significant weight and height catch-up was observed in patients with PEG in place in whom weight/age z score increased from -2.6 to -1.7 (P < 0.01) and height/age z score also increased from -2.1 to -1.6 (P < 0.01). In patients who had their PEG removed weight/age z score increased from -2.5 to -1.6 (P < 0.01) and height/age z score from -2.8 to -1.4 (P = 0.01) at the time of weaning. Early complications occurred in 152 patients, whereas late complications occurred in 191 patients. Most complications were minor (85%). After multivariate analyses, the factors associated with late complications were digestive and ear, nose, and throat (ENT) diseases, age <1 year at the time of PEG placement, and use of PEG longer than 2 years. Early complications were less frequent in patients with respiratory diseases. CONCLUSIONS PEG allows nutritional and growth catch-up and is safe in the long term.
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Affiliation(s)
- Arnaud Lalanne
- *Reference Centre for Congenital and Malformative Esophageal Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Faculty of Medicine and Jeanne de Flandre Children's Hospital, Lille University †Department of Biostatistics, CHRU Lille, University of Lille Nord de France, Lille, France
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Abstract
Rett syndrome (RTT) has experienced remarkable progress over the past three decades since emerging as a disorder of worldwide proportions, particularly with discovery of the linkage of RTT to MECP2 mutations. The advances in clinical research and the increasing pace of basic science investigations have accelerated the pattern of discovery and understanding. Clinical trials are ongoing and others are planned. A review of these events and the prospects for continued success are highlighted below. The girls and women encountered today with RTT are, overall, in better general, neurologic, and behavioral health than those encountered earlier. This represents important progress worldwide from the concerted efforts of a broadly based and diverse clinical and basic research consortium as well as the efforts of parents, family, and friends.
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Hammett T, Harris A, Boreham B, Mehdian SMH. Surgical correction of scoliosis in Rett syndrome: cord monitoring and complications. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 1:S72-5. [PMID: 24487557 DOI: 10.1007/s00586-014-3170-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/05/2014] [Accepted: 01/06/2014] [Indexed: 11/30/2022]
Abstract
AIM Rett syndrome is a progressive neurodevelopmental disorder that predominantly affects females and is associated with a high incidence of scoliosis and epilepsy. There is scant published work about intraoperative spinal cord monitoring in these patients and little more regarding the rate of perioperative complications. We investigated our institutions' experience with both. METHODS We retrospectively reviewed the records of 11 patients with Rett syndrome who underwent surgical correction of scoliosis at our institution between 2004 and 2010. RESULTS Eleven patients underwent successful correction of their scoliosis at an average age of 12. Eight of the patients suffered one or more significant complications. The average curve was corrected from 71° to 27°. Successful spinal cord monitoring was achieved in eight of the nine patients where it was attempted. No patient suffered any neurological complications. Average inpatient stay was 18.2 days. CONCLUSION Scoliosis surgery in patients with Rett syndrome carries a very high rate of complications and an average hospital stay approaching 3 weeks. Both caregivers and surgeons should be aware of this when planning any intervention. These patients frequently have useful lower limb function and spinal cord monitoring is a valid tool to aid in its preservation. We would suggest aggressive optimisation of these patients prior to surgery, with an emphasis on nutrition.
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Affiliation(s)
- T Hammett
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham, UK,
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Leonard H, Ravikumara M, Baikie G, Naseem N, Ellaway C, Percy A, Abraham S, Geerts S, Lane J, Jones M, Bathgate K, Downs J. Assessment and management of nutrition and growth in Rett syndrome. J Pediatr Gastroenterol Nutr 2013; 57:451-60. [PMID: 24084372 PMCID: PMC3906202 DOI: 10.1097/mpg.0b013e31829e0b65] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES We developed recommendations for the clinical management of poor growth and weight gain in Rett syndrome through evidence review and the consensus of an expert panel of clinicians. METHODS Initial draft recommendations were created based upon literature review and 34 open-ended questions in which the literature was lacking. Statements and questions were made available to an international, multidisciplinary panel of clinicians in an online format and a Microsoft Word-formatted version of the draft via e-mail. Input was sought using a 2-stage modified Delphi process to reach consensus. Items included clinical assessment of growth, anthropometry, feeding difficulties and management to increase energy intake, decrease feeding difficulties, and consideration of gastrostomy. RESULTS Agreement was achieved on 101 of 112 statements. A comprehensive approach to the management of poor growth in Rett syndrome is recommended that takes into account factors such as feeding difficulties and nutritional needs. A body mass index of approximately the 25th centile can be considered as a reasonable target in clinical practice. Gastrostomy is indicated for extremely poor growth, if there is risk of aspiration and if feeding times are prolonged. CONCLUSIONS These evidence- and consensus-based recommendations have the potential to improve care of nutrition and growth in a rare condition and stimulate research to improve the present limited evidence base.
