1
|
Weeda JE, van Kuijk SMJ, van den Berg MP, Bastiaenen CHG, Borst HE, van Rhijn LW, de Bie RA. Identification of Predictors for Progression of Scoliosis in Rett Syndrome. Dev Neurorehabil 2024; 27:126-133. [PMID: 38907992 DOI: 10.1080/17518423.2024.2365794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 06/04/2024] [Indexed: 06/24/2024]
Abstract
Rett syndrome is a neurodevelopmental disorder in which scoliosis is a common orthopedic complication. This explorative study aims to identify predictors for rapid progression of scoliosis in Rett syndrome to enable variable selection for future prediction model development. A univariable logistic regression model was used to identify variables that discriminate between individuals with and without rapid progression of scoliosis (>10 ∘ Cobb angle/6 months) based on multi-center data. Predictors were identified using univariable logistic regression with OR (95% CI) and AUC (95% CI). Age at inclusion, Cobb angle at baseline and epilepsy have the highest discriminative ability for rapid progression of scoliosis in Rett syndrome.
Collapse
Affiliation(s)
- J E Weeda
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
- Rett Expertise Centre, Maastricht University Medical Centre and School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Dutch Rett Syndrome Association (NRSV), Utrecht, the Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M P van den Berg
- Rett Expertise Centre, Maastricht University Medical Centre and School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Dutch Rett Syndrome Association (NRSV), Utrecht, the Netherlands
| | - C H G Bastiaenen
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - H E Borst
- Rett Expertise Centre, Maastricht University Medical Centre and School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Dutch Rett Syndrome Association (NRSV), Utrecht, the Netherlands
| | - L W van Rhijn
- Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Orthopedic Surgery, Universitair Medisch Centrum Utrecht, Utrecht, the Netherlands
| | - R A de Bie
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
2
|
Stone LE, Kelly MP, Alexander M, Brandel M, Lam SK, Ravindra VM. Rett Syndrome-Associated Scoliosis: Analysis of National Trends and Treatment Patterns of a Rare Indication for Posterior Instrumented Fusion. Spine (Phila Pa 1976) 2023; 48:E409-E416. [PMID: 37642479 DOI: 10.1097/brs.0000000000004802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023]
Abstract
STUDY DESIGN Retrospective database cohort study. OBJECTIVE To evaluate U.S. treatment trends and inpatient outcomes for children undergoing posterior spinal fusion (PSF) for Rett syndrome (RTT)-associated scoliosis (RAS). SUMMARY OF BACKGROUND DATA RTT is a rare, sporadic neurodevelopmental disorder presenting in childhood with developmental regression, ataxia, and seizures. RAS occurs in 50% to 80% of cases of RTT, but little is known about the case volume and perioperative experience for children undergoing PSF. MATERIALS AND METHODS Using the International Classification of Diseases Ninth and 10th revision codes in the national Kids' Inpatient Database, we identified children with RTT who underwent PSF from 2000 to 2019. Annual case volumes were analyzed. Clinical characteristics and outcomes were compared with those of a cohort of patients with neuromuscular scoliosis (NMS). RESULTS Among 220 patients with RAS, 216 (98.2%) were females (mean age at surgery: 12.3±3.3 yr). Surgical case incidence steadily increased over 19 years, with more RAS admissions in the South (31.4%). Overall, patients with RAS demonstrated a higher mean Elixhauser Comorbidity Index score (2 vs . 1, P < 0.001) and had more perioperative complications (41.4% vs . 18%, P < 0.001) than patients with NMS. RTT diagnosis independently predicted higher odds of any complications (odds ratio: 1.98, P < 0.001) and increased length of stay (odds ratio: 1.18, P = 0.009) for admissions for PSF. CONCLUSIONS Surgical treatment for RAS is rare but increased over a 19-year period. Cases appear to be clustering by region, with the highest proportion in the South. The higher Elixhauser Comorbidity Index in RAS patients predicted higher costs, longer hospital stays, more complications (particularly respiratory), and more nonroutine discharge disposition than in other patients with NMS. RTT was independently associated with higher odds of complications and longer length of stay. Because RAS cases appear to be increasing in number, future studies should emphasize methods to reduce morbidity and investigate deformity-specific metrics to help better understand this population.
