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Murray D, Rooney J, Al-Chalabi A, Bunte T, Chiwera T, Choudhury M, Chio A, Fenton L, Fortune J, Maidment L, Manera U, Mcdermott C, Meldrum D, Meyjes M, Tattersall R, Torrieri MC, Van Damme P, Vanderlinden E, Wood C, Van Den Berg LH, Hardiman O. Correlations between measures of ALS respiratory function: is there an alternative to FVC? Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:495-504. [PMID: 34590504 DOI: 10.1080/21678421.2021.1908362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: An ongoing longitudinal study in six European sites includes a 3-monthly assessment of forced vital capacity (FVC), slow vital capacity (SVC), peak cough flow (PCF), and Sniff nasal inspiratory pressure (SNIP). The aim of this interim analysis was to assess the potential for SNIP to be a surrogate for aerosol generating procedures given COVID-19 related restrictions. Methods: This was a prospective observational study. Patients attending six study sites with King's Stage 2 or 3 ALS completed baseline FVC/SVC/SNIP/PCF and repeated assessments 3 monthly. Data were collected from March 2018 to March 2020, after which a COVID-19 related study suspension was imposed. Correlations between the measures were calculated. A Bayesian multiple outcomes random-effects model was constructed to investigate rates of decline across measures. Results: In total, 270 cases and 828 assessments were included (Mean age 65.2 ± 15.4 years; 32.6% Female; 60% Kings stage 2; 81.1% spinal onset). FVC and SVC were the most closely correlated outcomes (0.95). SNIP showed the least correlation with other metrics 0.53 (FVC), 0.54 (SVC), 0.60 (PCF). All four measures significantly declined over time. SNIP in the bulbar onset group showed the fastest rate of decline. Discussion: SNIP was not well correlated with FVC and SVC, probably because it examines a different aspect of respiratory function. Respiratory measures declined over time, but differentially according to the site of onset. SNIP is not a surrogate for FVC and SVC, but is a complementary measure, declining linearly and differentiating spinal and bulbar onset patients.
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Affiliation(s)
- Deirdre Murray
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - James Rooney
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Amar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Tommy Bunte
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theresa Chiwera
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Mutahhara Choudhury
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Adriano Chio
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, Azienda Ospedale Università Città della Salute e della Scienza, Turin, Italy
| | - Lauren Fenton
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Jennifer Fortune
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Lindsay Maidment
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Umberto Manera
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Chris Mcdermott
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK.,Sheffield Institute for Translational Neuroscience, Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Dara Meldrum
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Myrte Meyjes
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rachel Tattersall
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - Maria Claudia Torrieri
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Philip Van Damme
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and.,KU Leuven, Department of Neuroscience, Leuven Brain Institute and VIB Center for Brain & Disease Research, Leuven, Belgium
| | - Elien Vanderlinden
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and
| | - Claire Wood
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | | | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
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Murray D, Rooney J, Campion A, Fenton L, Hammond M, Heverin M, Meldrum D, Moloney H, Tattersall R, Hardiman O. Longitudinal analysis of sniff nasal inspiratory pressure assessed using occluded and un-occluded measurement techniques in amyotrophic lateral sclerosis and primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:481-489. [DOI: 10.1080/21678421.2019.1639194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Deirdre Murray
