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Bhushan NL, Romano CD, Gras-Najjar J, Reno J, Rockwood N, Quattrone W, Adams ET, Kelly B, McLeod L, Bhavnani SP, Bocell FD, Campbell M, Kontson K, Reasner D, Zhang C, Retzky S. Remote-Use Applications of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised Clinical Outcome Assessment Tool: A Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1454-1465. [PMID: 38795957 DOI: 10.1016/j.jval.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 05/06/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES In 2021, the US Congress passed the Accelerating Access to Critical Therapies for Amyotrophic Lateral Sclerosis Act. The law encourages development of "tools, methods, and processes" to improve clinical trial efficiency for neurodegenerative diseases. The Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) is an outcome measure administered during in-person clinic visits and used to support investigational studies for persons living with amyotrophic lateral sclerosis. Availability of a standardized, remote-use version of the ALSFRS-R may promote more inclusive, decentralized clinical trials. A scoping literature review was conducted to identify existing remote-use ALSFRS-R tools, synthesize feasibility and comparability of administration modes, and summarize barriers and facilitators to inform development of a standardized remote-use ALSFRS-R tool. METHODS Included studies reported comparisons between remote and in-person, clinician-reported, ALSFRS-R administration and were published in English (2002-2022). References were identified by searching peer-reviewed and gray literature. Twelve studies met the inclusion criteria and were analyzed to compare findings within and across modes of administration. RESULTS Remote modes of ALSFRS-R administration were categorized into 4 nonmutually exclusive categories: telephone (n = 6), videoconferencing (n = 3), computer or online platforms (n = 3), mobile applications and wearables (n = 2), and 1 unspecified telemedicine modality (n = 1). Studies comparing in-person to telephone or videoconferencing administration reported high ALSFRS-R rating correlations and nonsignificant between-mode differences. CONCLUSIONS There is insufficient information in the ALSFRS-R literature to support remote clinician administration for collecting high quality data. Future research should engage persons living with amyotrophic lateral sclerosis, care partners, and providers to develop a standardized remote-use ALSFRS-R version.
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Affiliation(s)
| | | | | | - Jenna Reno
- RTI International, Research Triangle Park, NC, USA
| | | | | | | | | | - Lori McLeod
- RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | | | - Fraser D Bocell
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - David Reasner
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Caiyan Zhang
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sandra Retzky
- US Food and Drug Administration, Silver Spring, Maryland, USA
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2
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Fang T, Pacut P, Bose A, Sun Y, Gao J, Sivakumar S, Bloom B, Nascimento Andrade EI, Trombetta B, Ghasemi M. Clinical and genetic factors affecting diagnostic timeline of amyotrophic lateral sclerosis: a 15-year retrospective study. Neurol Res 2024; 46:859-867. [PMID: 38825034 DOI: 10.1080/01616412.2024.2362578] [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: 09/28/2023] [Accepted: 05/27/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Amyotrophic Lateral Sclerosis (ALS) diagnosis can take 10-16 months from symptom onset, leading to delays in treatment and patient counselling. We studied the impact of clinical and genetic risk factors on the diagnostic timeline of ALS. METHODS Baseline characteristics, family history, gene testing, onset location, time from symptom onset to diagnosis, and time from first doctor visit to suspected ALS was collected. We used multiple regression to assess the interaction of these factors on ALS diagnostic timeline. We analysed a subgroup of patients with genetic testing and compared positive or negative tests, sporadic or familial and ALS-related genes to time for diagnosis. RESULTS Four hundred and forty-eight patients diagnosed with ALS at the University of Massachusetts Chan Medical Center between January 2007 and December 2021 were analysed. The median time to ALS diagnosis was 12 months and remained unchanged from 2007 to 2021 (p = 0.20). Diagnosis was delayed in patients with sporadic compared with familial ALS (mean months [standard deviation], 16.5[13.5] and 11.2[8.5], p < 0.001); cognitive onset (41[21.26]) had longer time to diagnosis than bulbar (11.9[8.2]), limb (15.9[13.2]), respiratory (19.7[13.9]) and ALS with multiple onset locations (20.77[15.71], p < 0.001). One hundred and thirty-four patients had gene testing and 32 tested positive (23.8%). Gene testing (p = 0.23), a positive genetic test (p = 0.16), different ALS genes (p = 0.25) and sporadic (p = 0.92) or familial (p = 0.85) ALS testing positive for ALS genes did not influence time to diagnosis. DISCUSSION Time for ALS diagnosis remained unchanged from 2007 to 2021, bulbar-onset and familial ALS made for faster diagnosis.
