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Sonoo M. Split phenomena in manual muscle testing that are helpful for clinical practice. Muscle Nerve 2025; 71:1-2. [PMID: 39460585 DOI: 10.1002/mus.28281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 10/02/2024] [Accepted: 10/13/2024] [Indexed: 10/28/2024]
Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
- Department of Orthoptics, Faculty of Medical Technology, Teikyo University, Tokyo, Japan
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2
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Bhat A, Dean J, Aboussouan LS. Perioperative Management in Neuromuscular Diseases: A Narrative Review. J Clin Med 2024; 13:2963. [PMID: 38792504 PMCID: PMC11122304 DOI: 10.3390/jcm13102963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/04/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.
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Affiliation(s)
| | | | - Loutfi S. Aboussouan
- Respiratory and Neurological Institutes, Cleveland Clinic, Cleveland, OH 44195, USA; (A.B.); (J.D.)
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Kamei N, Nakamae T, Maruyama T, Nakao K, Farid F, Adachi N. Differentiating Neurodegenerative Disease From Compressive Cervical Myelopathy Using Motor-Evoked Potentials. Spine (Phila Pa 1976) 2024; 49:726-732. [PMID: 37040469 DOI: 10.1097/brs.0000000000004675] [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: 02/22/2023] [Accepted: 03/28/2023] [Indexed: 04/13/2023]
Abstract
STUDY DESIGN A retrospective case-control study. OBJECTIVE To differentiate neurodegenerative diseases from compressive cervical myelopathy (CCM) using motor-evoked potentials (MEPs). SUMMARY OF BACKGROUND DATA When considering surgery for CCM, it may be necessary to differentiate the condition from a neurodegenerative disease. MATERIALS AND METHODS A total of 30 healthy volunteers, 52 typical CCM patients with single-level compression of the spinal cord at C4-5 or C5-6, 7 patients with amyotrophic lateral sclerosis (ALS), and 12 patients with demyelinating disease of the central nervous system, including 11 patients with multiple sclerosis and 1 patient with neuromyelitis optica spectrum disorder, formed our study population. MEPs were recorded from the bilateral abductor digiti minimi (ADM) and abductor hallucis (AH) muscles using transcranial magnetic stimulation and electrical stimulation of the ulnar and tibial nerves. Central motor conduction time, peripheral conduction time, amplitude of MEPs, and frequency of F waves were evaluated. Receiver operating characteristic curve analysis was used to determine the cutoff value for distinguishing between CCM and ALS. RESULTS Significant differences were observed in the amplitude of MEPs and frequency of F waves evoked by peripheral nerve stimulation between patients with CCM and ALS. The MEP amplitude of AH was more accurate in differentiating between the two diseases compared with ADM (cutoff value, 11.2 mV, sensitivity, 87.5%; specificity, 85.7%). All 7 patients with ALS showed reduced frequency of F waves from ADM or AH, but none of the healthy volunteers or patients with other diseases demonstrated this finding. Moreover, there were no significant differences between CCM and demyelinating disease of the central nervous system in any of the assessments. CONCLUSION The amplitude of MEPs and frequency of F waves evoked by peripheral nerve stimulation could be helpful in differentiating ALS from CCM.
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Affiliation(s)
- Naosuke Kamei
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshio Nakamae
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toshiaki Maruyama
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuto Nakao
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Fadlyansyah Farid
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Orthopedic and Traumatology, Hasanuddin University, Makassar, Indonesia
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Zhang D, Xu R, Huo T, Liu Y, Hao Z, Sun Y, Xi X, Du X, Wang L, Du J. Perioperative management of a patient with unexpectedly detected early-stage ovarian mucinous carcinoma combined with progressive bulbar paralysis: a case report and literature review. BMC Womens Health 2024; 24:274. [PMID: 38704534 PMCID: PMC11069129 DOI: 10.1186/s12905-024-03117-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/26/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Giant ovarian cysts (GOCs)complicated with progressive bulbar paralysis (PBP) are very rare, and no such literature about these cases have been reported. Through the diagnosis and treatment of this case, the perioperative related treatment of such patients was analyzed in detail, and early-stage ovarian mucinous carcinoma was unexpectedly found during the treatment, which provided reference for clinical diagnosis and treatment of this kind of diseases. CASE PRESENTATION In this article, we reported a 38-year-old female patient. The patient was diagnosed with PBP 2 years ago. Examination revealed a large fluid-dominated cystic solid mass in the pelvis measuring approximately 28.6×14.2×8.0 cm. Carbohydrate antigen19-9(CA19-9) 29.20 IU/mL and no other significant abnormalities were observed. The patient eventually underwent transabdominal right adnexal resection under regional anesthesia, epidural block. Postoperative pathology showed mucinous carcinoma in some areas of the right ovary. The patient was staged as stage IA, and surveillance was chosen. With postoperative follow-up 1 month later, her CA19-9 decreased to 14.50 IU/ml. CONCLUSIONS GOCs combined with PBP patients require a multi-disciplinary treatment. Preoperative evaluation of the patient's PBP progression, selection of the surgical approach in relation to the patient's fertility requirements, the nature of the ovarian cyst and systemic condition are required. Early mucinous ovarian cancer accidentally discovered after operation and needs individualized treatment according to the guidelines and the patient's situation. The patient's dysphagia and respiratory function should be closely monitored during the perioperative period. In addition, moral support from the family is also very important.
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Affiliation(s)
- Dingbei Zhang
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Ruibo Xu
- Department of Gynecology, Handan first hospital, Handan, 056000, Hebei, China
| | - Tingting Huo
- Department of Anaesthesiology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300072, China
| | - Ying Liu
- Department of Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Zengfang Hao
- Department of Pathology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Yao Sun
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Xiaoyu Xi
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Xiaoli Du
- Department of Gynecology, Traditional Chinese Medicine Hospital of Shijiazhuang, Hebei, 050000, China
| | - Lili Wang
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China
| | - Jiexian Du
- Department of Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, Hebei, China.
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Harvey C, Weinreich M, Lee JA, Shaw AC, Ferraiuolo L, Mortiboys H, Zhang S, Hop PJ, Zwamborn RA, van Eijk K, Julian TH, Moll T, Iacoangeli A, Al Khleifat A, Quinn JP, Pfaff AL, Kõks S, Poulton J, Battle SL, Arking DE, Snyder MP, Veldink JH, Kenna KP, Shaw PJ, Cooper-Knock J. Rare and common genetic determinants of mitochondrial function determine severity but not risk of amyotrophic lateral sclerosis. Heliyon 2024; 10:e24975. [PMID: 38317984 PMCID: PMC10839612 DOI: 10.1016/j.heliyon.2024.e24975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 02/07/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease involving selective vulnerability of energy-intensive motor neurons (MNs). It has been unclear whether mitochondrial function is an upstream driver or a downstream modifier of neurotoxicity. We separated upstream genetic determinants of mitochondrial function, including genetic variation within the mitochondrial genome or autosomes; from downstream changeable factors including mitochondrial DNA copy number (mtCN). Across three cohorts including 6,437 ALS patients, we discovered that a set of mitochondrial haplotypes, chosen because they are linked to measurements of mitochondrial function, are a determinant of ALS survival following disease onset, but do not modify ALS risk. One particular haplotype appeared to be neuroprotective and was significantly over-represented in two cohorts of long-surviving ALS patients. Causal inference for mitochondrial function was achievable using mitochondrial haplotypes, but not autosomal SNPs in traditional Mendelian randomization (MR). Furthermore, rare loss-of-function genetic variants within, and reduced MN expression of, ACADM and DNA2 lead to ∼50 % shorter ALS survival; both proteins are implicated in mitochondrial function. Both mtCN and cellular vulnerability are linked to DNA2 function in ALS patient-derived neurons. Finally, MtCN responds dynamically to the onset of ALS independently of mitochondrial haplotype, and is correlated with disease severity. We conclude that, based on the genetic measures we have employed, mitochondrial function is a therapeutic target for amelioration of disease severity but not prevention of ALS.
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Affiliation(s)
- Calum Harvey
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Marcel Weinreich
- Clinical Neurobiology, German Cancer Research Center and University Hospital Heidelberg, Germany
| | - James A.K. Lee
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Allan C. Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Laura Ferraiuolo
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Heather Mortiboys
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Sai Zhang
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
| | - Paul J. Hop
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ramona A.J. Zwamborn
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kristel van Eijk
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Thomas H. Julian
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Tobias Moll
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Alfredo Iacoangeli
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Basic and Clinical Neuroscience, London, UK
| | - Ahmad Al Khleifat
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Basic and Clinical Neuroscience, London, UK
| | - John P. Quinn
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular & Integrative Biology, Liverpool, UK
| | - Abigail L. Pfaff
- Perron Institute for Neurological and Translational Science, Perth, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, Australia
| | - Sulev Kõks
- Perron Institute for Neurological and Translational Science, Perth, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, Australia
| | - Joanna Poulton
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Stephanie L. Battle
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dan E. Arking
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P. Snyder
- Center for Genomics and Personalized Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Project MinE ALS Sequencing Consortium
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
- Clinical Neurobiology, German Cancer Research Center and University Hospital Heidelberg, Germany
- Department of Epidemiology, University of Florida, Gainesville, FL, USA
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, UK
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Basic and Clinical Neuroscience, London, UK
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular & Integrative Biology, Liverpool, UK
- Perron Institute for Neurological and Translational Science, Perth, Australia
- Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, Australia
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Center for Genomics and Personalized Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jan H. Veldink
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kevin P. Kenna
- Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Johnathan Cooper-Knock
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
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Hill J, Sanghani N, Li Y. Features Suggestive of Coexisting Amyotrophic Lateral Sclerosis in Patients With Spinal Stenosis and Influence of Spinal Decompression. Cureus 2024; 16:e51587. [PMID: 38313873 PMCID: PMC10836407 DOI: 10.7759/cureus.51587] [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] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Spinal stenosis and amyotrophic lateral sclerosis (ALS) can co-occur and both manifest as signs of dysfunction of lower and/or upper motor neurons. Few studies have identified factors that alert the diagnosis of ALS in patients with spinal stenosis, and the influence of spinal decompression surgery on ALS progression remains unclear. OBJECTIVE The objective of this study is to describe factors that are suggestive of an ALS diagnosis in patients with spinal stenosis and influence of spinal decompression surgery on the progression of ALS Materials and methods: A retrospective review of the institutional ALS database and electronic medical records was performed to identify patients with coexisting diagnoses of ALS and moderate to severe cervical and/or lumbosacral spine stenosis. Identified patients were divided into two subgroups: those with spinal decompression surgery and those without. Comparisons of clinical features and progression of ALS were made between subgroups. RESULTS A total of 77 patients with ALS and coexisting moderate to severe cervical or lumbosacral spine stenosis were included. Among them, 50 patients underwent spinal decompression surgery and 27 did not. In comparison to patients with spinal decompression, patients without spinal decompression surgery were seen more frequently by neurologists (74% versus 26%), had less prominent radicular pain (19% versus 50%), demonstrated more frequent bulbar signs (30% versus 8%), experienced more likely weight loss (41% versus 4%), and disclosed more noticeable axonal loss changes on electromyography. Spinal decompression surgery did not modify the progression of ALS based on ALSFRS-R score change and analysis of survival duration. CONCLUSION Our study identified a number of useful features that are suggestive of an ALS diagnosis when evaluating patients with spinal stenosis and may support the performance of spinal decompression surgery in a subset of selected ALS patients with symptomatic spinal stenosis.