Collapse
Affiliation(s)
- Lauren E Stone
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - Michael P Kelly
- Department of Orthopedic Surgery, University of California San Diego, San Diego, CA
- Division of Pediatric Orthopedics and Scoliosis, Rady Children's Hospital, San Diego, CA
| | - Madison Alexander
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - Michael Brandel
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, Northwestern University, Chicago, IL
| | - Vijay M Ravindra
- Department of Neurosurgery, University of California San Diego, San Diego, CA
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
- Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA
| |
Collapse
|
3
|
Taylor TN, Bridges CS, Nordstrom LA, Hanson DS, Gerow FT, Smith BG. Early Complications After Posterior Spinal Fusion in Patients With Rett Syndrome. J Pediatr Orthop 2023; 43:e326-e330. [PMID: 36882895 DOI: 10.1097/bpo.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Neuromuscular scoliosis in Rett syndrome (RS) is common, progressive, and often requires posterior spinal fusion (PSF). While PSF is associated with improved overall outcomes, there is a paucity of information describing complications. We aimed to report the postoperative complications, readmissions, and reoperations for patients with RS undergoing PSF. METHODS Female pediatric patients with RS treated by PSF with segmental instrumentation, with or without concurrent pelvis fixation, during January 2012 to August 2022 were included. Preoperative patient characteristics, intraoperative data (estimated blood loss, cell saver, packed red blood cells transfused), postoperative complications according to the Modified Clavien-Dindo-Sink classification within 90 days, unplanned readmissions within 30 days, and unplanned reoperations within 90 days were recorded. RESULTS A total of 25 females were included. The mean (SD) age at surgery was 12.9 (1.8) years and the mean follow-up of 38.6 (24.9) months. The mean preoperative major coronal curve was 79 degrees (23 degrees) which decreased to 32 degrees (15 degrees) by the last follow-up ( P <0.001). The median estimated blood loss was 600 mL and length of stay was 7 days. There were 81 total postoperative complications (3.2 complications/patient). Eight (32%) had grade IVa complications (disseminated intravascular coagulopathy, hypotensive shock, respiratory failure, chronic urosepsis). Five (20%) patients experienced seizures, 48% had pulmonary complications, and 56% had gastrointestinal complications. There were 3 readmissions (12%) within 30 days for pneumonia and 2 (8%) reoperations (an incision and drainage and C2-T2 fusion for significant kyphosis) within 90 days. One patient also had their fusion extended to the pelvis 1 year later. There were more nonambulatory patients in the group fused to the pelvis, but otherwise no differences between those fused and unfused to the pelvis. CONCLUSIONS This is the largest review of early postoperative complications for patients with RS who underwent PSF. PSF effectively reduced the major coronal curve, but surgeons and families should be aware of a high postoperative seizure and respiratory complication rate, as well as 8% having reoperations within 90 days and 12% being readmitted within 30 days. LEVEL OF EVIDENCE Level IV-therapeutic study.
Collapse
|
4
|
Fabio RA, Chiarini L, Canegallo V. Pain in Rett syndrome: a pilot study and a single case study on the assessment of pain and the construction of a suitable measuring scale. Orphanet J Rare Dis 2022; 17:356. [PMID: 36104823 PMCID: PMC9476284 DOI: 10.1186/s13023-022-02519-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/05/2022] [Indexed: 11/19/2022] Open
Abstract
Background Rett Syndrome (RTT) is a severe, neurodevelopmental disorder mainly caused by mutations in the MECP2 gene, affecting around 1 in 10,000 female births. Severe physical, language, and social impairments impose a wide range of limitations in the quality of life of the patients with RTT. Comorbidities of patients with RTT are varied and cause a lot of pain, but communicating this suffering is difficult for these patients due to their problems, such as apraxia that does not allow them to express pain in a timely manner, and their difficulties with expressive language that also do not permit them to communicate. Two studies, a pilot study and a single case study, investigate the manifestation of pain of patients with RTT and propose a suitable scale to measure it.
Aims of this study The first aim was to describe pain situations of RTT by collecting information by parents; the second aim was to test and compare existing questionnaires for non-communicating disorders on pain such as Pain assessment in advanced demenzia (PAINAD), the Critical care pain observation tool (CPOT) and the Non-communicating Children’s Pain Checklist-Revised (NCCPC-R) to assess which of them is best related to the pain behavior of patients with RTT. The third aim was to identify the specific verbal and non-verbal behaviors that characterize pain in girls with Rett syndrome, discriminating them from non-pain behaviors.