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Affiliation(s)
- Ton Fang
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Peter Pacut
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Abigail Bose
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Yuyao Sun
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Jeff Gao
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Shravan Sivakumar
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Brooke Bloom
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | - Bianca Trombetta
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, MA, USA
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3
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Meyer T, Dreger M, Grehl T, Weyen U, Kettemann D, Weydt P, Günther R, Lingor P, Petri S, Koch JC, Großkreutz J, Rödiger A, Baum P, Hermann A, Prudlo J, Boentert M, Weishaupt JH, Löscher WN, Dorst J, Koc Y, Bernsen S, Cordts I, Vidovic M, Steinbach R, Metelmann M, Kleinveld VE, Norden J, Ludolph A, Walter B, Schumann P, Münch C, Körtvélyessy P, Maier A. Serum neurofilament light chain in distinct phenotypes of amyotrophic lateral sclerosis: A longitudinal, multicenter study. Eur J Neurol 2024; 31:e16379. [PMID: 38859579 PMCID: PMC11295170 DOI: 10.1111/ene.16379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/01/2024] [Accepted: 05/21/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To assess the performance of serum neurofilament light chain (sNfL) in clinical phenotypes of amyotrophic lateral sclerosis (ALS). METHODS In 2949 ALS patients at 16 ALS centers in Germany and Austria, clinical characteristics and sNfL were assessed. Phenotypes were differentiated for two anatomical determinants: (1) upper and/or lower motor involvement (typical, typMN; upper/lower motor neuron predominant, UMNp/LMNp; primary lateral sclerosis, PLS) and (2) region of onset and propagation of motor neuron dysfunction (bulbar, limb, flail-arm, flail-leg, thoracic onset). Phenotypes were correlated to sNfL, progression, and survival. RESULTS Mean sNfL was - compared to typMN (75.7 pg/mL, n = 1791) - significantly lower in LMNp (45.1 pg/mL, n = 413), UMNp (58.7 pg/mL n = 206), and PLS (37.6 pg/mL, n = 84). Also, sNfL significantly differed in the bulbar (92.7 pg/mL, n = 669), limb (64.1 pg/mL, n = 1305), flail-arm (46.4 pg/mL, n = 283), flail-leg (53.6 pg/mL, n = 141), and thoracic (74.5 pg/mL, n = 96) phenotypes. Binary logistic regression analysis showed highest contribution to sNfL elevation for faster progression (odds ratio [OR] 3.24) and for the bulbar onset phenotype (OR 1.94). In contrast, PLS (OR 0.20), LMNp (OR 0.45), and thoracic onset (OR 0.43) showed reduced contributions to sNfL. Longitudinal sNfL (median 12 months, n = 2862) showed minor monthly changes (<0.2%) across all phenotypes. Correlation of sNfL with survival was confirmed (p < 0.001). CONCLUSIONS This study underscored the correlation of ALS phenotypes - differentiated for motor neuron involvement and region of onset/propagation - with sNfL, progression, and survival. These phenotypes demonstrated a significant effect on sNfL and should be recognized as independent confounders of sNfL analyses in ALS trials and clinical practice.
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Affiliation(s)
- Thomas Meyer
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Marie Dreger
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Torsten Grehl
- Department of NeurologyCenter for ALS and Other Motor Neuron Disorders, Alfried Krupp KrankenhausEssenGermany
| | - Ute Weyen
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersBerufsgenossenschaftliches Universitätsklinikum BergmannsheilBochumGermany
| | - Dagmar Kettemann
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Patrick Weydt
- Department for Neuromuscular DisordersBonn UniversityBonnGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)BonnGermany
| | - René Günther
- Department of NeurologyTechnische Universität Dresden, University Hospital Carl Gustav CarusDresdenGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)DresdenGermany
| | - Paul Lingor
- Department of NeurologyTechnical University of Munich, School of Medicine, Klinikum rechts der IsarMunichGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)MunichGermany
| | - Susanne Petri
- Department of NeurologyHannover Medical SchoolHannoverGermany
| | | | - Julian Großkreutz
- Department of NeurologyUniversitätsmedizin Schleswig‐Holstein, Campus LübeckLübeckGermany
| | - Annekathrin Rödiger
- Department of NeurologyJena University HospitalJenaGermany
- Zentrum für Seltene Erkrankungen (ZSE)Jena University HospitalJenaGermany
| | - Petra Baum
- Department of NeurologyUniversity Hospital LeipzigLeipzigGermany
| | - Andreas Hermann