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Affiliation(s)
- Jeremy Hill
- Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, USA
| | - Nirav Sanghani
- Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, USA
| | - Yuebing Li
- Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, USA
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de Carvalho M, Swash M. Diagnosis and differential diagnosis of MND/ALS: IFCN handbook chapter. Clin Neurophysiol Pract 2023; 9:27-38. [PMID: 38249779 PMCID: PMC10796809 DOI: 10.1016/j.cnp.2023.12.003] [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: 08/23/2023] [Revised: 11/01/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
•Accurate and rapid diagnosis of amyotrophic lateral sclerosis (ALS) is important to prevent erroneous interventions. •The recent Gold Coast criteria are easily applicable and have high sensitivity and specificity. •Future developments will help to distinguish ALS as a specific clinical-pathologic entity. Accurate and rapid diagnosis of amyotrophic lateral sclerosis (ALS) is essential in order to provide accurate information for patient and family, to avoid time-consuming investigations and to permit an appropriate management plan. ALS is variable regarding presentation, disease progression, genetic profile and patient reaction to the diagnosis. It is obviously important to exclude treatable conditions but, in most patients, for experienced neurologists the diagnosis is clear-cut, depending on the presence of progressive upper and lower motor neuron signs. Patients with signs of restricted lower motor neuron (LMN) or upper motor neuron (UMN) dysfunction may present diagnostic difficulty, but electromyography (EMG) is often a determinant diagnostic test since it may exclude other disorders. Transcranial magnetic stimulation may aid detection of UMN dysfunction, and brain and spinal cord MRI, ultrasound and blood neurofilament measurements, have begun to have clinical impact, although none are themselves diagnostic tests. Several sets of diagnostic criteria have been proposed in the past; all rely on clinical LMN and UMN signs in different anatomic territories, EMG changes, exclusion of other disorders, and disease progression, in particular evidence of spreading to other anatomic territories. Fasciculations are a characteristic clinical feature and increased importance is now attached to fasciculation potentials detected by EMG, when associated with classical signs of denervation and reinnervation. The Gold Coast diagnostic criteria rely on the presence of UMN and LMN signs in one (or more) anatomic territory, or LMN signs in two (or more) anatomic territories, recognizing the fundamental clinical requirements of disease progression and exclusion of other diseases. Recent studies confirm a high sensitivity without loss of specificity using these Gold Coast criteria. In considering the diagnosis of ALS a critical question for future understanding is whether ALS should be considered a syndrome or a specific clinico-pathologic entity; this can only be addressed in the light of more complete knowledge.
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Affiliation(s)
- Mamede de Carvalho
- Faculdade de Medicina- Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| | - Michael Swash
- Faculdade de Medicina- Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
- Departments of Neurology and Neurosciences, Barts and the London School of Medicine, Queen Mary University of London and Royal London Hospital, UK
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Gwathmey KG, Corcia P, McDermott CJ, Genge A, Sennfält S, de Carvalho M, Ingre C. Diagnostic delay in amyotrophic lateral sclerosis. Eur J Neurol 2023; 30:2595-2601. [PMID: 37209406 DOI: 10.1111/ene.15874] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disease, and the time from symptom onset to diagnosis remains long. With the advent of disease-modifying treatments, the need to identify and diagnose ALS in a timely fashion has never been greater. METHODS We reviewed the literature to define the severity of ALS diagnostic delay, the various factors that contribute to this delay (including patient and physician factors), and the role that site of symptom onset plays in a patient's diagnostic journey. RESULTS Diagnostic delay is influenced by general practitioners' lack of recognition of ALS due to disease rarity and heterogenous presentations. As a result, patients are referred to non-neurologists, have unnecessary diagnostic testing, and may ultimately be misdiagnosed. Patient factors include their illness behavior-which impacts diagnostic delay-and their site of symptom onset. Limb-onset patients have the greatest diagnostic delay because they are frequently misdiagnosed with degenerative spine disease or peripheral neuropathy. CONCLUSION Prompt ALS diagnosis results in more effective clinical management, with earlier access to disease-modifying therapies, multidisciplinary care, and, if desired, clinical trial involvement. Due to lack of commercially available ALS biomarkers, alternative strategies to identify and triage patients who likely have ALS must be employed. Several diagnostic tools have been developed to encourage general practitioners to consider ALS and make an urgent referral to ALS specialists, bypassing unnecessary referrals to non-neurologists and unnecessary diagnostic workup.
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Affiliation(s)
- Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Philippe Corcia
- CRMR SLA, CHU Tours, Tours, France
- UMR1253 iBrain UMR, Université de Tours, INSERM, Tours, France
| | - Chris J McDermott
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Angela Genge
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Stefan Sennfält
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mamede de Carvalho
- Institute of Physiology, Instituto de Medicina Molecular João Lobo Antunes, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Lopez-Bernal D, Balderas D, Ponce P, Rojas M, Molina A. Implications of Artificial Intelligence Algorithms in the Diagnosis and Treatment of Motor Neuron Diseases-A Review. Life (Basel) 2023; 13:life13041031. [PMID: 37109560 PMCID: PMC10146231 DOI: 10.3390/life13041031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/17/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023] Open
Abstract
Motor neuron diseases (MNDs) are a group of chronic neurological disorders characterized by the progressive failure of the motor system. Currently, these disorders do not have a definitive treatment; therefore, it is of huge importance to propose new and more advanced diagnoses and treatment options for MNDs. Nowadays, artificial intelligence is being applied to solve several real-life problems in different areas, including healthcare. It has shown great potential to accelerate the understanding and management of many health disorders, including neurological ones. Therefore, the main objective of this work is to offer a review of the most important research that has been done on the application of artificial intelligence models for analyzing motor disorders. This review includes a general description of the most commonly used AI algorithms and their usage in MND diagnosis, prognosis, and treatment. Finally, we highlight the main issues that must be overcome to take full advantage of what AI can offer us when dealing with MNDs.
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Affiliation(s)
- Diego Lopez-Bernal
- Tecnologico de Monterrey, National Department of Research, Puente 222, Del. Tlalpan, Mexico City 14380, Mexico
| | - David Balderas
- Tecnologico de Monterrey, National Department of Research, Puente 222, Del. Tlalpan, Mexico City 14380, Mexico
| | - Pedro Ponce
- Tecnologico de Monterrey, National Department of Research, Puente 222, Del. Tlalpan, Mexico City 14380, Mexico
| | - Mario Rojas
- Tecnologico de Monterrey, National Department of Research, Puente 222, Del. Tlalpan, Mexico City 14380, Mexico
| | - Arturo Molina
- Tecnologico de Monterrey, National Department of Research, Puente 222, Del. Tlalpan, Mexico City 14380, Mexico
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10
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Samworth AG, Miller K, Haswah M, Tureanu L, Weeks J. Neuraxial and Regional Anesthesia in a Patient With Amyotrophic Lateral Sclerosis: A Case Report. Cureus 2023; 15:e37364. [PMID: 37182071 PMCID: PMC10170567 DOI: 10.7759/cureus.37364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 05/16/2023] Open
Abstract
Patients with amyotrophic lateral sclerosis (ALS) who undergo lower extremity joint arthroplasty are rarely encountered. Patients with ALS are at an increased risk for perioperative anesthetic complications. Anesthetic techniques, regional or general, present different risks to patients with ALS. The historical concern of worsening pre-existing neurologic symptoms with regional anesthesia is being re-examined in light of emerging evidence supporting its use in patients with ALS. Here, we present the successful perioperative management of a patient with severe bulbar ALS undergoing total knee arthroplasty. Despite his advanced bulbar symptoms, he was independently ambulatory with severe knee pain related to osteoarthritis. During multidisciplinary planning with the patient and his wife, it became clear that his primary perioperative concern was avoiding intubation, prolonged ventilation, and tracheostomy placement. With this in mind, we planned for a neuraxial anesthetic without intraoperative sedation, a postoperative adductor canal peripheral nerve block, and multimodal non-opioid analgesia. There were no perioperative complications. At the six-week follow-up, he experienced improved ambulation and showed no signs of worsened ALS symptoms.
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Affiliation(s)
- Alexander G Samworth
- Regional Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Kenneth Miller
- Regional Anesthesiology, University of California San Diego, San Diego, USA
| | - Muin Haswah
- Regional Anesthesiology, North Star Anesthesia, Irving, USA
| | - Luminita Tureanu
- Regional Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jessica Weeks
- Regional Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, USA
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Diagnostic utility of neurofilament markers for MND is limited in restricted disease phenotype and for differentiation from compressive myeloradiculopathies. J Neurol 2023; 270:1600-1614. [PMID: 36456758 DOI: 10.1007/s00415-022-11504-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022]
Abstract
Misdiagnosis is frequent in early motor neuron disease (MND), typically compressive radiculopathy, or in patients with restricted MND phenotype. In this retrospective, single tertiary centre study, we measured levels of neurofilament light (NfL) and phosphorylated neurofilament heavy (p-NfH) chain in cerebrospinal fluid (CSF) and of p-NfH in serum with commercially available ELISA kits and assessed their respective diagnostic performance as a marker of MND. The entire study population (n = 164) comprised 71 MND patients, 30 patients with compressive myelo- or radiculopathy, and 63 disease controls (DC). Among MND patients, we specified subgroups with only lower motoneuron involvement (MND-LMN, n = 15) and with confounding nerve roots or spinal cord compression (MND-C, n = 18), representing clinical diagnostic pitfalls. MND-LMN displayed significantly lower CSF NfL (p = 0.003) and p-NFH (p = 0.017), but not serum p-NfH (p = 0.347) levels compared to other MND patients (n = 56). The discriminative ability (area under the curve-AUC) of both CSF Nfs towards all MND patients was comparable to each other but significantly higher than that of p-NfH in serum (ps < 0.001). AUC of both CSF Nfs between MND-LMN and DC and also between MND-C and myelo-/radiculopathies were reduced, as compared to AUC between other MND and DC or myelo-/radiculopathies, respectively. Our results suggest that both Nfs in CSF represent a reliable diagnostic marker in a general MND population, fulfilling Awaji criteria. As for diagnostic pitfalls, and also for p-NfH in serum, their discriminative ability and, therefore, clinical utility appears to be limited.
