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Chrastina J, Haroková M. End of Life in Boys and Young Men With Duchenne Muscular Dystrophy - The Perspective of Dying Men and Their Families: A Systematic Review and Thematic Synthesis of Qualitative Evidence. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231186358. [PMID: 37408104 DOI: 10.1177/00302228231186358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Understanding the perceptions and experiences related to the end of life (EoL) of boys and men with Duchenne muscular dystrophy from their own and/or family perspective is limited based on the available qualitative empirical studies. This systematic review was done with a thematic synthesis of qualitative evidence according to the PRISMA Statement Guidelines and the SPIDER search tool. The review included empirical, qualitative, and relevant full-text studies published in 2000-2023 in the EBSCO Discovery Service, ISI Web of Science, Scopus, PubMed, and ProQuest databases. From o total of eight included qualitative studies, four main key themes were identified: "Being a parent/caregiver" - psychosocial aspects, needs, and experiences; "Communication about EoL with healthcare and other professionals" - positive experiences and personal shortcomings; "Discussions about…" - the issue of EoL, dying and death; and "End of life" - end-of-life care, planning and the need for palliative care.
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Affiliation(s)
- Jan Chrastina
- Institute of Special Education Studies, Faculty of Education, Palacký University Olomouc, Olomouc, Czech Republic
| | - Martina Haroková
- Institute of Special Education Studies, Faculty of Education, Palacký University Olomouc, Olomouc, Czech Republic
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Corsello A, Scatigno L, Govoni A, Zuccotti G, Gottrand F, Romano C, Verduci E. Gut dysmotility in children with neurological impairment: the nutritional management. Front Neurol 2023; 14:1200101. [PMID: 37213895 PMCID: PMC10196023 DOI: 10.3389/fneur.2023.1200101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.
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Affiliation(s)
- Antonio Corsello
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Lorenzo Scatigno
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Annalisa Govoni
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
| | - Gianvincenzo Zuccotti
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, Milan, Italy
| | - Frédéric Gottrand
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, CHU Lille, University of Lille, Lille, France
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Elvira Verduci
- Department of Pediatrics, Vittore Buzzi Children’s Hospital, University of Milan, Milan, Italy
- Department of Health Science, University of Milan, Milan, Italy
- *Correspondence: Elvira Verduci,
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Dhaliwal A, Madiraju S, Dhindsa BS, Hassen GW, Rochling FA. Gigantic Stomach: A Rare Manifestation of Duchenne Muscular Dystrophy. Cureus 2019; 11:e4609. [PMID: 31309032 PMCID: PMC6609291 DOI: 10.7759/cureus.4609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is characterized by degeneration and atrophy of skeletal, cardiac, and smooth muscles after a latent period of apparently normal development and function. The gastrointestinal manifestations start in the second decade of life and are mainly due to atrophy of smooth muscle layers. Refractory gastroparesis and chronic constipation can lead to severe gastric and small bowel dilatation, which can be life threatening. Here, we present a case of a 21-year-old male with a gigantic stomach secondary to DMD resolved with conservative management and no surgical intervention.
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Affiliation(s)
| | | | - Banreet S Dhindsa
- Internal Medicine, University of Nevada School of Medicine, Las Vegas, USA
| | - Getaw W Hassen
- Emergency Medicine, New York Medical College and Metropolitan Hospital Center, New York, USA
| | - Fedja A Rochling
- Gastroenterology, University of Nebraska Medical Center, Omaha, USA
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Brumbaugh D, Watne L, Gottrand F, Gulyas A, Kaul A, Larson J, Tomezsko J. Nutritional and Gastrointestinal Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S53-S61. [PMID: 30275249 DOI: 10.1542/peds.2018-0333g] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
Advances in treatment and multidisciplinary management have resulted in improved survival of individuals with Duchenne muscular dystrophy (DMD). Updated DMD treatment recommendations as found in the 2018 DMD Care Considerations are aimed to assist multidisciplinary care teams in providing standardized care to their patients, including attention to nutritional and gastrointestinal health. Challenges remain for care teams in accurately estimating height and nutritional status for individuals with DMD. It can be difficult for patients to maintain a healthy weight. Risk factors for obesity include glucocorticoid therapy and loss of ambulation. In contrast, in the later stages of the disease, swallowing dysfunction can lead to poor nutrition and consideration for gastrostomy tube placement. Constipation is highly prevalent, underrecognized, and undertreated in DMD. With this article, we address the assessment and management of gastrointestinal and nutritional issues, as well as clinical controversies.