- Translational Neurodegeneration Section “Albrecht‐Kossel”, Department of NeurologyUniversity of Rostock, University Medical CenterRostockGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)GreifswaldGermany
| | - Johannes Prudlo
- Translational Neurodegeneration Section “Albrecht‐Kossel”, Department of NeurologyUniversity of Rostock, University Medical CenterRostockGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)GreifswaldGermany
| | | | - Jochen H. Weishaupt
- Division for Neurodegenerative Diseases, Neurology Department, Mannheim Center for Translational MedicineUniversity Medicine Mannheim, Heidelberg UniversityMannheimGermany
| | | | - Johannes Dorst
- Department of NeurologyUlm UniversityUlmGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)UlmGermany
| | - Yasemin Koc
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Sarah Bernsen
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Department for Neuromuscular DisordersBonn UniversityBonnGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)BonnGermany
| | - Isabell Cordts
- Department of NeurologyTechnical University of Munich, School of Medicine, Klinikum rechts der IsarMunichGermany
| | - Maximilian Vidovic
- Department of NeurologyTechnische Universität Dresden, University Hospital Carl Gustav CarusDresdenGermany
| | | | - Moritz Metelmann
- Department of NeurologyUniversity Hospital LeipzigLeipzigGermany
| | | | - Jenny Norden
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Albert Ludolph
- Department of NeurologyUlm UniversityUlmGermany
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE)UlmGermany
| | - Bertram Walter
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - Peggy Schumann
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Christoph Münch
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
- Ambulanzpartner Soziotechnologie APST GmbHBerlinGermany
| | - Péter Körtvélyessy
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
| | - André Maier
- Department of Neurology, Center for ALS and Other Motor Neuron DisordersCharité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt‐Universität zu Berlin and Berlin Institute of HealthBerlinGermany
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4
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Witzel S, Huss A, Nagel G, Rosenbohm A, Rothenbacher D, Peter RS, Bäzner H, Börtlein A, Dempewolf S, Schabet M, Hecht M, Kohler A, Opherk C, Naegele A, Sommer N, Lindner A, Alexudis C, Bachhuber F, Halbgebauer S, Brenner D, Ruf W, Weiland U, Mayer B, Schuster J, Dorst J, Tumani H, Ludolph AC. Population-Based Evidence for the Use of Serum Neurofilaments as Individual Diagnostic and Prognostic Biomarkers in Amyotrophic Lateral Sclerosis. Ann Neurol 2024. [PMID: 39177232 DOI: 10.1002/ana.27054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 07/04/2024] [Accepted: 07/31/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVE Neurofilament light chains (NfL) and phosphorylated neurofilament heavy chains (pNfH), established as diagnostic and prognostic biomarkers in hospital-based amyotrophic lateral sclerosis (ALS) cohorts, are now surrogate markers in clinical trials. This study extends their evaluation to a population level, with the aim of advancing their full establishment and assessing the transferability of biomarker findings from controlled cohorts to real-world ALS populations. METHODS We measured serum NfL and pNfH levels in all ALS patients (n = 790) and general population controls (n = 570) with available baseline samples participating in the epidemiological ALS Registry Swabia, providing platform-specific (ELLA™) reference data and Z-scores for controls, as well as reference data, disease-specific Z-scores and longitudinal data in ALS. We evaluated the diagnostic and prognostic utility of neurofilaments and quantified the impact of ALS-related factors and non-ALS confounders. RESULTS Neurofilaments showed high diagnostic and prognostic utility at the population level, with NfL superior to pNfH. The novel concept of a population-based ALS Z-score significantly improved the prognostic utility compared to absolute raw values. Both biomarkers increased more strongly with age in controls than in ALS, and age adjustment improved diagnostic accuracy. Our data show that disease progression rates, ALS phenotype, body mass index (BMI), and renal function need to be considered when interpreting neurofilament levels; longitudinal neurofilament levels were generally stable in individual patients, especially when adjusted for age and baseline levels. INTERPRETATION Population-based assessment enhances the utility of particularly serum NfL as a diagnostic and prognostic biomarker in ALS and improves the translation of findings from controlled cohorts to real-world populations. ANN NEUROL 2024.