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Matsukura K, Hokkoku K, Mukai T, Oishi C, Kanbayashi T, Takahashi T, Sonoo M. Tibial nerve SEPs in diagnosing lumbar spinal stenosis: The utility of segmental evaluation using P15 and N21. Clin Neurophysiol Pract 2023; 8:49-57. [PMID: 37008279 PMCID: PMC10064344 DOI: 10.1016/j.cnp.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Objective To establish the utility of the additional evaluation of the P15 potential generated at the greater sciatic foramen in the tibial nerve somatosensory evoked potentials (SEPs) in diagnosing lumbar spinal stenosis (LSS). Methods We retrospectively reviewed tibial nerve SEP findings in patients having MRI-confirmed LSS at the cauda equina or conus/epiconus region. P15 and N21 potentials were recorded and the following findings were defined as localizing abnormalities: 1) normal P15 latency either with prolonged P15-N21 interval or with absent N21; 2) decreased ratio of the N21 amplitude to P15 amplitude. As non-localizing abnormalities, N21 and P38 latencies were also evaluated. Tibial nerve F-wave findings were also investigated. Results According to the entry criteria, 18 patients were included, 15 with cauda equina lesions and 3 with conus/epiconus lesions. Localizing abnormalities in SEPs were found in 67% of patients, achieving significantly higher sensitivity than delayed P38 latency (28%), and higher sensitivity than N21 abnormalities (39%), though this was not significant. Localizing abnormalities were observed even in 6 out of 11 patients lacking both sensory symptoms and signs. Tibial nerve F-wave was abnormal in 36% of 14 patients with F-wave examinations, whereas the localizing abnormalities in SEPs were found in 64% of the same patient population. P15 amplitude was depressed in 4 patients (22%), which may indicate the involvement of the dorsal root ganglion in LSS, although its latency was normal even for these patients. Conclusions Tibial nerve SEPs with the recording of P15 and N21 potentials achieved sufficiently high sensitivity in diagnosing LSS. They have the advantage over F-wave in that they can localize the lesion at the cauda equina or conus/epiconus level. Significance Tibial nerve SEPs are promising in evaluating LSS, especially in documenting sensory tract involvement in cases lacking sensory symptoms/signs.
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Falcão de Campos C, Gromicho M, Uysal H, Grosskreutz J, Kuzma-Kozakiewicz M, Oliveira Santos M, Pinto S, Petri S, Swash M, de Carvalho M. Trends in the diagnostic delay and pathway for amyotrophic lateral sclerosis patients across different countries. Front Neurol 2023; 13:1064619. [PMID: 36733448 PMCID: PMC9886675 DOI: 10.3389/fneur.2022.1064619] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
Background Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disease with a median survival of 2-5 years. An early diagnosis is essential for providing ALS patients the finest management possible. Studies from different countries report a similar median diagnostic delay of around 12 months, which is still far from desirable. We analyzed the diagnostic pathway in different countries in order to identify the major challenges. Methods We studied a cohort of 1,405 ALS patients from five different centers, in four different countries (Turkey, Germany, Poland, and Portugal), which collaborated in a common database. Demographic, disease and sociocultural factors were collected. Time from first symptom onset to first medical evaluation and to diagnosis, the specialist assessment and investigations requested were analyzed. Factors contributing to diagnostic delay were evaluated by multivariate linear regression. Results The median diagnostic delay from first symptom onset was 11 months and was similar between centers. Major differences were seen in the time from symptom onset to first medical evaluation. An earlier first medical evaluation was associated with a longer time to diagnosis, highlighting that ALS diagnosis is not straightforward in the early stages of the disease. The odds for ALS diagnosis were superior when evaluated by a neurologist and increased over time. Electromyography was decisive in establishing the diagnosis. Conclusions We suggest that a specific diagnostic test for ALS-a specific biomarker-will be needed to achieve early diagnosis. Early referral to a neurologist and to electromyography is important for early ALS diagnosis.
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Affiliation(s)
- Catarina Falcão de Campos
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal,*Correspondence: Catarina Falcão de Campos ✉
| | - Marta Gromicho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Hilmi Uysal
- Department of Neurology and Clinical Neurophysiology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Julian Grosskreutz
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Miguel Oliveira Santos
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal
| | - Susana Pinto
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Michael Swash
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Department of Neurology and Neuroscience, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal
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Mahoney CJ, Sleeman R, Errington W. Assessment of suspected motor neuron disease. BMJ 2022; 379:e073857. [PMID: 36418041 DOI: 10.1136/bmj-2022-073857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Colin J Mahoney
- Forefront Motor Neuron Disease Clinic, Brain and Mind Centre, University of Sydney, Australia
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Borghetti VS, Cintra VP, Ramos JDO, Marques VD, Onofre PT, Santana VAS, Bezerra LFP, Tomaselli PJ, dos Santos ACJ, Sobreira CFDR, Marques W. Misdiagnoses in a Brazilian population with amyotrophic lateral sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:676-680. [PMID: 36254439 PMCID: PMC9685820 DOI: 10.1055/s-0042-1755224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that affects the upper and lower motor neurons. The correct diagnosis at the onset of the disease is sometimes very difficult, due to the symptoms being very similar to those of other neurological syndromes. OBJECTIVE This study aimed to analyze the initial manifestations, the specialty of the first physician visited due the initial complaint, the misdiagnoses, as well as the unnecessary surgical interventions in a new ALS Brazilian population. METHODS The medical records of 173 patients with typical ALS were reviewed. RESULTS The present study demonstrated that other symptoms, besides weakness, were very frequent as initial presentation of ALS, and orthopedics was the medical specialty most sought by patients at the onset of symptoms. Our frequency of misdiagnoses was 69.7%, and in 7.1% of them, an unnecessary surgical intervention was performed. CONCLUSIONS Amyotrophic lateral sclerosis presents a very large pool of signs and symptoms; therefore, there is an urgent need of increasing the disease awareness to other specialties due to the high frequency of misdiagnoses observed in clinical practice.
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Affiliation(s)
| | - Vívian Pedigone Cintra
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
- Centro Universitário Municipal de Franca, Franca SP, Brazil
| | - Jean de Oliveira Ramos
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Vanessa Daccach Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Patrícia Toscano Onofre
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | | | | | - Pedro José Tomaselli
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | | | | | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
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de Carvalho M. Diagnostic track in amyotrophic lateral sclerosis: the Brazilian experience. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:661-662. [PMID: 36254436 PMCID: PMC9685819 DOI: 10.1055/s-0042-1755281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Mamede de Carvalho
- Universidade de Lisboa, Faculdade de Medicina, Centro de Estudos Egas Moniz, Instituto de Fisiologia, Instituto de Medicina Molecular, Lisboa, Portugal
- Centro Hospitalar Universitário de Lisboa Norte, Hospital de Santa Maria, Departamento de Neurociências e Saúde Mental, Lisboa, Portugal
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Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review. Anaesth Intensive Care 2022; 50:345-360. [DOI: 10.1177/0310057x211065042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Amyotrophic lateral sclerosis, or motor neuron disease, is an uncommon progressive neurological disorder. Professionals working in the perioperative field may encounter patients with amyotrophic lateral sclerosis only rarely. The relevant published literature on amyotrophic lateral sclerosis is broad in scope, but a contemporary review focused on the perioperative period is absent. This structured narrative review seeks to provide a summary of the contemporary management of patients and then focuses on eliciting if there are perioperative management considerations specific to amyotrophic lateral sclerosis that can be optimised. A comprehensive structured narrative literature review, including grey literature searching, indicated worsening ventilatory failure is of prime concern but that patients may present with a broad range of neurological symptoms, and that cardiovascular and cognitive dysfunction specific to amyotrophic lateral sclerosis may exist and be occult. Exacerbation of neuromuscular weakness during the perioperative period is multifaceted and requires the application of a high standard of the core principles of surgical and anaesthetic management of neuromuscular disease. Standard perioperative approaches require rigorous attention and potential exists for significant alteration. There is a potential high risk of postoperative increased morbidity from neurological decline and mortality from pulmonary complications. A meticulous approach to planning preoperative assessment, shared decision-making, intraoperative and postoperative care is required.
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Roth AF, Harris MJ. Combined Spinal-Epidural for Loop Ileostomy in a Patient With End-Stage Amyotrophic Lateral Sclerosis: A Case Report. A A Pract 2022; 16:e01588. [DOI: 10.1213/xaa.0000000000001588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hamada Y, Kanbayashi T, Takahashi K, Kamiya H, Kobayashi S, Sonoo M. Weak shoulder and arm sparing signs in amyotrophic lateral sclerosis. Muscle Nerve 2021; 65:311-316. [PMID: 34952966 DOI: 10.1002/mus.27480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION/AIMS A number of signs of selective involvement have been reported in amyotrophic lateral sclerosis (ALS). In this study, we describe two new ones, "weak shoulder" and "arm sparing" signs. METHODS Subjects were retrospectively identified from our electrodiagnosis database. Medical Research Council scores of relevant muscles were evaluated. Weak shoulder was defined as the deltoid (Del) muscle being weaker than the biceps brachii (BB)/ triceps brachii (TB) muscles, i.e. Del was weaker than either or both of the two muscles and no stronger than either. Arm sparing was defined as both Del and the first dorsal interosseous (FDI) being weaker than BB/TB. Sensitivities of these signs were compared with other signs of selective involvement. The specificities of these signs were investigated in patients with cervical spondylotic amyotrophy (CSA) and multifocal motor neuropathy (MMN). RESULTS We reviewed 130 patients with ALS, 64 patients with CSA, and 16 patients with MMN. The weak shoulder and the arm sparing signs were observed in 73% and 55% of patients with ALS, 44% and 2% of patients with CSA (93% and 0% of patients with proximal CSA), respectively, and no patients with MMN. The sensitivity of the weak shoulder was higher than conventional signs, whereas that of the arm sparing sign was no different from them. DISCUSSION The weak shoulder sign was highly sensitive in ALS, and was specific in comparison with MMN. The arm sparing sign was highly specific for ALS. The two new signs are promising as clinical clues to diagnosing ALS.