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
- Beaumont Hospital, Dublin, Ireland
| | - James Rooney
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | | | - Lauren Fenton
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | - Michaela Hammond
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | - Mark Heverin
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | - Dara Meldrum
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | - Hannah Moloney
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
| | | | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland and
- Beaumont Hospital, Dublin, Ireland
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3
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Martínez-Llorens J, Balañá Corberó A. Esclerosis lateral amiotrófica: valoración del fracaso muscular inspiratorio. Arch Bronconeumol 2019; 55:345-346. [DOI: 10.1016/j.arbres.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
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Janssens JP, Adler D, Iancu Ferfoglia R, Poncet A, Genton Graf L, Leuchter I, Escher Imhof M, Héritier Barras AC. Assessing Inspiratory Muscle Strength for Early Detection of Respiratory Failure in Motor Neuron Disease: Should We Use MIP, SNIP, or Both? Respiration 2019; 98:114-124. [DOI: 10.1159/000498972] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 02/19/2019] [Indexed: 11/19/2022] Open
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5
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Pinto S, de Carvalho M. Sniff nasal inspiratory pressure (SNIP) in amyotrophic lateral sclerosis: Relevance of the methodology for respiratory function evaluation. Clin Neurol Neurosurg 2018; 171:42-45. [PMID: 29807198 DOI: 10.1016/j.clineuro.2018.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/31/2018] [Accepted: 05/10/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We investigated two different methodological approaches for determining nasal inspiratory pressure during a sniff (SNIP) in patients with Amyotrophic Lateral Sclerosis (ALS). PATIENTS AND METHODS We included 37 ALS patients and 11 controls. SNIP was measured in the sitting position, performed in each nostril with (SNIPocclud) and without (SNIPopen) closing the contralateral nostril. The best of 3 consistent results was considered for analyses. Patients were also assessed with MIP and the revised functional ALS rating scale (ALSFRS-R). Mann-Whitney U test, Wilcoxon test and Spearman's rank correlation coefficient with Bonferroni correction were applied. Coefficient of variation (CV) was calculated. RESULTS SNIP was significantly lower in patients than controls, either for SNIPopen (p = 0.011) or SNIPocclud (p = 0.002). SNIPopen values were significantly lower both in ALS patients and controls than SNIPocclud (p < 0.001 and p = 0.007, respectively). SNIPopen CV was 8.14% and 8.51%, while SNIPocclud CV was 4.98% and 6.37%, respectively for controls and patients. SNIPopen and SNIPocclud were strongly correlated in both groups (r = 0.761 for controls; r = 0.768 for patients). In ALS, both methods were moderately correlated with MIP (respectively r = 0.525, p = 0.006 and r = 0.685, p < 0.001) and the respiratory subscore of ALSFRS-R (respectively r = 0.525, p = 0.001 and r = 0.64, p < 0.001). Although bulbar and spinal onset patients presented no differences for SNIPopen (p = 0.157), significant differences were found for SNIPocclud (p = 0.018). CONCLUSION SNIPocclud should be considered when evaluating ALS patients as its values present lower variability and favor longer follow-up.
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Affiliation(s)
- Susana Pinto
- Institute of Physiology, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.
| | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Department of Neurosciences and Mental Health, Hospital de Santa Maria-CHLN, Lisbon, Portugal.
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Sarmento A, Aliverti A, Marques L, Pennati F, Dourado-Júnior ME, Fregonezi G, Resqueti V. Multiparametric Analysis of Sniff Nasal Inspiratory Pressure Test in Middle Stage Amyotrophic Lateral Sclerosis. Front Neurol 2018; 9:306. [PMID: 29770120 PMCID: PMC5940741 DOI: 10.3389/fneur.2018.00306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/18/2018] [Indexed: 11/24/2022] Open
Abstract