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Affiliation(s)
- Simon Witzel
- Department of Neurology, Ulm University, Ulm, Germany
| | - André Huss
- Department of Neurology, Ulm University, Ulm, Germany
| | - Gabriele Nagel
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | | | | | - Raphael S Peter
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
| | - Axel Börtlein
- Department of Neurology, Klinikum Stuttgart, Katharinenhospital, Stuttgart, Germany
| | - Silke Dempewolf
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Schabet
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Hecht
- Department of Neurology, Klinikum Kaufbeuren, Kliniken Ostallgaeu-Kaufbeuren, Kaufbeuren, Germany
| | - Andreas Kohler
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Christian Opherk
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Andrea Naegele
- Department of Neurology, Christophsbad Goeppingen, Göppingen, Germany
| | - Norbert Sommer
- Department of Neurology, Christophsbad Goeppingen, Göppingen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | | | - Steffen Halbgebauer
- Department of Neurology, Ulm University, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE), Site Ulm, Ulm, Germany
| | - David Brenner
- Department of Neurology, Ulm University, Ulm, Germany
| | - Wolfgang Ruf
- Department of Neurology, Ulm University, Ulm, Germany
| | | | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Joachim Schuster
- Department of Neurology, Ulm University, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE), Site Ulm, Ulm, Germany
| | | | - Hayrettin Tumani
- Department of Neurology, Ulm University, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE), Site Ulm, Ulm, Germany
| | - Albert C Ludolph
- Department of Neurology, Ulm University, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE), Site Ulm, Ulm, Germany
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5
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Erb MK, Calcagno N, Brown R, Burke KM, Scheier ZA, Iyer AS, Clark A, Higgins MP, Keegan M, Gupta AS, Johnson SA, Chew S, Berry JD. Longitudinal comparison of the self-administered ALSFRS-RSE and ALSFRS-R as functional outcome measures in ALS. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:570-580. [PMID: 38501453 DOI: 10.1080/21678421.2024.2322549] [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: 12/05/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Test the feasibility, adherence rates and optimal frequency of digital, remote assessments using the ALSFRS-RSE via a customized smartphone-based app. METHODS This fully remote, longitudinal study was conducted over a 24-week period, with virtual visits every 3 months and weekly digital assessments. 19 ALS participants completed digital assessments via smartphone, including a digital version of the ALSFRS-RSE and mood survey. Interclass correlation coefficients (ICC) and Bland-Altman plots were used to assess agreement between staff-administered and self-reported ALSFRS-R pairs. Longitudinal change was evaluated using ANCOVA models and linear mixed models, including impact of mood and time of day. Impact of frequency of administration of the ALSFRS-RSE on precision of the estimate slope was tested using a mixed effects model. RESULTS In our ALS cohort, digital assessments were well-accepted and adherence was robust, with completion rates of 86%. There was excellent agreement between the digital self-entry and staff-administered scores computing multiple ICCs (ICC range = 0.925-0.961), with scores on the ALSFRS-RSE slightly higher (1.304 points). Digital assessments were associated with increased precision of the slope, resulting in higher standardized response mean estimates for higher frequencies, though benefit appeared to diminish at biweekly and weekly frequency. Effects of participant mood and time of day on total ALSFRS-RSE score were evaluated but were minimal and not statistically significant. CONCLUSION Remote collection of digital patient-reported outcomes of functional status such as the ALSFRS-RSE yield more accurate estimates of change over time and provide a broader understanding of the lived experience of people with ALS.
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Affiliation(s)
| | - Narghes Calcagno
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
- Neurology Residency Program, University of Milan, Milan, Italy
| | | | - Katherine M Burke
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Zoe A Scheier
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Amrita S Iyer
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Alison Clark
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Max P Higgins
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Mackenzie Keegan
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Anoopum S Gupta
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Stephen A Johnson
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - Sheena Chew
- Biogen, Inc, Cambridge, MA, USA
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
| | - James D Berry
- Department of Neurology, Massachusetts General Hospital, Sean M. Healey & AMG Center for ALS, Boston, MA, USA, and
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6
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Hobson E, McDermott C. Advances in symptom management and in monitoring disease progression in motor neuron disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:119-169. [PMID: 38802174 DOI: 10.1016/bs.irn.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The aim of supportive management of motor neuron disease is to improve survival, promote good quality of life and patient independence and autonomy whilst preparing for future progression and the end of life. Multidisciplinary specialist care aims to address the multifaceted and interacting biopsychosocial problems associated with motor neuron disease that leads to proven benefits in both survival and quality of life. This chapter will explore principles, structure and details of treatment options, and make recommendations for practice and for future research.
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Affiliation(s)
- Esther Hobson
- Sheffield Institute for Translational Neuroscience, Division of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Christopher McDermott
- Sheffield Institute for Translational Neuroscience, Division of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom.