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Affiliation(s)
- Helen Leonard
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, Western Australia
| | - Gordon Baikie
- Department of Developmental Medicine, Royal Children’s Hospital, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Nusrat Naseem
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia
| | - Carolyn Ellaway
- Western Sydney Genetics Program, The Children’s Hospital at Westmead, Discipline of Paediatrics and Genetic Medicine, University of Sydney, Australia
| | - Alan Percy
- Civitan International Research Centre, University of Alabama, Birmingham, Alabama, USA
| | - Suzanne Abraham
- Department of Otolaryngology Head Neck Surgery and Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Suzanne Geerts
- Civitan International Research Centre, University of Alabama, Birmingham, Alabama, USA
| | - Jane Lane
- Civitan International Research Centre, University of Alabama, Birmingham, Alabama, USA
| | - Mary Jones
- Katie's Clinic for Rett Syndrome, Children's Hospital & Research Center, Oakland, California, USA
| | - Katherine Bathgate
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia
- School of Public Health and Curtin Health Innovation Research Institute, Perth, Western Australia
| | - Jenny Downs
- Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia
- School of Physiotherapy and Curtin Health Innovation Research Institute, Perth, Western Australia
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Tarquinio DC, Motil KJ, Hou W, Lee HS, Glaze DG, Skinner SA, Neul JL, Annese F, McNair L, Barrish JO, Geerts SP, Lane JB, Percy AK. Growth failure and outcome in Rett syndrome: specific growth references. Neurology 2012; 79:1653-61. [PMID: 23035069 DOI: 10.1212/wnl.0b013e31826e9a70] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Prominent growth failure typifies Rett syndrome (RTT). Our aims were to 1) develop RTT growth charts for clinical and research settings, 2) compare growth in children with RTT with that of unaffected children, and 3) compare growth patterns among RTT genotypes and phenotypes. METHODS A cohort of the RTT Rare Diseases Clinical Research Network observational study participants was recruited, and cross-sectional and longitudinal growth data and comprehensive clinical information were collected. A reliability study confirmed interobserver consistency. Reference curves for height, weight, head circumference, and body mass index (BMI), generated using a semiparametric model with goodness-of-fit tests, were compared with normative values using Student's t test adjusted for multiple comparisons. Genotype and phenotype subgroups were compared using analysis of variance and linear regression. RESULTS Growth charts for classic and atypical RTT were created from 9,749 observations of 816 female participants. Mean growth in classic RTT decreased below that for the normative population at 1 month for head circumference, 6 months for weight, and 17 months for length. Mean BMI was similar in those with RTT and the normative population. Pubertal increases in height and weight were absent in classic RTT. Classic RTT was associated with more growth failure than atypical RTT. In classic RTT, poor growth was associated with worse development, higher disease severity, and certain MECP2 mutations (pre-C-terminal truncation, large deletion, T158M, R168X, R255X, and R270X). CONCLUSIONS RTT-specific growth references will allow effective screening for disease and treatment monitoring. Growth failure occurs less frequently in girls with RTT with better development, less morbidity typically associated with RTT, and late truncation mutations.