The relaxation rates and contractile properties of inspiratory muscles are altered with inspiratory muscle weakness and fatigue. This fact plays an important role in neuromuscular disorders patients and had never been extensively studied in amyotrophic lateral sclerosis (ALS). In this cross-sectional study, these parameters were investigated non-invasively through nasal inspiratory sniff pressure test (SNIP) in 39 middle stage spinal onset ALS subjects and compared with 39 healthy controls. ALS patients were also divided into three subgroups according to a decline in their percentage of predicted forced vital capacity (FVC%pred) as well as a decline in the ALS functional rating scale score and its respiratory subscore (R-subscore) in order to determine the best parameter linked to early respiratory muscle weakness. When compared with healthy subjects, middle stage ALS subjects exhibited a significantly lower (p < 0.0001) maximum relaxation rate and maximum rate of pressure development (MRPD), as well as a significantly higher (p < 0.0001) tau (τ), contraction time, and half-relaxation time. The results from receiver operating characteristic curves showed that MRPD (AUC 0.735, p < 0.001) and FVC%pred (AUC 0.749, p = 0.009) were the best discriminator parameters between ALS patients with ≤30 and >30 points in the ALS functional rating scale. In addition, 1/2RT (AUC 0.720, p = 0.01), FVC%pred (AUC 0.700, p = 0.03), τ (AUC 0.824, p < 0.0001), and MRPD (AUC 0.721, p = 0.01) were the parameters more sensitive in detecting a fall of three points in the R-subscore. On the other hand, MRPD (AUC 0.781, p < 0.001), τ (AUC 0.794, p = 0.0001), and percentage of predicted of SNIP (AUC 0.769, p = 0.002) were the parameters able to detect a fall in 30% of the FVC%pred in middle stage ALS patients. The contractile properties and relaxation rates of the diaphragm are altered in middle stage spinal onset ALS when compared with healthy subjects. These parameters are able to discriminate between those middle stage ALS subjects with early decline in inspiratory muscle function and those who not.
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Affiliation(s)
- Antonio Sarmento
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Layana Marques
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Mario Emílio Dourado-Júnior
- Ambulatório de Neurologia, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Medicina Integrada, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Guilherme Fregonezi
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Vanessa Resqueti
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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7
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Lechtzin N, Cudkowicz ME, de Carvalho M, Genge A, Hardiman O, Mitsumoto H, Mora JS, Shefner J, Van den Berg LH, Andrews JA. Respiratory measures in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:321-330. [PMID: 29566571 DOI: 10.1080/21678421.2018.1452945] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes skeletal muscle weakness, including muscles involved with respiration. Death often results from respiratory failure within 3-5 years. Monitoring respiratory status is therefore critical to ALS management, as respiratory/pulmonary function tests (PFTs) are used to make decisions including when to initiate noninvasive ventilation. Understanding the different respiratory and PFTs as they relate to disease progression and survival may help determine which tests are most suitable. METHODS This review describes the tests used to assess respiratory muscle and pulmonary function in patients with ALS and the correlations between different respiratory measures and clinical outcomes measures. RESULTS The most commonly used measurement, forced vital capacity (VC), has been shown to correlate with clinical milestones including survival, but also requires good motor coordination and facial strength to form a tight seal around a mouthpiece. Other tests such as slow VC, sniff inspiratory pressure, or transdiaphragmatic pressure with magnetic stimulation are also associated with distinct advantages and disadvantages. CONCLUSIONS Therefore, how and when to use different tests remains unclear. Understanding how each test relates to disease progression and survival may help determine which is best suited for specific clinical decisions.