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Affiliation(s)
- Yuichi Hamada
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Kazusa Takahashi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.,Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hisao Kamiya
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - Shunsuke Kobayashi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
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Aljabri A, Halawani A, Bin Lajdam G, Labban S, Alshehri S, Felemban R. The Safety and Efficacy of Stem Cell Therapy as an Emerging Therapy for ALS: A Systematic Review of Controlled Clinical Trials. Front Neurol 2021; 12:783122. [PMID: 34938264 PMCID: PMC8685950 DOI: 10.3389/fneur.2021.783122] [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: 09/25/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a heterogeneous course that ultimately leads to death. Currently, there is no cure, and new treatments that can slow the progression of the disease are needed. Stem cell (SC) transplantation is an emerging therapy that has shown a lot of potential in recent clinical trials. This review is aimed to examine the results of various clinical trials on this topic, thus assessing the safety and efficacy of SC transplantation as a potential treatment for ALS. We identified 748 studies in our search, of which 134 full-text studies were assessed for eligibility. Six studies met the inclusion criteria and were included in this review. Although some of the included studies showed the positive effect of SC transplantation, other studies found that there was no significant difference compared to the control group. We observed more positive effects with bone marrow mesenchymal stem cells (BM-MSC) treatments than Granulocyte colony-stimulating factor (G-CSF) ones. However, other factors, such as route of administration, number of doses, and number of cells per dose, could also play a role in this discrepancy. Based on this information, we conclude that more properly conducted clinical trials are needed to appreciate the benefit of this treatment.
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Affiliation(s)
- Ammar Aljabri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alhussain Halawani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ghassan Bin Lajdam
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Suhail Labban
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Samah Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Razaz Felemban
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
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Ishikawa Y, Miyakoshi N, Kobayashi T, Kikuchi T. Treatment of progressive paralysis associated with cervical myelopathy and suspected amyotrophic lateral sclerosis: A case report. Surg Neurol Int 2021; 12:550. [PMID: 34877036 PMCID: PMC8645501 DOI: 10.25259/sni_830_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Amyotrophic lateral sclerosis (ALS) is an intractable progressive disease, with an incidence of 2.2– 2.3 per 100,000 individuals, which is not extremely low. ALS symptoms are accompanied by spinal myeloradicular motor deficit; its differential diagnosis is must because progressive paralysis needs emergency surgery. Case Description: A 64-year-old man with suspected ALS showing progressive paralysis with cervical myelopathy was diagnosed as normal after performing a nerve conduction study preoperatively. Postoperative diffuse fasciculation after posterior decompression allowed the diagnosis of ALS through needle electromyography (EMG). Thereafter, the patient’s condition slowly deteriorated and he died after 16 months. Conclusion: Surgery might aggravate ALS symptoms; however, surgery for progressive paralysis in patients with suspected ALS is required for distinguishing patients with non-ALS paralysis. Approximately 70% of cases have spinal-onset ALS lacking typical cranial nerve symptoms; thus, to prevent unnecessary surgery, surgeons should at least know the characteristic features of ALS and should be aware that early diagnosis requires needle EMG for definitive diagnosis of ALS.
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Affiliation(s)
- Yoshinori Ishikawa
- Department of Orthopedic Surgery, Akita Kousei Medical Center, Hondo, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Hondo, Japan
| | - Takashi Kobayashi
- Department of Orthopedic Surgery, Akita Kousei Medical Center, Hondo, Japan
| | - Toshihiko Kikuchi
- Department of Orthopedic Surgery, Yuri Kumiai General Hospital, Yurihonjo, Akita, Japan
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22
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Tsukahara A, Hosokawa T, Nishioka D, Kotani T, Ishida S, Takeuchi T, Kimura F, Arawaka S. Neuron-specific enolase level is a useful biomarker for distinguishing amyotrophic lateral sclerosis from cervical spondylotic myelopathy. Sci Rep 2021; 11:22827. [PMID: 34819571 PMCID: PMC8613178 DOI: 10.1038/s41598-021-02310-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/08/2021] [Indexed: 11/09/2022] Open
Abstract
The current study aimed to evaluate whether cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels are elevated in amyotrophic lateral sclerosis (ALS) and are effective in distinguishing ALS from cervical spondylotic myelopathy (CSM). We retrospectively evaluated 45 patients with ALS, 23 with CSM, 28 controls, and 10 with Parkinson's disease (PD) who underwent analysis of CSF NSE levels. The control group comprised patients aged above 45 years who underwent lumbar puncture because of suspected neurological disorders that were ruled out after extensive investigations. CSF NSE levels were evaluated using the electro-chemiluminescent immunoassay. The ALS group had significantly higher CSF NSE levels than the CSM and control groups (P < 0.001 for both comparisons). The CSM, control, and PD groups did not significantly differ in terms of CSF NSE levels. A receiver-operating characteristic curve analysis was performed to assess the diagnostic value of CSF NSE levels in distinguishing ALS from CSM. The area under the curve for CSF NSE levels was 0.86. The optimal cutoff value was 17.7 ng/mL, with a specificity of 87% and a sensitivity of 80%. Hence, CSF NSE levels are elevated in ALS and are effective in distinguishing ALS from CSM.
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Affiliation(s)
- Akihiro Tsukahara
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Takafumi Hosokawa
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Daisuke Nishioka
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Takuya Kotani
- Division of Rheumatology, Department of Internal Medicine IV, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Shimon Ishida
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Tohru Takeuchi
- Department of Medical Statistics, Research and Development Center, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Fumiharu Kimura
- Department of Internal Medicine, Osaka Medical and Pharmaceutical University Mishima-Minami Hospital, Takatsuki, Osaka, Japan
| | - Shigeki Arawaka
- Division of Neurology, Department of Internal Medicine IV, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Nishi M, Miyamoto R, Shima K, Miki H, Terasawa H, Takasu C, Yoshikawa K, Oyama T, Tanaka K, Izumi Y, Shimada M. Robot-assisted total gastrectomy for gastric cancer in a patient with amyotrophic lateral sclerosis receiving long-term tracheostomy invasive ventilation. Int Cancer Conf J 2021; 10:318-323. [PMID: 34567945 DOI: 10.1007/s13691-021-00499-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 07/04/2021] [Indexed: 11/28/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease. Although affected patients may develop cancers, major surgical intervention has been hampered by its questionable overall benefit due to limited prognosis and risk of postoperative respiratory collapse. A recent study, however, showed that tracheostomy invasive ventilation (TIV) prolonged median survival to 11.3 years; thus, patients with ALS receiving TIV might benefit from major surgery. A 66-year-old man with ALS, who had received TIV and enteral tube feeding for 8 years, presented with bloody stool. The patient also had type 2 diabetes mellitus, stage 4 chronic kidney disease, abdominal aortic aneurysm, and anti-phospholipid syndrome, as well as multiple episodes of pneumonia and catheter-related urinary tract infection treated by antibiotics. Medical examination and esophagogastroduodenoscopy revealed a type 3 tumor in the middle part of the stomach. The patient's preoperative diagnosis was gastric cancer (GC), MU, type3, Less-Post, T3(SS), N1, H0, P0, M0, cStage III. The estimated mortality rate was 30.5%, according to the Japanese National Clinical Database. The patient and his family were fully informed of the risk of surgery; the patient clearly requested curative surgery by eye movement. Thus, robot-assisted total gastrectomy (RATG) was performed. The tissues were extremely fragile and hemorrhagic. The surgical time was 7 h 0 min; intraoperative blood loss was 324 ml. Pathological examination revealed GC, MU, type3, T4a(SE), N2, H0, CY0, P0, M0 fStage IIIB. The postoperative course was uneventful. He has remained in stable condition for 3 months. Our findings suggest that patients with ALS who achieve longer survival with TIV can undergo major cancer surgery, including robot-assisted surgery, which may facilitate a better mid-long-term prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s13691-021-00499-7.
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Affiliation(s)
- Masaaki Nishi
- Department of Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima University, Tokushima, 770-8503 Japan
| | - Ryosuke Miyamoto
- Department of Neurology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503 Japan
| | - Kasane Shima
- Department of Neurology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503 Japan
| | - Hirokazu Miki
- Division of Transfusion Medicine and Cell Therapy, Tokushima University Hospital, Tokushima, 770-8503 Japan
| | - Hideo Terasawa
- Department of Neurology, Hyogo Brain and Heart Center, Himeji, 670-0981 Japan
| | - Chie Takasu
- Department of Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima University, Tokushima, 770-8503 Japan
| | - Kozo Yoshikawa
- Department of Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima University, Tokushima, 770-8503 Japan
| | - Takuro Oyama
- Department of Anesthesiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, 770-8503 Japan
| | - Katsuya Tanaka
- Department of Anesthesiology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, 770-8503 Japan
| | - Yuishin Izumi
- Department of Neurology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503 Japan
| | - Mitsuo Shimada
- Department of Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima University, Tokushima, 770-8503 Japan
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Vázquez-Costa J, Martínez-Molina M, Fernández-Polo M, Fornés-Ferrer V, Frasquet-Carrera M, Sevilla-Mantecón T. Analysis of the diagnostic pathway and delay in patients with amyotrophic lateral sclerosis in the Valencian Community. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:504-513. [DOI: 10.1016/j.nrleng.2018.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/10/2018] [Indexed: 10/24/2022] Open
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Vázquez-Costa J, Martínez-Molina M, Fernández-Polo M, Fornés-Ferrer V, Frasquet-Carrera M, Sevilla-Mantecón T. Análisis del trayecto y retraso diagnóstico de los pacientes con esclerosis lateral amiotrófica en la Comunidad Valenciana. Neurologia 2021. [DOI: 10.1016/j.nrl.2018.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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26
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Sumikawa M, Yano T, Mizutani M, Fujishiro T, Nakaya Y, Hayama S, Nakano A, Fujiwara K, Neo M. Hidden coexisting pathology diagnosed after cervical surgery in patients with degenerative cervical myelopathy or myeloradiculopathy: A case series report. J Clin Neurosci 2021; 93:253-258. [PMID: 34090764 DOI: 10.1016/j.jocn.2021.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 05/10/2021] [Accepted: 05/23/2021] [Indexed: 11/17/2022]
Abstract
Many neurological disorders can present similar symptomatology to degenerative cervical myelopathy (DCM) or myeloradiculopathy (DCMR). Therefore, to avoid misdiagnosis, it is important to recognise the differential diagnosis, which has been well described in previous literature. Additionally, DCM or DCMR can also coexist with other diseases that overlap some of its clinical manifestations, which may be overlooked before cervical surgery. Nevertheless, few studies have addressed this clinical situation. In clinical practice, the diagnosis of coexisting disease with DCM or DCMR would be typically made when some symptoms persist without improvement after cervical surgery. To inform the patients of this possibility preoperatively and arrive at the early diagnosis during the postoperative period, some knowledge of the possible coexisting diseases would be necessary. In this report, we reviewed 230 patients who underwent surgery for DCM or DCMR in an academic centre to examine the prevalence and kind of underlying disease that was overlooked preoperatively. The coexisting diseases relevant to their baseline symptoms were diagnosed only after cervical surgery in three patients (1.3%) and included amyotrophic lateral sclerosis, lung cancer and polymyalgia rheumatica. The overlapping symptoms were gait difficulty, scapular pain and neck pain, respectively. Surgeons should recognise that the coexisting disease with DCM or DCMR may be overlooked before cervical surgery because of overlapping symptomatology, although its prevalence is not certainly high. Further, when the specific symptom persisted without improvement after surgery for DCM or DCMR, the patient should be comprehensively examined, considering diverse pathological conditions, not only neurological disorders.