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Affiliation(s)
| | - Laura Watne
- Children's Hospital Colorado, Aurora, Colorado
| | - Frederic Gottrand
- Jean de Flandre Hospital, Université de Lille, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Ann Gulyas
- Western Maryland Hospital Center, Hagerstown, Maryland
| | - Ajay Kaul
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jean Tomezsko
- Medical Nutrition Consulting of Media LLC, Philadelphia, Pennsylvania
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Abstract
Introduction Duchenne Muscular Dystrophy is a genetic disease that is caused by a deficiency of dystrophin protein. Both Duchenne Muscular Dystrophy patients and dystrophic mice suffer from intestinal dysfunction. Methods The present study arose from a chance observation of differences in fecal output of dystrophic vs. normal mice during 20-minutes of forced continuous treadmill exercise. Here, we report on the effects of exercise on fecal output in two different dystrophic mutants and their normal background control strains. All fecal materials evacuated during exercise were counted, dried and weighed. Results Mice of both mutant dystrophic strains produced significantly more fecal material during the exercise bout than the relevant control strains. iscussion We propose that exercise--induced Colo--Rectal Activation Phenotype test could be used as a simple, highly sensitive, non-invasive biomarker to determine efficacy of dystrophin replacement therapies.
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Affiliation(s)
- Marie Nearing
- Children's National Health System, Children's Research Institute, Center for Genetic Medicine Research, Washington DC, United States
| | - James Novak
- Center for Genetic Medicine Research, Children's National Health System, Washington DC, United States
| | - Terence Partridge
- Center for Genetic Medicine Research, Children's Research Institute, Children's National Medical Center, Washington DC, United States
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Kraus D, Wong B, Hu S, Kaul A. Gut Transit in Duchenne Muscular Dystrophy Is Not Impaired: A Study Utilizing Wireless Motility Capsules. J Pediatr 2018; 194:238-240. [PMID: 29224937 DOI: 10.1016/j.jpeds.2017.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/28/2017] [Accepted: 10/26/2017] [Indexed: 10/18/2022]
Abstract
We examined gut transit in 7 young adults (18-24 years of age) with Duchenne muscular dystrophy using wireless motility capsules. Total and segmental gut transit times were normal in essentially all patients. Our study using a validated tool suggests normal transit constipation as the pathophysiologic basis for constipation in Duchenne muscular dystrophy.
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Affiliation(s)
- Dror Kraus
- Department of Neurology, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.
| | - Brenda Wong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shengyong Hu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ajay Kaul
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Lo Cascio CM, Goetze O, Latshang TD, Bluemel S, Frauenfelder T, Bloch KE. Gastrointestinal Dysfunction in Patients with Duchenne Muscular Dystrophy. PLoS One 2016; 11:e0163779. [PMID: 27736891 PMCID: PMC5063332 DOI: 10.1371/journal.pone.0163779] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/14/2016] [Indexed: 12/14/2022] Open
Abstract
Background In adult patients with Duchenne muscular dystrophy (DMD) life-threatening constipation has been reported. Since gastrointestinal function in DMD has not been rigorously studied we investigated objective and subjective manifestations of gastrointestinal disturbances in DMD patients. Methods In 33 patients with DMD, age 12–41 years, eating behavior and gastrointestinal symptoms were evaluated by questionnaires. Gastric emptying half time (T1/2) and oro-cecal transit time (OCTT) were evaluated by analyzing 13CO2 exhalation curves after ingestion of 13C labeled test meals. Colonic transit time (CTT) was measured by abdominal radiography following ingestion of radiopaque markers. Results The median (quartiles) T1/2 was 187 (168, 220) minutes, the OCTT was 6.3 (5.0, 7.9) hours, both substantially longer than normal data (Goetze 2005, T1/2: 107±10; Geypens 1999, OCTT 4.3±0.1 hours). The median CTT was 60 (48, 82) hours despite extensive use of laxative measures (Meier 1995, upper limit of normal: 60 hours). T1/2 and OCTT did not correlate with symptoms evaluated by the Gastroparesis Cardinal Symptom Index (GCSI) (Spearman r = -0.3, p = 0.1; and r = -0.15, p = 0.4, respectively). CTT was not correlated with symptoms of constipation assessed by ROME III criteria (r = 0.12, p = 0.5). Conclusions DMD patients have a markedly disturbed gastrointestinal motor function. Since objective measures of impaired gastrointestinal transport are not correlated with symptoms of gastroparesis or constipation our findings suggest that measures assuring adequate intestinal transport should be taken independent of the patient’s perception in order to prevent potentially life threatening constipation, particularly in older DMD patients.