Method Nineteen participants, eighteen girls with RTT and one girl with RTT with 27 manifestations of pain were video-recorded both in pain and base-line conditions. Two independent observers codified the 90 video-recording (36 and 54) to describe their behavioral characteristics. Results The two studies showed that the most significant pain behaviors expressed by girls with respect to the baseline condition, at the facial level were a wrinkled forehead, wide eyes, grinding, banging teeth, complaining, making sounds, crying and screaming, and the most common manifestations of the body were tremors, forward and backward movement of the torso, tension in the upper limbs, increased movement of the lower limbs and a sprawling movement affecting the whole body. Conclusion The results of the two studies helped to create an easy-to-apply scale that healthcare professionals can use to assess pain in patients with Rett’s syndrome. This scale used PAINAD as its basic structure, with some changes in the items related to the behavior of patients with RTT.
Collapse
|
5
|
Improving clinical trial readiness to accelerate development of new therapeutics for Rett syndrome. Orphanet J Rare Dis 2022; 17:108. [PMID: 35246185 PMCID: PMC8894842 DOI: 10.1186/s13023-022-02240-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 02/06/2022] [Indexed: 12/16/2022] Open
Abstract
Rett syndrome is associated with severe functional impairments and many comorbidities, each in urgent need of treatments. Mutations in the MECP2 gene were identified as causing Rett syndrome in 1999. Over the past 20 years there has been an abundance of preclinical research with some studies leading to human clinical trials. Despite this, few viable therapeutic options have emerged from this investment of effort. Reasons for this lack of success as they relate both to preclinical research and the clinical trial landscape are discussed. Considering what needs to be done to promote further success in the field, we take a positive and constructive approach and introduce the concept of clinical trial readiness and its necessary ingredients for Rett syndrome. These include: listening to the needs of families; support from advocacy groups; optimising use of existing clinic infrastructures and available natural history data; and, finally, the validation of existing outcome measures and/or the development and validation of new measures. We conclude by reiterating the need for a collaborative and coordinated approach amongst the many different stakeholder groups and the need to engage in new types of trial design which could be much more efficient, less costly and much less burdensome on families.
Collapse
|
6
|
Intensive Postural and Motor Activity Program Reduces Scoliosis Progression in People with Rett Syndrome. J Clin Med 2022; 11:jcm11030559. [PMID: 35160011 PMCID: PMC8837095 DOI: 10.3390/jcm11030559] [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: 11/29/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 12/04/2022] Open
Abstract
Background: A scoliosis prevalence of 94% was reported in the population with Rett syndrome (RTT), with an annual progression rate of 14 to 21° Cobb which may result in pain, loss of sitting balance, deterioration of motor skills, and lung disfunction. This paper describes the efficacy of an intensive conservative individualized physical and postural activity program in preventing scoliosis curvature progression in patients with RTT. Methods: Twenty subjects diagnosed with RTT and scoliosis were recruited, and an individualized intensive daily physical activity program was developed for each participant. Each program was conducted for six months by participants’ primary caregivers in their daily living environment. Fortnightly remote supervision of the program implementation was provided by an expert therapist. Pre- and post-intervention radiographs and motor functioning were analyzed. Results: An averaged progression of +1.7° ± 8.7° Cobb, over one year (12.3 ± 3.5 months) was observed in our group, together with motor function improvements. A relation between curve progression and motor skill improvement was observed. Conclusions: The intervention prevented scoliosis progression in our group. The achievement of functional motor improvements could enable better body segment control and muscle balancing, with a protective effect on scoliosis progression. The intervention was effective for individuals with RTT across various ages and severity levels. Individual characteristics of each participant and the details of their activity program are described.