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Affiliation(s)
- Minako Sumikawa
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Toma Yano
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Masahiro Mizutani
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Takashi Fujishiro
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan.
| | - Yoshiharu Nakaya
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Sachio Hayama
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Atsushi Nakano
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Kenta Fujiwara
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686, Japan
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Looking backward to move forward: a meta-analysis of stem cell therapy in amyotrophic lateral sclerosis. NPJ Regen Med 2021; 6:20. [PMID: 33795700 PMCID: PMC8016966 DOI: 10.1038/s41536-021-00131-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
Transplantation of several types of stem cells (SC) for the treatment of amyotrophic lateral sclerosis (ALS) has been evaluated in numerous Phase I/II clinical trials with inconclusive results. Here, we conducted a meta-analysis to systematically assess the outcome of SC therapy trials which report the evolution of each patient before and after cell administration. In this way, we aimed to determine the effect of the SC intervention despite individual heterogeneity in disease progression. We identified 670 references by electronic search and 90 full-text studies were evaluated according to the eligibility criteria. Eleven studies were included comprising 220 cell-treated patients who received mesenchymal (M) SC (n = 152), neural (N) SC (n = 57), or mononuclear cells (MNC: CD34, CD117, and CD133 positive cells) (n = 11). Our analyses indicate that whereas intrathecal injection of mesenchymal stromal cells appears to have a transient positive effect on clinical progression, as measured by the ALS functional rating score, there was a worsening of respiratory function measured by forced vital capacity after all interventions. Based on current evidence, we conclude that optimal cell product and route of administration need to be determined in properly controlled preclinical models before further advancing into ALS patients. In addition, in-depth understanding of disease mechanisms in subsets of patients will help tailoring SC therapy to specific targets and increase the likelihood of improving outcomes.
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Torrieri MC, Monticelli M, Vasta R, Cofano F, Ajello M, Canosa A, Penner F, Marengo N, Manera U, Calvo A, Chiò A, Garbossa D, Moglia C. Comorbidity of Cervical Spondylogenic Myelopathy and Amyotrophic Lateral Sclerosis: When Electromyography Makes the Difference in Diagnosis. Eur Neurol 2020; 83:626-629. [PMID: 33296894 DOI: 10.1159/000512269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/08/2020] [Indexed: 11/19/2022]
Abstract
Cervical spondylogenic myelopathy (CSM) represents a common differential diagnosis for spinal onset Amyotrophic Lateral Sclerosis (ALS). Identifying occurrence of ALS in patients with CSM may be challenging. We evaluated the accuracy of Awaji criteria in the diagnosis of ALS in a cohort of patients with CSM. We screened all patients attending Turin ALS Center during the 2006-2018 period. We selected only patients for whom cervical cord MRI showed radiological signs of CSM. All patients underwent electromyography (EMG), and Awaji criteria were used for diagnosis of clinically probable ALS. All patients were followed up clinically for at least 6 months, and ALS diagnosis was eventually confirmed according to El-Escorial revised criteria, based on disease progression. Of 2,059 patients screened, in 42 cases, MRI showed signs of CSM; CSM incidence and prevalence risks were 0.16 and 2.04%, respectively. Based on clinical progression, 72.7% of patients were diagnosed as CSM and 27.3% as CSM + ALS. At EMG 6 (18.2%) patients fulfilled the criteria for ALS, 5 of them (83.3%) during clinical follow-up were diagnosed as clinical definite ALS + CSM. Accuracy of Awaji criteria in diagnosing ALS was good (AUC = 0.757, p = 0.03). Sensitivity and specificity of Awaji criteria were, respectively, 55.6 and 95.8%. Positive predictive value was 83.3%, while negative predictive value was 85.2%. CSM-ALS comorbidity is a relatively common problem in clinical practice. To better choose patients who could benefit from surgery, EMG should be performed in CSM patients, due to its good accuracy in recognizing ALS.
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Affiliation(s)
- Maria Claudia Torrieri
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Matteo Monticelli
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Rosario Vasta
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Fabio Cofano
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Marco Ajello
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Antonio Canosa
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Federica Penner
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Nicola Marengo
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Umberto Manera
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Andrea Calvo
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Adriano Chiò
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Diego Garbossa
- Neurosurgery Unit, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Cristina Moglia
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy,
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Woo AL, Tchoe HJ, Shin HW, Shin CM, Lim CM. Assisted Breathing with a Diaphragm Pacing System: A Systematic Review. Yonsei Med J 2020; 61:1024-1033. [PMID: 33251776 PMCID: PMC7700882 DOI: 10.3349/ymj.2020.61.12.1024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Patients with respiratory failure associated with neurological dysfunction often require mechanical ventilator support, which poses increased economic burden and ventilator-associated complications. A diaphragm pacing system (DPS) is an implanted device that provides respiratory support for such patients. In this systematic review, we reviewed the literature to assess the safety and efficacy of DPS for patients with respiratory failure resulting from amyotrophic lateral sclerosis (ALS) or cervical spinal cord injuries. MATERIALS AND METHODS The following databases were searched from July 10 to July 30, 2018: MEDLINE, EMBASE, Cochran library, KoreaMed, Research Information Sharing Service, Korean studies Information Service System, Korea Institute of Science and Technology Information, and Korean Medical database. The abstracts and full texts of the searched articles were reviewed by two reviewers. RESULTS The search keywords generated 197 articles: two randomized controlled trials, two case-control studies, and one case report involving patients with ALS; one cohort study, one case-control study, and two case reports involving patients with cervical spine injury; and one case report involving patients with both conditions were included. The primary outcome was safety profile (complications and adverse event) and efficacy (overall survival and sleep improvement). Complications and adverse events were more common in patients with ALS and spinal cord injury receiving DPS than in controls. Efficacy outcomes were inconsistent across ALS studies. CONCLUSION Based on safety and efficacy results, we do not support using DPS to manage respiratory failure in patients with ALS or cervical spine injury.
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Affiliation(s)
- A La Woo
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ha Jin Tchoe
- Division for New Technology Assessment, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Hae Won Shin
- Division for New Technology Assessment, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Chae Min Shin
- Division for New Technology Assessment, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Chae Man Lim
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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Panchamia JK, Gurrieri C, Amundson AW. Spinal Anesthesia for Amyotrophic Lateral Sclerosis Patient Undergoing Lower Extremity Orthopedic Surgery: An Overview of the Anesthetic Considerations. Int Med Case Rep J 2020; 13:249-254. [PMID: 32765120 PMCID: PMC7369305 DOI: 10.2147/imcrj.s256716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/13/2020] [Indexed: 01/10/2023] Open
Abstract
Background Amyotrophic lateral sclerosis is a progressive neurodegenerative disease primarily affecting the upper and lower motor neurons. Patients present with a variety of clinical manifestations inevitably resulting in death secondary to respiratory insufficiency from muscle weakness and consequential pulmonary complications. Despite the lack of universal consensus on the ideal anesthetic approach to amyotrophic lateral sclerosis patients undergoing lower extremity total joint surgery, there are few noteworthy anesthetic considerations in this cohort. Case Report A 75-year-old male with multiple medical comorbidities, including a recent diagnosis of amyotrophic lateral sclerosis, presented to a large academic medical center for a right total hip arthroplasty revision. The patient’s preoperative neurologic examination demonstrated brisk deep tendon reflexes, visible fasciculations of lower extremities, and motor weakness of upper and lower extremities. Serology demonstrated an elevated creatine kinase, and an electromyography study showed active denervation in the cervical, thoracic, and lumbosacral regions. After a careful risk-benefit analysis was performed, involving a multidisciplinary team approach, the patient successfully underwent the surgical procedure with a spinal anesthetic and minimal sedation. Perioperative course was unremarkable, and there were no neurologic complications in the first 6 months after surgery. Conclusion Patients with amyotrophic lateral sclerosis present unique challenges for anesthesia providers. General anesthesia may potentially worsen respiratory function; therefore, alternative methods to avoiding airway manipulation should be considered. Conversely, regional techniques may carry the risk of exacerbating pre-existing neurologic symptoms. Currently, no definite guidelines exist on the perioperative anesthetic management of amyotrophic lateral sclerosis patients; ultimately, the decision to perform regional anesthesia should be based on analyzing a patient’s risk against the potential benefits.