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Affiliation(s)
- Christian M. Lo Cascio
- Pulmonary Division, University Hospital of Zurich, Neuromuscular and Sleep Disorders Center, University Hospital of Zurich, Zurich, Switzerland
- Center for Human Integrative Physiology, University of Zurich, Zurich, Switzerland
| | - Oliver Goetze
- Division of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Tsogyal D. Latshang
- Pulmonary Division, University Hospital of Zurich, Neuromuscular and Sleep Disorders Center, University Hospital of Zurich, Zurich, Switzerland
- Center for Human Integrative Physiology, University of Zurich, Zurich, Switzerland
| | - Sena Bluemel
- Division of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Konrad E. Bloch
- Pulmonary Division, University Hospital of Zurich, Neuromuscular and Sleep Disorders Center, University Hospital of Zurich, Zurich, Switzerland
- Center for Human Integrative Physiology, University of Zurich, Zurich, Switzerland
- * E-mail:
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Kraus D, Wong BL, Horn PS, Kaul A. Constipation in Duchenne Muscular Dystrophy: Prevalence, Diagnosis, and Treatment. J Pediatr 2016; 171:183-8. [PMID: 26831528 DOI: 10.1016/j.jpeds.2015.12.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/09/2015] [Accepted: 12/16/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the prevalence and clinical characteristics of constipation among patients with Duchenne muscular dystrophy (DMD). STUDY DESIGN This cross-sectional prospective study included 120 patients (age range 5-30 years old) with an established diagnosis of DMD. Participants filled out the constipation section of a validated Questionnaire on Pediatric Gastrointestinal Symptoms based on Rome-III Criteria (QPGS-RIII) for the diagnosis of functional constipation as part of a routine clinic visit. We evaluated several potential screening methods for constipation: the Bristol stool form scale, routine physical examination, and fecal load on abdominal radiograph. These methods were compared with the QPGS-RIII in diagnosing functional constipation. Risk factors for the development of functional constipation were determined. RESULTS Based on the QPGS-RIII, 46.7% of patients with DMD in this cohort were diagnosed with functional constipation. Prevalence was not affected by age or functional status. None of the screening methods tested were sensitive enough to diagnose functional constipation. Among patients with constipation, only 43.6% received specific treatment for constipation and only one-half of these treated patients reported resolution of constipation. CONCLUSIONS This study systematically examined constipation among patients with DMD and provides evidence that constipation among patients with DMD is highly prevalent, underdiagnosed, and undertreated. QPGS-RIII is easy to administer and is an efficient tool to diagnose functional constipation in patients with DMD in a clinic setting.