Collapse
|
7
|
Bisgaard AM, Wong K, Højfeldt AK, Larsen JL, Schönewolf-Greulich B, Rønde G, Downs J, Stahlhut M. Decline in gross motor skills in adult Rett syndrome; results from a Danish longitudinal study. Am J Med Genet A 2021; 185:3683-3693. [PMID: 34296518 DOI: 10.1002/ajmg.a.62429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 07/02/2021] [Indexed: 12/22/2022]
Abstract
Longevity of individuals with neurodevelopmental diseases as Rett syndrome (RTT) has increased and many reach adulthood and old age. There is therefore a need to increase knowledge about the course of RTT in adults in order to improve medical care management and quality of life. We did a longitudinal study to address if a possible decline in motor skills in adults with RTT can be explained by the presence of common medical conditions as epilepsy, breathing disturbance, and scoliosis. Data from the Danish RTT database, medical files, and videos from visits at the national Center for Rett syndrome were reviewed. The study included 24 individuals aged 30-66 years at last visit after a follow-up period of 6-12 years. Results showed a clinically observable and significant decline in gross motor skills using the Rett syndrome Gross Motor Scale (RSGMS) with a tendency of less decline in the individuals with the best motor abilities. The frequencies of comorbidities were high. Decline in RSGMS score was associated with the presence of epilepsy and severe scoliosis that had been conservatively managed. The results emphasize that epilepsy plays a significant role in the adult RTT life and management of severe scoliosis in the younger years has impact on the motor abilities in adulthood.
Collapse
Affiliation(s)
- Anne-Marie Bisgaard
- Department of Paediatrics and Adolescent Medicine, Center for Rett syndrome, Rigshospitalet, Copenhagen, Denmark
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Anne-Katrine Højfeldt
- Department of Paediatrics and Adolescent Medicine, Center for Rett syndrome, Rigshospitalet, Copenhagen, Denmark
| | - Jane Lunding Larsen
- Department of Paediatrics and Adolescent Medicine, Center for Rett syndrome, Rigshospitalet, Copenhagen, Denmark
| | | | - Gitte Rønde
- Department of Paediatrics and Adolescent Medicine, Herlev Hospital, Copenhagen, Denmark
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Michelle Stahlhut
- Department of Paediatrics and Adolescent Medicine, Center for Rett syndrome, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
8
|
Pecorelli A, Cordone V, Schiavone ML, Caffarelli C, Cervellati C, Cerbone G, Gonnelli S, Hayek J, Valacchi G. Altered Bone Status in Rett Syndrome. Life (Basel) 2021; 11:life11060521. [PMID: 34205017 PMCID: PMC8230033 DOI: 10.3390/life11060521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022] Open
Abstract
Rett syndrome (RTT) is a monogenic neurodevelopmental disorder primarily caused by mutations in X-linked MECP2 gene, encoding for methyl-CpG binding protein 2 (MeCP2), a multifaceted modulator of gene expression and chromatin organization. Based on the type of mutation, RTT patients exhibit a broad spectrum of clinical phenotypes with various degrees of severity. In addition, as a complex multisystem disease, RTT shows several clinical manifestations ranging from neurological to non-neurological symptoms. The most common non-neurological comorbidities include, among others, orthopedic complications, mainly scoliosis but also early osteopenia/osteoporosis and a high frequency of fractures. A characteristic low bone mineral density dependent on a slow rate of bone formation due to dysfunctional osteoblast activity rather than an increase in bone resorption is at the root of these complications. Evidence from human and animal studies supports the idea that MECP2 mutation could be associated with altered epigenetic regulation of bone-related factors and signaling pathways, including SFRP4/WNT/β-catenin axis and RANKL/RANK/OPG system. More research is needed to better understand the role of MeCP2 in bone homeostasis. Indeed, uncovering the molecular mechanisms underlying RTT bone problems could reveal new potential pharmacological targets for the treatment of these complications that adversely affect the quality of life of RTT patients for whom the only therapeutic approaches currently available include bisphosphonates, dietary supplements, and physical activity.
Collapse
Affiliation(s)
- Alessandra Pecorelli
- Animal Science Department, Plants for Human Health Institute, North Carolina State University, Kannapolis, NC 28081, USA;
- Correspondence: (A.P.); (G.V.)
| | - Valeria Cordone
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy;
| | - Maria Lucia Schiavone
- Animal Science Department, Plants for Human Health Institute, North Carolina State University, Kannapolis, NC 28081, USA;
| | - Carla Caffarelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy; (C.C.); (S.G.)
| | - Carlo Cervellati
- Department of Translational Medicine and for Romagna, University of Ferrara, 44121 Ferrara, Italy;
| | - Gaetana Cerbone
- Division of Medical Genetics, “S.G. Moscati” Hospital, 74100 Avellino, Italy;
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy; (C.C.); (S.G.)