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Affiliation(s)
- Jason K Panchamia
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carmelina Gurrieri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam W Amundson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Palese F, Sartori A, Logroscino G, Pisa FE. Predictors of diagnostic delay in amyotrophic lateral sclerosis: a cohort study based on administrative and electronic medical records data. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:176-185. [PMID: 30656971 DOI: 10.1080/21678421.2018.1550517] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives: To characterize the timing and pathway of amyotrophic lateral sclerosis (ALS) diagnosis and to identify predictors of delayed diagnosis in a retrospective cohort. Methods: The cohort included all patients with incident ALS between 2010 and 2014 in Friuli-Venezia Giulia (FVG) region, Italy, admitted to two University Hospitals. Information on demographics, clinical presentation, and healthcare use was obtained from health databases and electronic medical records (EMRs). Total diagnostic time (TDT), the interval between ALS symptoms onset and diagnosis, was compared between patient groups through Wilcoxon-Mann-Whitney test. The adjusted odds ratio (aOR), with 95% confidence interval (95% CI), of having a TDT ≥12 months was estimated using unconditional logistic regression. Results: Among 134 patients, median TDT (interquartile range [IQR]) was 11.5 months (7.1-18.3), shorter in those aged <60 years vs. ≥60 years (8.1; 5.1-11.1 vs. 12.4; 7.4-21.5; p = 0.0064), first referred to a neurologist vs. other specialist (10.2; 6.1-16.3 vs. 13.2; 8.1-24.5; p = 0.0386) and without neurologic comorbidities (11.1; 7.1-16.5 vs. 19.7; 8.8-33.7; p = 0.0243). TDT was ≥12 months in 64 (48.5%) patients and was predicted by male sex (aOR: 2.47; 95% CI: 1.06-5.75), age at onset ≥60 years (11.46; 3.13-41.9), spinal onset (2.04; 1.00-5.93), and prior therapies or first referral to a non-neurologist (3.15; 1.36-7.29). Conclusions: In this cohort, delayed diagnosis was common, particularly in older patients and in those with neurological comorbidities. Timely referral to a neurologist may improve diagnostic timing.
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Affiliation(s)
| | - Arianna Sartori
- b Department of Medical, Surgical and Health Sciences, Neurology Clinic , Azienda Sanitaria Universitaria Integrata di Trieste , Trieste , Italy
| | - Giancarlo Logroscino
- c Neurodegenerative Diseases Unit, Department of Basic Medicine Sciences, Neuroscience, and Sense Organs, University of Bari , Bari , Italy.,d Neurodegenerative Diseases Unit, Department of Clinical Research in Neurology, University of Bari "Aldo Moro" at "Pia Fondazione Card. G. Panico", Tricase, Lecce , Italy
| | - Federica Edith Pisa
- e Leibniz Institute for Prevention Research and Epidemiology-BIPS , Bremen , Germany
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Swash M. Physical activity as a risk factor in ALS. J Neurol Neurosurg Psychiatry 2018; 89:793. [PMID: 29685900 DOI: 10.1136/jnnp-2018-318147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/28/2018] [Indexed: 11/04/2022]
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Ratner MH, Jabre JF, Ewing WM, Abou-Donia M, Oliver LC. Amyotrophic lateral sclerosis-A case report and mechanistic review of the association with toluene and other volatile organic compounds. Am J Ind Med 2018; 61:251-260. [PMID: 29125194 DOI: 10.1002/ajim.22791] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2017] [Indexed: 12/11/2022]
Abstract
Unmasking of latent neurodegenerative disease has been reported following exposure to chemicals that share one or more mechanisms of action in common with those implicated in the specific disease. For example, unmasking of latent Parkinson's disease (PD) has been associated with exposure to anti-dopaminergic agents, while the progression of pre-existing mild cognitive impairment and unmasking of latent Alzheimer's disease has been associated with exposure to general anesthetic agents which promote Aβ protein aggregation. This literature review and clinical case report about a 45-year-old man with no family history of motor neuron disease who developed overt symptoms of a neuromuscular disorder in close temporal association with his unwitting occupational exposure to volatile organic compounds (VOCs) puts forth the hypothesis that exposure to VOCs such as toluene, which disrupt motor function and increase oxidative stress, can unmask latent ALS type neuromuscular disorder in susceptible individuals.
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Affiliation(s)
- Marcia H Ratner
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, Boston, Massachusetts
| | - Joe F Jabre
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Mohamed Abou-Donia
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina
| | - L Christine Oliver
- Department of Medicine (Pulmonary and Critical Care Division), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Watanabe Y, Watanabe T. Meta-analytic evaluation of the association between head injury and risk of amyotrophic lateral sclerosis. Eur J Epidemiol 2017; 32:867-879. [DOI: 10.1007/s10654-017-0327-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/20/2017] [Indexed: 11/30/2022]
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de Carvalho M, Gooch CL. The yin and yang of gastrostomy in the management of ALS: Friend or foe? Neurology 2017; 89:1435-1436. [PMID: 28864678 DOI: 10.1212/wnl.0000000000004547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Mamede de Carvalho
- From the Physiology Institute (M.d.C.), Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon; Department of Neurosciences and Mental Health (M.d.C.), Hospital de Santa Maria-CHLN, Lisbon, Portugal; and Department of Neurology (C.L.G.), University of South Florida Morsani College of Medicine, Tampa.
| | - Clifton L Gooch
- From the Physiology Institute (M.d.C.), Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon; Department of Neurosciences and Mental Health (M.d.C.), Hospital de Santa Maria-CHLN, Lisbon, Portugal; and Department of Neurology (C.L.G.), University of South Florida Morsani College of Medicine, Tampa
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Tai H, Cui L, Shen D, Li D, Cui B, Fang J. Military service and the risk of amyotrophic lateral sclerosis: A meta-analysis. J Clin Neurosci 2017; 45:337-342. [PMID: 28864407 DOI: 10.1016/j.jocn.2017.08.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 06/18/2017] [Accepted: 08/10/2017] [Indexed: 12/12/2022]
Abstract
To explore the relationship between the risk of amyotrophic lateral sclerosis and exposure to overall military service, we conducted a search of articles relevant to military service and the risk of ALS that used human subjects and were published in English through 20 May 2016, using Ovid Medline and Embase databases. Studies specially investigating the risk of ALS for Gulf war veterans were excluded. Quality of the cohort and case-control studies was assessed according to the Newcastle-Ottawa Scale (NOS). Analysis of data and publication bias were performed with Review Manager 5.3. A total of 8 case-control studies and 3 cohort studies were included in the meta-analysis. Only two case-control studies were conducted in Japan, comparing to 9 studies conducted in Europe/USA. The NOS scores of all studies were ≥6/9. The risk of ALS was significantly increased in military personnel compared to non-military personnel (pooled OR=1.29, 95% CI: 1.08-1.54, by random-effects model), with a moderate heterogeneity (P=0.01, I2=55%) due to some studies with lower quality, conformed by subgroup and sensitivity analysis. The present meta-analysis supports a positive association between overall military service and the risk of ALS. Additional studies are needed to find out related factors influencing the ALS risk of veterans, especially by gender and for specific geographic regions such as Asia. That would also do some favor to explore the etiology and mechanism of ALS.
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Affiliation(s)
- Hongfei Tai
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; Neurosciences Center, Chinese Academy of Medical Sciences, Beijing, China.
| | - Dongchao Shen
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dawei Li
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bo Cui
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Fang
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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De Carvalho M, Ryczkowski A, Andersen P, Gromicho M, Grosskreutz J, Kuźma-Kozakiewicz M, Petri S, Piotrkiewicz M, Miltenberger Miltenyi G. International Survey of ALS Experts about Critical Questions for Assessing Patients with ALS. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:505-510. [PMID: 28705085 DOI: 10.1080/21678421.2017.1349150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To define an applicable dataset for ALS patient registries we weighted specific clinical items as scored by worldwide ALS experts. METHODS Sixty participants were invited based on relevant clinical work, publications and personal acquaintance. They rated 160 clinical items consensually agreed by the members of our project, incorporating specialists from five European Centres. Scoring scheme was defined as: 1 - essential; 2 - important; 3 - not very important. A mixed effect model was applied to rank items and to find possible correlations with geographical region (Europe vs. outside Europe). RESULTS We received 40 responses, 20 from Europe and 20 from outside; 42/160 data were scored as essential by >50% of the respondents, including: date of birth, gender, date of disease onset, date of diagnosis, ethnicity, region of onset, predominant upper neuron (UMN) or lower motor neuron (LMN) impairment, proximal versus distal weakness, respiratory symptoms, dysarthria, weight loss, signs of LMN/UMN involvement, emotional incontinence, cognitive changes, respiratory signs, neck weakness, body mass index, ALSFRS-R at entry, ALSFRS-R subscores at entry, timing and pattern of spreading and staging, electromyography, spirometry, MRI, CK level, riluzole intake, genetic background, history of physical exercise and previous and current main occupation. Four components were scored as non-relevant, including place of birth, blood pressure and pain at onset. There was no significant difference between regions (European vs. non-European countries). CONCLUSIONS Our study identified a consensual set of clinical data with 42 specific items that can be used as a minimal data set for patient registers and for clinical trials.
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Affiliation(s)
- Mamede De Carvalho
- a Institute of Physiology, Instituto de Medicina Molecular, Faculty of Medicine , University of Lisbon , Lisbon , Portugal.,b Department of Neurosciences and Mental Health , Hospital de Santa Maria-CHLN , Lisbon , Portugal
| | - Adam Ryczkowski
- c Department of Neuromuscular System Engineering , Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences , Warsaw , Poland
| | - Peter Andersen
- d Institute of Pharmacology and Clinical Neuroscience , Umeå University , Umeå , Sweden
| | - Marta Gromicho
- a Institute of Physiology, Instituto de Medicina Molecular, Faculty of Medicine , University of Lisbon , Lisbon , Portugal
| | - Julian Grosskreutz
- e Hans Berger Department of Neurology , Jena University Hospital , Jena , Germany
| | - Magdalena Kuźma-Kozakiewicz
- f Department of Neurology , Medical University of Warsaw , Warsaw , Poland.,g Neurodegenerative Disease Research Group , Medical University of Warsaw , Warsaw , Poland , and
| | - Susanne Petri
- h Department of Neurology , Hannover Medical School , Hannover , Germany
| | - Maria Piotrkiewicz
- c Department of Neuromuscular System Engineering , Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences , Warsaw , Poland
| | - Gabriel Miltenberger Miltenyi
- a Institute of Physiology, Instituto de Medicina Molecular, Faculty of Medicine , University of Lisbon , Lisbon , Portugal
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Ansari S, Bromberg MB, Gibson SB. Physician perceptions about living organ donation in patients with Amyotrophic Lateral Sclerosis. Clin Neurol Neurosurg 2017; 160:125-129. [PMID: 28727995 DOI: 10.1016/j.clineuro.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/27/2017] [Accepted: 07/04/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients with Amyotrophic Lateral Sclerosis (ALS) have expressed desire to become living organ donors but are unable to do so with current organ donation policies. Our objective is to assess ALS patient's interest in organ donation, and perceived concerns of this practice by ALS neurologists. PATIENTS AND METHODS An electronic survey was administered to ALS neurologists across the United States regarding living organ donation in ALS patients prior to respiratory failure. RESULTS 52 complete responses were received from 121 invites. 67% (35/52) of neurologists expressed no concerns about living organ donation in ALS patients, and 33% had concerns. The concerns related to respiratory failure, anesthesia exposure and renal dysfunction. With their concerns addressed, 71% of neurologists reported that they would endorse living organ donation. 49% of neurologists reported being asked by a patient for information regarding living organ donation. ALS neurologists felt that 22.8% of ALS patients (median 19%) would be interested in learning more about organ donation, while only 6% of neurologists broach this subject with their patients. CONCLUSION Our results indicate that 1 in every 4 ALS patients may be interested in exploring options for living organ donation, and this topic is not routinely addressed by ALS clinics. These results indicate an unexplored area of patient interest. To honor a patient's wishes to donate, the transplant community will have to accommodate living organ donation from terminally ill patients, and address neurologist concerns. Such a practice could benefit two groups of patients.