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Affiliation(s)
- Noah Lechtzin
- a Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | | | - Mamede de Carvalho
- c Faculty of Medicine, IMM, University of Lisbon , Department of Neurosciences-CHLN , Lisbon , Portugal
| | - Angela Genge
- d Montreal Neurological Institute , Montreal , Canada
| | - Orla Hardiman
- e Trinity Biomedical Sciences Institute, Trinity College , Dublin , Ireland
| | - Hiroshi Mitsumoto
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
| | - Jesus S Mora
- g Unidad de ELA-Hospital Universitario La Paz-Hospital Carlos III , Madrid , Spain
| | - Jeremy Shefner
- h Department of Neurology , Barrow Neurological Institute , Phoenix , AZ , USA
| | - Leonard H Van den Berg
- i Department of Neurology , Brain Centre Rudolf Magnus, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Jinsy A Andrews
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
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8
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Pinto S, de Carvalho M. Correlation between Forced Vital Capacity and Slow Vital Capacity for the assessment of respiratory involvement in Amyotrophic Lateral Sclerosis: a prospective study. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:86-91. [DOI: 10.1080/21678421.2016.1249486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Susana Pinto
- Instituto de Medicina Molecular and Institute of Physiology, Faculty of Medicine, University of Lisbon, Portugal and
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Institute of Physiology, Faculty of Medicine, University of Lisbon, Portugal and
- Department of Neurosciences and Mental Health, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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9
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Kim DG, Hong YH, Shin JY, Lee KW, Park KS, Seong SY, Sung JJ. Pattern of Respiratory Deterioration in Sporadic Amyotrophic Lateral Sclerosis According to Onset Lesion by Using Respiratory Function Tests. Exp Neurobiol 2015; 24:351-7. [PMID: 26713082 PMCID: PMC4688334 DOI: 10.5607/en.2015.24.4.351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/05/2015] [Accepted: 10/24/2015] [Indexed: 11/24/2022] Open
Abstract
Most amyotrophic lateral sclerosis (ALS) patients show focal onset of upper and lower motor neuron signs and spread of symptoms to other regions or the other side clinically. Progression patterns of sporadic ALS are unclear. The aim of this study was to evaluate the pattern of respiratory deterioration in sporadic ALS according to the onset site by using respiratory function tests. Study participants included 63 (42 cervical-onset [C-ALS] and 21 lumbosacral-onset [L-ALS]) ALS patients and 31 healthy controls. We compared respiratory function test parameters among the 3 groups. Age was 57.4±9.6 (mean±SD), 60.8±9, and 60.5±7 years, and there were 28, 15, and 20 male participants, in the C-ALS, L-ALS, and control groups, respectively. Disease duration did not differ between C-ALS and L-ALS patients. Sniff nasal inspiratory pressure (SNIP) was significantly low in C-ALS patients compared with controls. Maximal expiratory pressure (MEP) and forced vital capacity percent predicted (FVC% predicted) were significantly low in C-ALS and L-ALS patients compared with controls. Maximal inspiratory pressure to maximal expiratory pressure (MIP:MEP) ratio did not differ among the 3 groups. Eighteen C-ALS and 5 L-ALS patients were followed up. ΔMIP, ΔMEP, ΔSNIP, ΔPEF, and ΔFVC% predicted were higher in C-ALS than L-ALS patients without statistical significance. Fourteen C-ALS (77.8%) and 3 L-ALS (60%) patients showed a constant MIP:MEP ratio above or below 1 from the first to the last evaluation. Our results suggest that vulnerability of motor neurons in sporadic ALS might follow a topographic gradient.
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Affiliation(s)
- Dong-Gun Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul 03080, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul 03080, Korea
| | - Je-Young Shin
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Korea
| | - Kwang-Woo Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul 03080, Korea
| | - Seung-Yong Seong
- Wide River Institute of Immunology, Department of Microbiology and Immunology, Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 03080, Korea
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Jenkins JAL, Sakamuri S, Katz JS, Forshew DA, Guion L, Moore D, Miller RG. Phrenic nerve conduction studies as a biomarker of respiratory insufficiency in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2015; 17:213-20. [DOI: 10.3109/21678421.2015.1112406] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J. A. Liberty Jenkins