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Motil KJ, Caeg E, Barrish JO, Geerts S, Lane JB, Percy AK, Annese F, McNair L, Skinner SA, Lee HS, Neul JL, Glaze DG. Gastrointestinal and nutritional problems occur frequently throughout life in girls and women with Rett syndrome. J Pediatr Gastroenterol Nutr 2012; 55:292-8. [PMID: 22331013 PMCID: PMC3393805 DOI: 10.1097/mpg.0b013e31824b6159] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We conducted a nationwide survey to determine the prevalence of common gastrointestinal and nutritional disorders in Rett syndrome (RTT) based on parental reporting and related the occurrence of these problems to age and methyl-CpG-binding protein 2 (MECP2) gene status. METHODS We designed a questionnaire that probed symptoms, diagnoses, diagnostic tests, and treatment interventions related to gastrointestinal and nutritional problems in RTT. The International Rett Syndrome Foundation distributed the questionnaire to 1666 family-based members and forwarded their responses for our review. We interrogated the Rare Disease Clinical Research Network database to supplement findings related to medications used to treat gastrointestinal problems in RTT. RESULTS Parents of 983 female patients with RTT (59%) responded and identified symptoms and diagnoses associated with gastrointestinal dysmotility (92%), chewing and swallowing difficulties (81%), weight deficits or excess (47%), growth deficits (45%), low bone mineral content or fractures (37%), and biliary tract disorders (3%). Height-for-age, weight-for-age, and body mass index z scores decreased significantly with age; height- and weight-, but not body mass index-for-age z scores were significantly lower in female subjects with MECP2 mutations than in those without. Vomiting, nighttime awakening, gastroesophageal reflux, chewing difficulty, and choking with feeding were significantly less likely to occur with increasing age. Short stature, low bone mineral content, fractures, and gastrostomy placement were significantly more likely to occur with increasing age. Chewing difficulty, choking with feeding, and nighttime awakening were significantly less likely to occur, whereas short stature was significantly more likely to occur, in female subjects with MECP2 mutations than in those without. Diagnostic evaluations and therapeutic interventions were used less frequently than the occurrence of symptoms or diagnoses in the RTT cohort. CONCLUSIONS Gastrointestinal and nutritional problems perceived by parents are prevalent throughout life in girls and women with RTT and may pose a substantial medical burden for their caregivers. Physician awareness of these features of RTT may improve the health and quality of life of individuals affected with this disorder.
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Affiliation(s)
- Kathleen J Motil
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
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Vignoli A, La Briola F, Peron A, Turner K, Savini M, Cogliati F, Russo S, Canevini MP. Medical care of adolescents and women with Rett syndrome: An Italian study. Am J Med Genet A 2011; 158A:13-8. [DOI: 10.1002/ajmg.a.34367] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 10/11/2011] [Indexed: 11/07/2022]
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Rosman NP, Tarquinio DC, Datseris M, Hou W, Mannheim GB, Emigh CE, Rivkin MJ. Postnatal-onset microcephaly: pathogenesis, patterns of growth, and prediction of outcome. Pediatrics 2011; 127:665-71. [PMID: 21422087 DOI: 10.1542/peds.2010-1576] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although children with postnatal-onset microcephaly (POM) generally have poor development, we speculated that better somatic growth would predict better development in these children. PATIENTS AND METHODS We followed 57 children with POM for an average of 4.2 years (13 encephaloclastic, 14 dysgenetic, 6 with Rett syndrome, 24 idiopathic) and calculated the developmental quotient (DQ) at each visit (DQ > 0.70 was considered normal). SD scores (SDS) for measurements were analyzed using a repeated measures mixed-effects model to assess effect of weight, height, head circumference (HC), and age on DQ. Pearson's correlation was used to examine the independent influence of each variable on final DQ. RESULTS Forty-four children (77%) had a low DQ (mean: 0.33), but 13 (23%) had a normal DQ (mean: 0.93), including 10 idiopathic and 3 encephaloclastic. Mean HC fell below -2 SDS in all before 1 year (destructive at 3.3 months, idiopathic low-DQ at 7.5 months, dysgenetic at 8.5 months, Rett syndrome at 11 months, and idiopathic normal-DQ at 11.5 months). Mean weights and heights both fell below -2 SDS for all low-DQ groups but remained normal in both normal-DQ groups. Weight, height, and HC were independent predictors of DQ (P < .0001). Final DQ correlated with weight (r = 0.27), height (r = 0.41), and HC (r = 0.13). CONCLUSIONS Most children with POM have poor later development. Whatever the cause of POM, persons in whom postnatal body growth (weight, height, HC) is better sustained have more favorable development, and in one-quarter of such persons (mostly idiopathic POM), final DQ is normal.
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Affiliation(s)
- N Paul Rosman
- Department of Pediatrics, Division of Pediatric Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts 02118, USA.
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