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Affiliation(s)
- S Ansari
- University of Utah, School of Medicine, Department of Neurology, Salt Lake City, UT, United States.
| | - M B Bromberg
- University of Utah, School of Medicine, Department of Neurology, Salt Lake City, UT, United States.
| | - S B Gibson
- University of Utah, School of Medicine, Department of Neurology, Salt Lake City, UT, United States.
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Amyotrophic lateral sclerosis with a sudden-onset history. Clin Neurophysiol Pract 2017; 2:103-104. [PMID: 30214980 PMCID: PMC6123847 DOI: 10.1016/j.cnp.2017.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 04/18/2017] [Accepted: 04/23/2017] [Indexed: 11/21/2022] Open
Abstract
We reported on two patients with ALS with a sudden-onset history. Marked weakness of the extensor digitorum with relatively mild weakness of the other muscles was characteristic. The risk of initial misdiagnosis is high for such patients. Objective We report on two patients with amyotrophic lateral sclerosis (ALS) complaining of sudden-onset difficulty in finger elevation. Case report A 65-year-old man (the first patient) and a 66-year-old man (the second patient) suddenly became aware of difficulty in finger elevation of one hand. They were not aware of any other symptoms prior to the onset. In the first patient, cerebral infarction at the precentral gyrus was initially suspected. In the second patient, cervical spondylosis was initially suspected, and cervical spine surgery was planned. However, needle EMG revealed widespread neurogenic changes and abundant fasciculation potentials for both patients. Widespread weakness emerged in time and relentlessly progressed, and finally the diagnosis of ALS was made. In both cases, notable weakness in the extensor digitorum (ED) muscle with relatively mild weakness in the other muscles in the affected limb was a characteristic finding. Loss of one motor unit in ED that has already enlarged due to reinnervation must have caused sudden awareness of the weakness. Significance Clinicians should recognize the presence of ALS patients with a sudden-onset history because the risk of initial misdiagnosis is high for such patients.
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Gonzalez-Bermejo J, Morélot-Panzini C, Tanguy ML, Meininger V, Pradat PF, Lenglet T, Bruneteau G, Forestier NL, Couratier P, Guy N, Desnuelle C, Prigent H, Perrin C, Attali V, Fargeot C, Nierat MC, Royer C, Ménégaux F, Salachas F, Similowski T. Early diaphragm pacing in patients with amyotrophic lateral sclerosis (RespiStimALS): a randomised controlled triple-blind trial. Lancet Neurol 2016; 15:1217-1227. [PMID: 27751553 DOI: 10.1016/s1474-4422(16)30233-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder associated with respiratory muscle weakness and respiratory failure. Non-invasive ventilation alleviates respiratory symptoms and prolongs life, but is a palliative intervention. Slowing the deterioration of diaphragm function before respiratory failure would be desirable. We aimed to assess whether early diaphragm pacing could slow down diaphragm deterioration and would therefore delay the need for non-invasive ventilation. METHODS We did a multicentre, randomised, controlled, triple-blind trial in patients with probable or definite ALS in 12 ALS centres in France. The main inclusion criterion was moderate respiratory involvement (forced vital capacity 60-80% predicted). Other key eligibility criteria were age older than 18 years and bilateral responses of the diaphragm to diagnostic phrenic stimulation. All patients were operated laparoscopically and received phrenic stimulators. Clinicians randomly assigned patients (1:1) to receive either active or sham stimulation with a central web-based randomisation system (computer-generated list). Investigators, patients, and an external outcome allocation committee were masked to treatment. The primary outcome was non-invasive ventilation-free survival, analysed in the intention-to-treat population. Safety outcomes were also assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01583088. FINDINGS Between Sept 27, 2012, and July 8, 2015, 74 participants were randomly assigned to receive either active (n=37) or sham (n=37) stimulation. On July 16, 2015, an unplanned masked analysis was done after another trial showed excess mortality with diaphragm pacing in patients with hypoventilation (DiPALS, ISRCTN 53817913). In view of this finding, we analysed mortality in our study and found excess mortality (death from any cause) in our active stimulation group. We therefore terminated the study on July, 16, 2015. Median non-invasive ventilation-free survival was 6·0 months (95% CI 3·6-8·7) in the active stimulation group versus 8·8 months (4·2-not reached) in the control (sham stimulation) group (hazard ratio 1·96 [95% CI 1·08-3·56], p=0·02). Serious adverse events (mainly capnothorax or pneumothorax, acute respiratory failure, venous thromboembolism, and gastrostomy) were frequent (24 [65%] patients in the active stimulation group vs 22 [59%] patients in the control group). No treatment-related death was reported. INTERPRETATION Early diaphragm pacing in patients with ALS and incipient respiratory involvement did not delay non-invasive ventilation and was associated with decreased survival. Diaphragm pacing is not indicated at the early stage of the ALS-related respiratory involvement. FUNDING Hospital Program for Clinical Research, French Ministry of Health; French Patients' Association for ALS Research (Association pour la Recherche sur la Sclérose Latérale Amyotrophique); and Thierry de Latran Foundation.
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Affiliation(s)
- Jésus Gonzalez-Bermejo
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.
| | - Capucine Morélot-Panzini
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Marie-Laure Tanguy
- AP-HP, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Unité de Recherche Clinique, Paris, France
| | - Vincent Meininger
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Pierre-François Pradat
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - Timothée Lenglet
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Gaëlle Bruneteau
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Institut du Cerveau et de la Moëlle Epinière, ICM, Paris, France
| | - Nadine Le Forestier
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | | | - Nathalie Guy
- CHU Gabriel Montpied, Service de Neurologie, Clermont-Ferrand, France; Faculté de Chirurgie Dentaire, Neuro-Dol, INSERM U1107, Douleur Trigéminale et Migraine, Clermont-Ferrand, France
| | | | - Hélène Prigent
- AP-HP, GHU Paris Ouest-site Raymond Poincaré-Service de Physiologie et d'Explorations Fonctionnelles, Garches, France
| | | | - Valérie Attali
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Service des Pathologies du Sommeil (Département "R3S"), Paris, France
| | - Catherine Fargeot
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service Pharmacie UFDMS, Paris, France
| | - Marie-Cécile Nierat
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Catherine Royer
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie et Réanimation, Paris, France
| | - Fabrice Ménégaux
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Chirurgie Viscérale, Paris, France
| | - François Salachas
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
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McDermott CJ, Bradburn MJ, Maguire C, Cooper CL, Baird WO, Baxter SK, Cohen J, Cantrill H, Dixon S, Ackroyd R, Baudouin S, Bentley A, Berrisford R, Bianchi S, Bourke SC, Darlison R, Ealing J, Elliott M, Fitzgerald P, Galloway S, Hamdalla H, Hanemann CO, Hughes P, Imam I, Karat D, Leek R, Maynard N, Orrell RW, Sarela A, Stradling J, Talbot K, Taylor L, Turner M, Simonds AK, Williams T, Wedzicha W, Young C, Shaw PJ. DiPALS: Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis - a randomised controlled trial. Health Technol Assess 2016; 20:1-186. [PMID: 27353839 DOI: 10.3310/hta20450] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease resulting in death, usually from respiratory failure, within 2-3 years of symptom onset. Non-invasive ventilation (NIV) is a treatment that when given to patients in respiratory failure leads to improved survival and quality of life. Diaphragm pacing (DP), using the NeuRx/4(®) diaphragm pacing system (DPS)™ (Synapse Biomedical, Oberlin, OH, USA), is a new technique that may offer additional or alternative benefits to patients with ALS who are in respiratory failure. OBJECTIVE The Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis (DiPALS) trial evaluated the effect of DP on survival over the study duration in patients with ALS with respiratory failure. DESIGN The DiPALS trial was a multicentre, parallel-group, open-label, randomised controlled trial incorporating health economic analyses and a qualitative longitudinal substudy. PARTICIPANTS Eligible participants had a diagnosis of ALS (ALS laboratory-supported probable, clinically probable or clinically definite according to the World Federation of Neurology revised El Escorial criteria), had been stabilised on riluzole for 30 days, were aged ≥ 18 years and were in respiratory failure. We planned to recruit 108 patients from seven UK-based specialist ALS or respiratory centres. Allocation was performed using 1 : 1 non-deterministic minimisation. INTERVENTIONS Participants were randomised to either standard care (NIV alone) or standard care (NIV) plus DP using the NeuRX/4 DPS. MAIN OUTCOME MEASURES The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Secondary outcomes were patient quality of life [assessed by European Quality of Life-5 Dimensions, three levels (EQ-5D-3L), Short Form questionnaire-36 items and Sleep Apnoea Quality of Life Index questionnaire]; carer quality of life (EQ-5D-3L and Caregiver Burden Inventory); cost-utility analysis and health-care resource use; tolerability and adverse events. Acceptability and attitudes to DP were assessed in a qualitative substudy. RESULTS In total, 74 participants were randomised into the trial and analysed, 37 participants to NIV plus pacing and 37 to standard care, before the Data Monitoring and Ethics Committee advised initial suspension of recruitment (December 2013) and subsequent discontinuation of pacing (on safety grounds) in all patients (June 2014). Follow-up assessments continued until the planned end of the study in December 2014. The median survival (interquartile range) was 22.5 months (lower quartile 11.8 months; upper quartile not reached) in the NIV arm and 11.0 months (6.7 to 17.0 months) in the NIV plus pacing arm, with an adjusted hazard ratio of 2.27 (95% confidence interval 1.22 to 4.25; p = 0.01). CONCLUSIONS Diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure. FUTURE WORK It may be that certain population subgroups benefit from DP. We are unable to explain the mechanism behind the excess mortality in the pacing arm, something the small trial size cannot help address. Future research should investigate the mechanism by which harm or benefit occurs further. TRIAL REGISTRATION Current Controlled Trials ISRCTN53817913. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 45. See the HTA programme website for further project information. Additional funding was provided by the Motor Neurone Disease Association of England, Wales and Northern Ireland.