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
| | - Sarada Sakamuri
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
- Stanford Hospital & Clinic, Stanford, California, USA
| | - Jonathan S. Katz
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
| | - Dallas A. Forshew
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
| | - Lee Guion
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
| | - Dan Moore
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
| | - Robert G. Miller
- Forbes Norris MDA/ALS Research and Treatment Center, California Pacific Medical Center, San Francisco, California, USA and
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11
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Cudkowicz ME, Titus S, Kearney M, Yu H, Sherman A, Schoenfeld D, Hayden D, Shui A, Brooks B, Conwit R, Felsenstein D, Greenblatt DJ, Keroack M, Kissel JT, Miller R, Rosenfeld J, Rothstein JD, Simpson E, Tolkoff-Rubin N, Zinman L, Shefner JM. Safety and efficacy of ceftriaxone for amyotrophic lateral sclerosis: a multi-stage, randomised, double-blind, placebo-controlled trial. Lancet Neurol 2014; 13:1083-1091. [PMID: 25297012 DOI: 10.1016/s1474-4422(14)70222-4] [Citation(s) in RCA: 156] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Glutamate excitotoxicity might contribute to the pathophysiology of amyotrophic lateral sclerosis. In animal models, decreased excitatory aminoacid transporter 2 (EAAT2) overexpression delays disease onset and prolongs survival, and ceftriaxone increases EAAT2 activity. We aimed to assess the safety and efficacy of ceftriaxone for amyotrophic lateral sclerosis in a combined phase 1, 2, and 3 clinical trial. METHODS This three-stage randomised, double-blind, placebo-controlled study was done at 59 clinical sites in the USA and Canada between Sept 4, 2006, and July 30, 2012. Eligible adult patients had amyotrophic lateral sclerosis, a vital capacity of more than 60% of that predicted for age and height, and symptom duration of less than 3 years. In stages 1 (pharmacokinetics) and 2 (safety), participants were randomly allocated (2:1) to ceftriaxone (2 g or 4 g per day) or placebo. In stage 3 (efficacy), participants assigned to ceftriaxone in stage 2 received 4 g ceftriaxone, participants assigned to placebo in stage 2 received placebo, and new participants were randomly assigned (2:1) to 4 g ceftriaxone or placebo. Participants, family members, and site staff were masked to treatment assignment. Randomisation was done by a computerised randomisation sequence with permuted blocks of 3. Participants received 2 g ceftriaxone or placebo twice daily through a central venous catheter administered at home by a trained caregiver. To minimise biliary side-effects, participants assigned to ceftriaxone also received 300 mg ursodeoxycholic acid twice daily and those assigned to placebo received matched placebo capsules. The coprimary efficacy outcomes were survival and functional decline, measured as the slope of Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) scores. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00349622. FINDINGS Stage 3 included 66 participants from stages 1 and 2 and 448 new participants. In total, 340 participants were randomly allocated to ceftriaxone and 173 to placebo. During stages 1 and 2, mean ALSFRS-R declined more slowly in participants who received 4 g ceftriaxone than in those on placebo (difference 0·51 units per month, 95% CI 0·02 to 1·00; p=0·0416), but in stage 3 functional decline between the treatment groups did not differ (0·09, -0·06 to 0·24; p=0·2370). No significant differences in survival between the groups were recorded in stage 3 (HR 0·90, 95% CI 0·71 to 1·15; p=0·4146). Gastrointestinal adverse events and hepatobiliary adverse events were more common in the ceftriaxone group than in the placebo group (gastrointestinal, 245 of 340 [72%] ceftriaxone vs 97 of 173 [56%] placebo, p=0·0004; hepatobiliary, 211 [62%] vs 19 [11%], p<0·0001). Significantly more participants who received ceftriaxone had serious hepatobiliary serious adverse events (41 participants [12%]) than did those who received placebo (0 participants). INTERPRETATION Despite promising stage 2 data, stage 3 of this trial of ceftriaxone in amyotrophic lateral sclerosis did not show clinical efficacy. The adaptive design allowed for seamless transition from one phase to another, and central venous catheter use in the home setting was shown to be feasible. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
| | - Sarah Titus
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Hong Yu
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Amy Shui
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | | | | | | | | | - Robert Miller