| | - Joussef Hayek
- Toscana Life Sciences Foundation, 53100 Siena, Italy;
| | - Giuseppe Valacchi
- Animal Science Department, Plants for Human Health Institute, North Carolina State University, Kannapolis, NC 28081, USA;
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy;
- Department of Food and Nutrition, Kyung Hee University, Seoul 02447, Korea
- Correspondence: (A.P.); (G.V.)
| |
Collapse
|
9
|
Abstract
Objectives Rett syndrome is a rare disorder characterised by severe scoliosis in 80% of cases. In this retrospective case series, we analysed the radiographic, clinical, and functional outcomes of consecutive patients treated for scoliosis associated with Rett syndrome. We sought to understand the results of the treatment of scoliosis in Rett syndrome and evaluate the need to fuse to the pelvis. Methods A retrospective case series was used to analyse the radiographic, clinical, and functional outcomes of consecutive patients treated for Rett syndrome scoliosis between the ages of 10 and 8 years in a single tertiary paediatric spinal unit. Cases were identified through departmental and neurophysiological records, and patients were excluded if the diagnosis of Rett syndrome was not confirmed. Results Seven eligible cases were identified. At presentation, the mean coronal Cobb angle was 90.9°, mean sagittal Cobb 72.0°, and pelvic obliquity 24.5°. The mean post-operative improvement in coronal Cobb was 53.2° and pelvic obliquity reduced to 5.8°. These did not change during a mean follow up of 3.5 years. None showed any post-operative complications. Three patients with a mean 16.1° pelvic obliquity underwent a fusion to L5. The postoperative result in those cases remained stable at 3.5 years mean follow-up and full skeletal maturity. Conclusion Our data suggests that with modern technology, severe curves can be safely treated. Fusion to the pelvis is not necessary in patients with mild, flexible pelvic obliquity.
Collapse
Affiliation(s)
- Brett Rocos
- Department of Orthopaedic Surgery, Hospital for Sick Children, Toronto, CAN
| | - Reinhard Zeller
- Department of Orthopaedic Surgery, Hospital for Sick Children, Toronto, CAN
| |
Collapse
|
10
|
Peron A, Canevini MP, Ghelma F, Arancio R, Savini MN, Vignoli A. Phenotypes in adult patients with Rett syndrome: results of a 13-year experience and insights into healthcare transition. J Med Genet 2020; 59:39-45. [PMID: 33106377 PMCID: PMC8685662 DOI: 10.1136/jmedgenet-2020-107333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/21/2020] [Accepted: 09/29/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Rett syndrome is a complex genetic disorder with age-specific manifestations and over half of the patients surviving into middle age. However, little information about the phenotype of adult individuals with Rett syndrome is available, and mainly relies on questionnaires completed by caregivers. Here, we assess the clinical manifestations and management of adult patients with Rett syndrome and present our experience in transitioning from the paediatric to the adult clinic. METHODS We analysed the medical records and molecular data of women aged ≥18 years with a diagnosis of classic Rett syndrome and/or pathogenic variants in MECP2, CDKL5 and FOXG1, who were in charge of our clinic. RESULTS Of the 50 women with classic Rett syndrome, 94% had epilepsy (26% drug-resistant), 20% showed extrapyramidal signs, 40% sleep problems and 36% behavioural disorders. Eighty-six % patients exhibited gastrointestinal problems; 70% had scoliosis and 90% low bone density. Breathing irregularities were diagnosed in 60%. None of the patients had cardiac issues. CDKL5 patients experienced fewer breathing abnormalities than women with classic Rett syndrome. CONCLUSION The delineation of an adult phenotype in Rett syndrome demonstrates the importance of a transitional programme and the need of a dedicated multidisciplinary team to optimise the clinical management of these patients.