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Affiliation(s)
- Dror Kraus
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Brenda L Wong
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Fecal Transplant for Treatment of Toxic Megacolon Associated With Clostridium Difficile Colitis in a Patient With Duchenne Muscular Dystrophy. Am J Ther 2016; 23:e609-13. [DOI: 10.1097/mjt.0000000000000062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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10
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Miller D. Tension Pneumoperitoneum Caused by Obstipation. West J Emerg Med 2015; 16:777-80. [PMID: 26587109 PMCID: PMC4644053 DOI: 10.5811/westjem.2015.6.25283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 05/13/2015] [Accepted: 06/03/2015] [Indexed: 11/11/2022] Open
Abstract
Emergency physicians are often required to evaluate and treat undifferentiated patients suffering acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a differential diagnosis including all causes of AHC that can be identified and treated during a primary assessment. Tension pneumoperitoneum (TP) is an uncommon condition with the potential to be rapidly fatal. It is amenable to prompt diagnosis and stabilization in the emergency department. We present a case of a 16-year-old boy with TP to demonstrate how TP should be incorporated into a differential diagnosis when evaluating an undifferentiated patient with AHC.
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Affiliation(s)
- Daniel Miller
- University of Iowa Hospitals and Clinics, Department of Emergency Medicine, Iowa City, Iowa
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11
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Davis J, Samuels E, Mullins L. Nutrition Considerations in Duchenne Muscular Dystrophy. Nutr Clin Pract 2015; 30:511-21. [PMID: 25977513 DOI: 10.1177/0884533615586202] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is a serious degenerative muscular disease affecting males. Diagnosis usually occurs in childhood and is confirmed through genetic testing and/or muscle biopsy. Accompanying the disease are several nutrition-related concerns: growth, body composition, energy and protein requirements, constipation, swallowing difficulties, bone health, and complementary medicine. This review article addresses the nutrition aspects of DMD.
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12
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Jordan-Ely J, Dobson KM, Appaduray S, Hynson J, Kornberg AJ, Hutson JM, Southwell BR. Management of severe faecal impaction in an adolescent with Duchenne muscular dystrophy (DMD) receiving palliative care. J Paediatr Child Health 2015; 51:351-2. [PMID: 25758316 DOI: 10.1111/jpc.12859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Julie Jordan-Ely
- Victorian Palliative Care Program, Royal Childrens Hospital, Melbourne, Victoria, Australia
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13
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Davis RH, Godshall BJ, Seffrood E, Marcus M, LaSalle BA, Wong B, Schroth MK, Swoboda KJ. Nutritional practices at a glance: spinal muscular atrophy type I nutrition survey findings. J Child Neurol 2014; 29:1467-72. [PMID: 24097849 PMCID: PMC4334580 DOI: 10.1177/0883073813503988] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Proactive nutritional management for children with spinal muscular atrophy type I can provide insight into improved spinal muscular atrophy care. This observational study consisted of a nutritional and medical history survey of children with spinal muscular atrophy type I collected in 2009-2011. Forty-four caregiver survey responses were evaluated using descriptive statistics. Average age of spinal muscular atrophy type I subjects was 5 years (5 mo-16 y). The subject cohort was composed of 22 males, 21 females, and 1 unreported. Nutrition support via feeding tube was utilized by 43 of 44 subjects. A majority of respondents reported using elemental or semi-elemental formula for subjects' essential caloric intake (34 of 44). Formula intolerance issues were reported by many caregivers (27 of 44). Half of caregivers implemented dietary changes on their own or with guidance from other families; 15 caregivers consulted a registered dietitian. Survey responses and comments indicate need for evidence-based nutritional guidelines for spinal muscular atrophy.