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Affiliation(s)
| | - Mike J Bradburn
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy L Cooper
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Wendy O Baird
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Dixon
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Roger Ackroyd
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Simon Baudouin
- Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and the University of Newcastle, Newcastle upon Tyne, UK
| | - Andrew Bentley
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | - Stephen Bianchi
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Stephen C Bourke
- North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust and Newcastle University, North Shields, UK
| | - Roy Darlison
- Independent patient and public involvement representative, UK
| | - John Ealing
- Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Mark Elliott
- Leeds Teaching Hospitals NHS Trust, St James' University Hospital, Leeds, UK
| | - Patrick Fitzgerald
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Galloway
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | | | - Philip Hughes
- Plymouth Hospitals NHS Trust Peninsula Medical and Dental Schools, Plymouth, UK
| | - Ibrahim Imam
- South Devon Healthcare NHS Foundation Trust, Devon, UK
| | - Dayalan Karat
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roger Leek
- Motor Neurone Disease Association, Birmingham, UK
| | - Nick Maynard
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard W Orrell
- The National Heart and Lung Institute, Imperial College London, London, UK
| | - Abeezar Sarela
- Leeds Teaching Hospitals NHS Trust, St James' University Hospital, Leeds, UK
| | | | - Kevin Talbot
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Lyn Taylor
- PAREXEL International Corporation, Sheffield, UK
| | | | - Anita K Simonds
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Tim Williams
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Wisia Wedzicha
- The National Heart and Lung Institute, Imperial College London, London, UK
| | - Carolyn Young
- Walton Centre for Neurology & Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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Mantero V, Rigamonti A, Basso F, Stanzani L, Scaioli V, Salmaggi A. When it rains it pours: amyotrophic lateral sclerosis concealed with Isaac’s syndrome. Neurol Sci 2016; 37:1181-3. [DOI: 10.1007/s10072-016-2528-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/18/2016] [Indexed: 12/13/2022]
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Karam CY, Paganoni S, Joyce N, Carter GT, Bedlack R. Palliative Care Issues in Amyotrophic Lateral Sclerosis: An Evidenced-Based Review. Am J Hosp Palliat Care 2016; 33:84-92. [PMID: 25202033 PMCID: PMC4439378 DOI: 10.1177/1049909114548719] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
As palliative care physicians become increasingly involved in the care of patients with amyotrophic lateral sclerosis (ALS), they will be asked to provide guidance regarding the use of supplements, diet, exercise, and other common preventive medicine interventions. Moreover, palliative care physicians have a crucial role assisting patients with ALS in addressing health care decisions to maximize quality of life and cope with a rapidly disabling disease. It is therefore important for palliative care physicians to be familiar with commonly encountered palliative care issues in ALS. This article provides an evidenced-based review of palliative care options not usually addressed in national and international ALS guidelines.
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Affiliation(s)
- Chafic Y Karam
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Sabrina Paganoni
- Harvard Medical School, Massachusetts General Hospital, Spaulding Rehabilitation Hospital, and Boston VA Healthcare System
| | - Nanette Joyce
- Department of Physical Medicine and Rehabilitation, Neuromuscular Section, University of California, Davis Medical School, Sacramento, CA, USA
| | - Gregory T Carter
- Department of Physical Medicine and Rehabilitation St Luke's Rehabilitation Institute, Spokane, WA, USA
| | - Richard Bedlack
- Duke University School of Medicine, and Durham Veterans Affairs Medical Center, Durham, NC, USA
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Safety and efficacy of diaphragm pacing in patients with respiratory insufficiency due to amyotrophic lateral sclerosis (DiPALS): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2015; 14:883-892. [PMID: 26234554 DOI: 10.1016/s1474-4422(15)00152-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/23/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Non-invasive ventilation is part of the standard of care for treatment of respiratory failure in patients with amyotrophic lateral sclerosis (ALS). The NeuRx RA/4 Diaphragm Pacing System has received Humanitarian Device Exemption approval from the US Food and Drug Administration for treatment of respiratory failure in patients with ALS. We aimed to establish the safety and efficacy of diaphragm pacing with this system in patients with respiratory muscle weakness due to ALS. METHODS We undertook a multicentre, open-label, randomised controlled trial at seven specialist ALS and respiratory centres in the UK. Eligible participants were aged 18 years or older with laboratory supported probable, clinically probable, or clinically definite ALS; stable riluzole treatment for at least 30 days; and respiratory insufficiency. We randomly assigned participants (1:1), via a centralised web-based randomisation system with minimisation that balanced patients for age, sex, forced vital capacity, and bulbar function, to receive either non-invasive ventilation plus pacing with the NeuRx RA/4 Diaphragm Pacing System or non-invasive ventilation alone. Patients, carers, and outcome assessors were not masked to treatment allocation. The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Analysis was by intention to treat. This trial is registered, ISRCTN number 53817913. FINDINGS Between Dec 5, 2011, and Dec 18, 2013, we randomly assigned 74 participants to receive either non-invasive ventilation alone (n=37) or non-invasive ventilation plus diaphragm pacing (n=37). On Dec 18, 2013, the Data Monitoring and Ethics Committee (DMEC) recommended suspension of recruitment on the basis of overall survival figures. Randomly assigned participants continued as per the study protocol until June 23, 2014, when the DMEC advised discontinuation of pacing in all patients. Follow-up assessments continued until the planned end of the study in December, 2014. Survival was shorter in the non-invasive ventilation plus pacing group than in the non-invasive ventilation alone group (median 11·0 months [95% CI 8·3-13·6] vs 22·5 months [13·6-not reached]; adjusted hazard ratio 2·27, 95% CI 1·22-4·25; p=0·009). 28 (76%) patients died in the pacing group and 19 (51%) patients died in the non-invasive ventilation alone group. We recorded 162 adverse events (5·9 events per person-year) in the pacing group, of which 46 events were serious, compared with 81 events (2·5 events per person-year) in the non-invasive ventilation alone group, of which 31 events were serious. INTERPRETATION Addition of diaphragm pacing to standard care with non-invasive ventilation was associated with decreased survival in patients with ALS. Our results suggest that diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure. FUNDING The National Institute for Health Research Health Technology Assessment Programme; the Motor Neurone Disease Association of England, Wales, and Northern Ireland.
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Oh KW, Moon C, Kim HY, Oh SI, Park J, Lee JH, Chang IY, Kim KS, Kim SH. Phase I trial of repeated intrathecal autologous bone marrow-derived mesenchymal stromal cells in amyotrophic lateral sclerosis. Stem Cells Transl Med 2015; 4:590-7. [PMID: 25934946 DOI: 10.5966/sctm.2014-0212] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/16/2015] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED Stem cell therapy is an emerging alternative therapeutic or disease-modifying strategy for amyotrophic lateral sclerosis (ALS). The aim of this open-label phase I clinical trial was to evaluate the safety of two repeated intrathecal injections of autologous bone marrow (BM)-derived mesenchymal stromal cells (MSCs) in ALS patients. Eight patients with definite or probable ALS were enrolled. After a 3-month lead-in period, autologous MSCs were isolated two times from the BM at an interval of 26 days and were then expanded in vitro for 28 days and suspended in autologous cerebrospinal fluid. Of the 8 patients, 7 received 2 intrathecal injections of autologous MSCs (1 × 10(6) cells per kg) 26 days apart. Clinical or laboratory measurements were recorded to evaluate the safety 12 months after the first MSC injection. The ALS Functional Rating Scale-Revised (ALSFRS-R), the Appel ALS score, and forced vital capacity were used to evaluate the patients' disease status. One patient died before treatment and was withdrawn from the study. With the exception of that patient, no serious adverse events were observed during the 12-month follow-up period. Most of the adverse events were self-limited or subsided after supportive treatment within 4 days. Decline in the ALSFRS-R score was not accelerated during the 6-month follow-up period. Two repeated intrathecal injections of autologous MSCs were safe and feasible throughout the duration of the 12-month follow-up period. SIGNIFICANCE Stem cell therapy is an emerging alternative therapeutic or disease-modifying strategy for amyotrophic lateral sclerosis (ALS). To the authors' best knowledge, there are no clinical trials to evaluate the safety of repeated intrathecal injections of autologous bone marrow mesenchymal stromal cells in ALS. After the clinical trial (phase I/II) was conducted, the stem cell (HYNR-CS, NEURONATA-R) was included in the revision of the regulations on orphan drug designation (number 160; December 31, 2013) and approved as a New Drug Application (Department of Cell and Gene Therapy 233; July 30, 2014) by the Korean Food and Drug Administration. The phase II trial is expected to be reported later.
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Affiliation(s)
- Ki-Wook Oh
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Chanil Moon
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Hyun Young Kim
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Sung-Il Oh
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Jinseok Park
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Jun Ho Lee
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - In Young Chang
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Kyung Suk Kim
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
| | - Seung Hyun Kim
- Department of Neurology, College of Medicine and Cell Therapy Center for Neurologic Disorders, Hanyang University Hospital, Seoul, Republic of Korea; Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea; Bioengineering Institute, Corestem Inc., Seoul, Republic of Korea
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Pinto S, de Carvalho M. Young slow-progressing ALS patients are at higher risk of inappropriate and disease-quickening surgeries. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:621. [PMID: 25125281 DOI: 10.3109/21678421.2014.948881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Susana Pinto
- Translational Clinical Physiology Unit, Instituto de Medicina Molecular, Institute of Physiology - Faculty of Medicine, University of Lisbon
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Delayed diagnosis in ALS: The problem continues. J Neurol Sci 2014; 343:173-5. [DOI: 10.1016/j.jns.2014.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 04/30/2014] [Accepted: 06/02/2014] [Indexed: 11/22/2022]
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