Collapse
Affiliation(s)
- Angela Peron
- Department of Health Sciences, Università degli Studi di Milano, Milano, Lombardia, Italy .,Division of Medical Genetics, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - Maria Paola Canevini
- Department of Health Sciences, Università degli Studi di Milano, Milano, Lombardia, Italy.,Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - Filippo Ghelma
- Department of Health Sciences, Università degli Studi di Milano, Milano, Lombardia, Italy.,Disabled Advanced Medical Assistance (DAMA), San Paolo Hospital, Milan, Italy
| | | | - Miriam Nella Savini
- Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - Aglaia Vignoli
- Department of Health Sciences, Università degli Studi di Milano, Milano, Lombardia, Italy.,Child Neuropsychiatry Unit - Epilepsy Center, San Paolo Hospital, Milan, Italy
| |
Collapse
|
11
|
Sandweiss AJ, Brandt VL, Zoghbi HY. Advances in understanding of Rett syndrome and MECP2 duplication syndrome: prospects for future therapies. Lancet Neurol 2020; 19:689-698. [PMID: 32702338 DOI: 10.1016/s1474-4422(20)30217-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 01/07/2023]
Abstract
The X-linked gene encoding MECP2 is involved in two severe and complex neurodevelopmental disorders. Loss of function of the MeCP2 protein underlies Rett syndrome, whereas duplications of the MECP2 locus cause MECP2 duplication syndrome. Research on the mechanisms by which MeCP2 exerts effects on gene expression in neurons, studies of animal models bearing different disease-causing mutations, and more in-depth observations of clinical presentations have clarified some issues even as they have raised further questions. Yet there is enough evidence so far to suggest possible approaches to therapy for these two diseases that could go beyond attempting to address specific signs and symptoms (of which there are many) and instead target the pathophysiology underlying MECP2 disorders. Further work could bring antisense oligonucleotides, deep brain stimulation, and gene therapy into the clinic within the next decade or so.
Collapse
Affiliation(s)
- Alexander J Sandweiss
- Department of Pediatrics, Section of Neurology and Developmental Neurosciences, Baylor College of Medicine, Houston, TX, USA; Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, USA
| | - Vicky L Brandt
- Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, USA
| | - Huda Y Zoghbi
- Department of Pediatrics, Section of Neurology and Developmental Neurosciences, Baylor College of Medicine, Houston, TX, USA; Howard Hughes Medical Institute, and Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA; Jan and Dan Duncan Neurological Research Institute at Texas Children's Hospital, Houston, TX, USA.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Respiratory Complications After Posterior Spinal Fusion for Neuromuscular Scoliosis: Children With Rett Syndrome at Greater Risk Than Those With Cerebral Palsy. Spine (Phila Pa 1976) 2019; 44:1396-1402. [PMID: 31261282 DOI: 10.1097/brs.0000000000003075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To determine how respiratory failure rates and duration of intensive care unit (ICU) stay after posterior spinal fusion (PSF) for neuromuscular scoliosis compare between children with Rett syndrome (RS) versus cerebral palsy (CP). SUMMARY OF BACKGROUND DATA Rett syndrome and CP are associated with high incidence of neuromuscular scoliosis and respiratory dysfunction. METHODS We included 21 patients with RS (mean age, 13 ± 3.1 yrs) and 124 with CP (mean age, 14 ± 3.2 yrs) who underwent PSF by one surgeon from 2004 to 2017. Preoperative motor function was assessed using the Gross Motor Function Classification System (GMFCS). Primary outcomes were respiratory failure and duration of ICU stay. Secondary outcomes were pneumonia and prolonged use of positive pressure ventilation (PPV). Using multivariate regression, we identified associations of age, intraoperative vital signs, duration of hospital stay, number of vertebral levels fused, anesthesia and surgery durations, and estimated blood loss with longer ICU stay and respiratory failure. RESULTS A greater proportion of CP patients (96%) than RS patients (66%) were in GMFCS IV or V (P < 0.01). Respiratory failure was more common in RS patients (43% vs. 19%; P = 0.02), as was PPV (67% vs. 31%; P < 0.01). RS patients had shorter median durations of anesthesia and surgery (P < 0.01). RS patients had a longer median (interquartile range) ICU stay (4 days [1-5] vs. 2 days [2-19]; P = 0.01). Incidence of pneumonia did not differ between groups (P = 0.69). Only RS diagnosis (P = 0.02) and prolonged PPV (P < 0.01) were associated with longer ICU stay. CONCLUSION Despite better preoperative motor function and shorter anesthesia and surgery durations, patients with RS experienced more respiratory failure, prolonged PPV use, and longer ICU stays after PSF than did children with CP. LEVEL OF EVIDENCE 4.