- California Pacific Medical Center, San Francisco, CA, USA
| | | | | | | | | | - Lorne Zinman
- Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Jeremy M Shefner
- State University of New York, Upstate Medical University, Syracuse, NY, USA
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12
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Huang CH, Yang GG, Chen TW. Sniff nasal inspiratory pressure does not decrease in elderly subjects. J Phys Ther Sci 2014; 26:1509-13. [PMID: 25276047 PMCID: PMC4175268 DOI: 10.1589/jpts.26.1509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 04/26/2014] [Indexed: 12/13/2022] Open
Abstract
[Purpose] Measurements of inspiratory strength are critical for detecting inspiratory muscle weakness. Sniff nasal inspiratory pressure (SNIP) is a quick, noninvasive measurement of global inspiratory strength; however, it is not clear how many trials are needed for reliable measurements. [Subjects and Methods] One hundred and nineteen subjects (age 39.9±16.5, range 18-69 yrs) completed the study. They were divided into subgroups of different ages and gender. Subjects were asked to take 20 maximal sniffs after normal expiration, with 30 seconds rest in-between. The highest values among the first 10 and last 10 SNIP maneuvers were recorded as SNIP1-10, and SNIP11-20, respectively. The paired t-test was used to compare the differences. Two-way measures ANOVA was used to compare the effects of age and gender on SNIP. [Results] SNIP 11-20 was significantly greater than SNIP1-10, suggesting that 10 trials is not enough to eliminate learning effects. Age did not affect SNIP in either gender, suggesting SNIP is preserved. In stepwise multiple linear regression analysis, the SNIP values were positively related with body mass index in women and positively related with weight in men. [Conclusion] The results suggest that twenty trials are needed for reliable SNIP measurements. The mean value and lower limits of normal SNIP are provided for clinical comparison.
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Affiliation(s)
| | - Gee-Gwo Yang
- Department of Pulmonary Medicine, Tzu Chi Medical Center, Taiwan
| | - Tung-Wei Chen
- Physical Education Office, National Taipei University of Technology, Taiwan
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Yamauchi R, Imai T, Tsuda E, Hozuki T, Yamamoto D, Shimohama S. Respiratory insufficiency with preserved diaphragmatic function in amyotrophic lateral sclerosis. Intern Med 2014; 53:1325-31. [PMID: 24930652 DOI: 10.2169/internalmedicine.53.2326] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE We performed a longitudinal study to elucidate the correlation between respiratory insufficiency and respiratory biomarkers, including diaphragmatic compound muscle action potential (DCMAP), at the initiation of noninvasive ventilation (NIV) in patients with amyotrophic lateral sclerosis (ALS). METHODS The patients were assessed at least every six months. Additional assessments were performed at the start of respiratory therapy when the patients met the criteria for the initiation of NIV. Each assessment consisted of a full neurological examination, a phrenic nerve conduction study, respiratory function tests, and nocturnal pulsed oximetry. PATIENTS We enrolled 43 patients with either definite or probable ALS as defined by the revised El Escorial criteria. RESULTS The patients were divided into two groups according to the timing of the initiation of respiratory therapy. Seventeen patients (group A) met the criteria for NIV initiation when their DCMAP remained normal. Twenty-six patients (group B) met the criteria when their DCMAP decreased below normal limits. Although respiratory function parameters were significantly worse in group B compared with group A at NIV initiation, more than 80% of the patients in both groups developed nocturnal desaturation during sleep. CONCLUSION DCMAP is not always a reliable indicator for determining the optimal timing for NIV initiation during the progression of respiratory insufficiency in ALS. Physicians should be aware of the risk of respiratory insufficiency during sleep in patients with ALS.
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Affiliation(s)
- Rika Yamauchi
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
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Czell D, Weber M. Authors' reply. ACTA ACUST UNITED AC 2013; 86:175. [PMID: 23548476 DOI: 10.1159/000348378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Carratù P, Dragonieri S, Resta O. Sniff nasal pressure is a sensitive marker of poor outcome in amyotrophic lateral sclerosis. ACTA ACUST UNITED AC 2013; 86:174. [PMID: 23548441 DOI: 10.1159/000348375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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