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Affiliation(s)
- Rebecca Hurst Davis
- Pediatric Motor Disorders Research Program, University of Utah, Department of Neurology, Salt Lake City, UT, USA
| | - Barbara J. Godshall
- Division of Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Erin Seffrood
- University of Wisconsin Pediatric Pulmonary Center, University of Wisconsin School of Medicine and Public Health, American Family Children’s Hospital, Madison, WI, USA
| | - Mary Marcus
- University of Wisconsin Pediatric Pulmonary Center, University of Wisconsin School of Medicine and Public Health, American Family Children’s Hospital, Madison, WI, USA
| | - Bernard A LaSalle
- Biomedical Research Informatics Service Core, University of Utah, Salt Lake City, UT, USA
| | - Brenda Wong
- Pediatric Neuromuscular Program, Comprehensive Neuromuscular Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mary K. Schroth
- University of Wisconsin Pediatric Pulmonary Center, University of Wisconsin School of Medicine and Public Health, American Family Children’s Hospital, Madison, WI, USA
| | - Kathryn J. Swoboda
- Pediatric Motor Disorders Research Program, University of Utah, Department of Neurology, Salt Lake City, UT, USA
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Bushby K, Finkel R, Birnkrant DJ, Case LE, Clemens PR, Cripe L, Kaul A, Kinnett K, McDonald C, Pandya S, Poysky J, Shapiro F, Tomezsko J, Constantin C. Diagnosis and management of Duchenne muscular dystrophy, part 2: implementation of multidisciplinary care. Lancet Neurol 2010; 9:177-89. [PMID: 19945914 DOI: 10.1016/s1474-4422(09)70272-8] [Citation(s) in RCA: 708] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Optimum management of Duchenne muscular dystrophy (DMD) requires a multidisciplinary approach that focuses on anticipatory and preventive measures as well as active interventions to address the primary and secondary aspects of the disorder. Implementing comprehensive management strategies can favourably alter the natural history of the disease and improve function, quality of life, and longevity. Standardised care can also facilitate planning for multicentre trials and help with the identification of areas in which care can be improved. Here, we present a comprehensive set of DMD care recommendations for management of rehabilitation, orthopaedic, respiratory, cardiovascular, gastroenterology/nutrition, and pain issues, as well as general surgical and emergency-room precautions. Together with part 1 of this Review, which focuses on diagnosis, pharmacological treatment, and psychosocial care, these recommendations allow diagnosis and management to occur in a coordinated multidisciplinary fashion.
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Affiliation(s)
- Katharine Bushby
- Institute of Human Genetics, Newcastle University, Newcastle upon Tyne, UK.
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Turturro F, Rocca B, Gumina S, De Cristofaro R, Mangiola F, Maggiano N, Evangelista A, Salsano V, Montanaro A. Impaired primary hemostasis with normal platelet function in Duchenne muscular dystrophy during highly-invasive spinal surgery. Neuromuscul Disord 2005; 15:532-40. [PMID: 16009551 DOI: 10.1016/j.nmd.2005.05.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Revised: 03/16/2005] [Accepted: 05/09/2005] [Indexed: 11/18/2022]
Abstract
A defective, normal or enhanced hemostasis has been reported in Duchenne muscular dystrophy (DMD). A retrospective analysis of intra-and postoperative (up to 36 h) estimated blood losses was performed in 156 patients undergoing spinal surgery for: DMD (n = 31), idiopathic scoliosis (IS) (n = 70), poliomyelitis (n = 10), cerebral palsy (CP) (n = 28), spinal muscular atrophy (SMA) (n = 17). Platelet aggregation and bleeding times were also investigated in DMD patients. Immunohistochemistry for dystrophin was performed in platelets, megakaryocytes and blood vessels of normal tissues. DMD patients showed significantly higher intraoperative estimated blood losses (DMD: 3495+/-890 ml; IS: 2269+/-804 ml; poliomyelitis: 2582+/-1252 ml; CP: 2071+/-683 ml; SMA: 2464+/-806 ml; P < 0.05), while postoperative blood losses were similar among different groups. Higher estimated blood losses in DMD were independent of the duration of surgery, body weight, gender, age, vertebral levels or preoperative Cobb angle. DMD children had significantly prolonged bleeding times, but retained normal platelet function. From control samples dystrophin was expressed in vascular smooth muscle cells, but not in platelets. DMD appears to be characterized by immediate bleeding during highly-invasive surgery and increased bleeding time without platelet abnormalities. Considering dystrophin expression in normal vascular smooth muscle cells, these results altogether suggest a selective defect of primary hemostasis in DMD, likely to be due to impaired vessel reactivity.
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Affiliation(s)
- Francesco Turturro
- Division of Paediatric Orthopedic Surgery, Ospedale Bambino Gesù, Palidoro, Rome, Italy
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