Collapse
|
14
|
Strugnell A, Leonard H, Epstein A, Downs J. Using directed-content analysis to identify a framework for understanding quality of life in adults with Rett syndrome. Disabil Rehabil 2019; 42:3800-3807. [PMID: 31074665 DOI: 10.1080/09638288.2019.1610801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: Rett syndrome (RTT) is a rare neurodevelopmental disorder mainly affecting females and is caused by a mutation in the MECP2 gene. Recent research identified the domains of quality of life (QOL) important for children with RTT but there has been no investigation of domains important for adults. This qualitative study explored QOL in adults with RTT and compared domains with those previously identified for children.Methods: The sample comprised parents and/or primary caregivers of 20 adults, aged 18-38 years, who were registered with the Australian Rett Syndrome Database. Semi-structured telephone interviews were conducted to investigate aspects of life that were observed to be satisfying or challenging. Data were analyzed using directed content analysis, based on existing QOL domains for children with RTT that related to health and wellbeing, daily activities, and community immersion and services.Results: Each of the domains identified for children with RTT was represented in the adult dataset, with no new domains emerging.Conclusion: This is the first study to identify QOL domains important for adults with RTT. Health and therapy needs are ongoing during adulthood but services may be limited. Findings will guide choice of an appropriate QOL measure for this group.IMPLICATIONS FOR REHABILITATIONKnowing the important domains of quality of life enables clinicians and service providers to systematically review and address key management issues.Despite a high level of dependency and sometimes poor health, parent caregivers perceive potential for strong quality of life in adulthood.Services that maintain functional skills and health throughout the lifespan are valued for their support of quality of life in adults with Rett syndrome.
Collapse
Affiliation(s)
- Aleisha Strugnell
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Nedlands, Australia
| | - Amy Epstein
- Telethon Kids Institute, The University of Western Australia, Nedlands, Australia
| | - Jenny Downs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia.,Telethon Kids Institute, The University of Western Australia, Nedlands, Australia
| |
Collapse
|
15
|
Lai YYL, Wong K, King NM, Downs J, Leonard H. Oral health experiences of individuals with Rett syndrome: a retrospective study. BMC Oral Health 2018; 18:195. [PMID: 30497449 PMCID: PMC6267076 DOI: 10.1186/s12903-018-0651-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/23/2018] [Indexed: 12/24/2022] Open
Abstract
Background There is relatively little literature on the oral health experiences of individuals with Rett syndrome. This study described the incidence of dental extractions and restorations in a population-based cohort, according to a range of demographic and clinical factors. The association between bruxism and age was also investigated. Methods Existing questionnaire data in the population-based Australian Rett Syndrome Database for the years 2004, 2006, 2009 or 2011 on genetically confirmed female cases (n = 242) were analysed. Results The incidence rate of restorations and extractions were 6.8 per 100 person years (py) and 9.3 per 100 py respectively. The incidence of extractions decreased with increasing levels of income. Compared to those with a C-terminal mutation, the incidence rate of extraction was higher for those with large deletions (Incidence Rate Ratio (IRR) 4.93; 95% CI 1.46–16.7, p = 0.01). There was a 5% decrease in the risk of frequent bruxism for every one-year increase in age (Risk Ratio 0.95; 95% CI 0.94–0.97). Conclusions Social advantage may provide some protection for dental health in individuals with Rett syndrome. Those with more severe genotypes seemed to have poorer oral health outcomes.
Collapse
Affiliation(s)
- Y Y L Lai
- Department of Paediatric Dentistry, School of Dentistry, The University of Western Australia, Perth, WA, Australia.,Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - K Wong
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - N M King
- Department of Paediatric Dentistry, School of Dentistry, The University of Western Australia, Perth, WA, Australia
| | - J Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - H Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.
| |
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
Leonard H, Cobb S, Downs J. Clinical and biological progress over 50 years in Rett syndrome. Nat Rev Neurol 2016; 13:37-51. [PMID: 27934853 DOI: 10.1038/nrneurol.2016.186] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the 50 years since Andreas Rett first described the syndrome that came to bear his name, and is now known to be caused by a mutation in the methyl-CpG-binding protein 2 (MECP2) gene, a compelling blend of astute clinical observations and clinical and laboratory research has substantially enhanced our understanding of this rare disorder. Here, we document the contributions of the early pioneers in Rett syndrome (RTT) research, and describe the evolution of knowledge in terms of diagnostic criteria, clinical variation, and the interplay with other Rett-related disorders. We provide a synthesis of what is known about the neurobiology of MeCP2, considering the lessons learned from both cell and animal models, and how they might inform future clinical trials. With a focus on the core criteria, we examine the relationships between genotype and clinical severity. We review current knowledge about the many comorbidities that occur in RTT, and how genotype may modify their presentation. We also acknowledge the important drivers that are accelerating this research programme, including the roles of research infrastructure, international collaboration and advocacy groups. Finally, we highlight the major milestones since 1966, and what they mean for the day-to-day lives of individuals with RTT and their families.
Collapse
Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, 100 Roberts Road, Subiaco, Perth, Western Australia 6008, Australia
| | - Stuart Cobb
- Institute of Neuroscience and Psychology, College of Medical, Veterinary and Life Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Jenny Downs
- Telethon Kids Institute, 100 Roberts Road, Subiaco, Perth, Western Australia 6008, Australia
| |
Collapse
|
18
|
Quantitative and qualitative insights into the experiences of children with Rett syndrome and their families. Wien Med Wochenschr 2016; 166:338-45. [PMID: 27491552 DOI: 10.1007/s10354-016-0494-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 12/27/2022]
Abstract
Rett syndrome is a rare neurodevelopmental disorder caused by a mutation in the MECP2 gene. It is associated with severe functional impairments and medical comorbidities such as scoliosis and poor growth. The population-based and longitudinal Australian Rett Syndrome Database was established in 1993 and has supported investigations of the natural history of Rett syndrome and effectiveness of treatments, as well as a suite of qualitative studies to identify deeper meanings. This paper describes the early presentation of Rett syndrome, including regression and challenges for families seeking a diagnosis. We discuss the importance of implementing strategies to enhance daily communication and movement, describe difficulties interpreting the presence of pain and discomfort, and argue for a stronger evidence base in relation to management. Finally, we outline a framework for understanding quality of life in Rett syndrome and suggest areas of life to which we can direct efforts in order to improve quality of life. Each of these descriptions is illustrated with vignettes of child and family experiences. Clinicians and researchers must continue to build this framework of knowledge and understanding with efforts committed to providing more effective treatments and supporting the best quality of life for those affected.
Collapse
|
19
|
Downs J, Forbes D, Johnson M, Leonard H. How can clinical ethics guide the management of comorbidities in the child with Rett syndrome? J Paediatr Child Health 2016; 52:809-13. [PMID: 27243819 PMCID: PMC4990489 DOI: 10.1111/jpc.13241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2016] [Indexed: 01/16/2023]
Abstract
Rett syndrome is a rare disorder caused by a mutation in the MECP2 gene. Those affected generally have severe functional impairments, and medical comorbidities such as scoliosis and poor growth are common. There is a paucity of information on the natural history of many rare disorders and an even greater deficit of evidence to guide best practice. The population-based and longitudinal Australian Rett Syndrome Database established in 1993 has supported investigations of the natural history of Rett syndrome and effectiveness of treatments. This paper reviews the disorder Rett syndrome and evidence for the management of scoliosis and poor growth within a clinical ethics framework. Compared with conservative management, we have shown that spinal fusion is associated with reduced mortality and better respiratory health. We have also shown that gastrostomy insertion is associated with subsequent weight gain. Family counselling for both procedures necessarily must include family perspectives and careful clinical attention to their needs and wishes. Vignettes describing family decision-making and experiences are presented to illustrate the principals of beneficence and autonomy in determining the best interests of the child and family. A blend of evidence-based practice with a strong clinical ethics framework has capacity to build existing strengths in families and reduce the negative impacts of disability and in so doing, optimise the health and wellbeing of those with Rett syndrome.
Collapse
Affiliation(s)
- Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia
| | - David Forbes
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia
| | - Michael Johnson
- Department of Orthopaedics, Royal Children’s Hospital, Melbourne, Victoria
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia
| |
Collapse
|
20
|
Humphreys P. What are the reasons for improved survival following spine fusion for severe scoliosis in Rett syndrome? Dev Med Child Neurol 2016; 58:538-9. [PMID: 26661711 DOI: 10.1111/dmcn.12993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Humphreys
- Division of Neurology, Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| |
Collapse
|