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7
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Genge A, Cedarbaum JM, Shefner J, Chio A, Al-Chalabi A, Van Damme P, McDermott C, Glass J, Berry J, van Eijk RPA, Fournier C, Grosskreutz J, Andrews J, Bertone V, Bunte TM, Couillard M, Cummings C, Kittle G, Polzer J, Salmon K, Straub C, van den Berg LH. The ALSFRS-R Summit: a global call to action on the use of the ALSFRS-R in ALS clinical trials. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:382-387. [PMID: 38396337 DOI: 10.1080/21678421.2024.2320880] [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: 12/14/2023] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
The Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS) was developed more than 25 years ago as an instrument to monitor functional change over time in patients with ALS. It has since been revised and extended to meet the needs of high data quality in ALS trials (ALSFRS-R), however a full re-validation of the scale was not completed. Despite this, the scale has remained a primary outcome measure in clinical trials. We convened a group of clinical trialists to discuss and explore opportunities to improve the scale and propose alternative measures. In this meeting report, we present a call to action on the use of the ALSFRS-Revised scale in clinical trials, focusing on the need for (1) harmonization of the ALSFRS-R administration globally, (2) alignment on a set of recommendations for clinical trial design and statistical analysis plans (SAPs), and (3) use of additional outcome measures.
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Affiliation(s)
- Angela Genge
- Montreal Neurological Institute-Hospital, ALS Center of Excellence, Montreal, Quebec, Canada
| | - Jesse M Cedarbaum
- Yale School of Medicine, Section of Movement Disorders, Coeruleus Clinical Sciences LLC, Woodbridge, CT, USA
| | | | - Adriano Chio
- Department of Neuroscience, University of Turin, Torino, Italy
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, King's College London, Institute of Psychiatry Psychology and Neuroscience, Maurice Wohl Clinical Neuroscience Institute, London, UK
| | | | - Chris McDermott
- Department of Neurology, The University of Sheffield, Sheffield, UK
| | - Jonathan Glass
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - James Berry
- Massachusetts General Hospital, Neurology, Boston, MA, USA
| | - Ruben P A van Eijk
- Department of Neurology and Biostatistics, UMC Utrecht Hersencentrum Rudolf Magnus, Utrecht, Netherlands
| | | | - Julian Grosskreutz
- Precision Neurology of Neuromuscular and Motoneuron Diseases, University of Lübeck, Lübeck, Germany
| | - Jinsy Andrews
- Columbia Presbyterian Medical Center, Neurology, New York, NY, USA
| | - Vanessa Bertone
- Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Tommy M Bunte
- Department of Neurology, UMC Utrecht Hersencentrum Rudolf Magnus, Utrecht, Netherlands
| | - Mathias Couillard
- Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Cathy Cummings
- International Alliance of ALS/MND Associations, Northampton, Northamptonshire, UK, and
| | - Gale Kittle
- Barrow Neurological Institute, Phoenix, AZ, USA
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Reilich P, Schöberl F, Hiebeler M, Tonon M, Ludolph AC, Senel M. Myelitis as a side effect of tofersen therapy in SOD1-associated ALS. J Neurol 2024; 271:2114-2118. [PMID: 38066205 PMCID: PMC10973064 DOI: 10.1007/s00415-023-12130-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 03/28/2024]
Affiliation(s)
- Peter Reilich
- Friedrich Baur Institute at the Department of Neurology, University Hospital, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany.
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.
| | - Florian Schöberl
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Miriam Hiebeler
- Friedrich Baur Institute at the Department of Neurology, University Hospital, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Matthias Tonon
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Albert C Ludolph
- Department of Neurology, University Clinic, University of Ulm, Ulm, Germany
| | - Makbule Senel
- Department of Neurology, University Clinic, University of Ulm, Ulm, Germany
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Spinelli EG, Ghirelli A, Basaia S, Canu E, Castelnovo V, Cividini C, Russo T, Schito P, Falzone YM, Riva N, Filippi M, Agosta F. Structural and Functional Brain Network Connectivity at Different King's Stages in Patients With Amyotrophic Lateral Sclerosis. Neurology 2024; 102:e207946. [PMID: 38165325 PMCID: PMC10962907 DOI: 10.1212/wnl.0000000000207946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There is currently no validated disease-stage biomarker for amyotrophic lateral sclerosis (ALS). The identification of quantitative and reproducible markers of disease stratification in ALS is fundamental for study design definition and inclusion of homogenous patient cohorts into clinical trials. Our aim was to assess the rearrangements of structural and functional brain connectivity underlying the clinical stages of ALS, to suggest objective, reproducible measures provided by MRI connectomics mirroring disease staging. METHODS In this observational study, patients with ALS and healthy controls (HCs) underwent clinical evaluation and brain MRI on a 3T scanner. Patients were classified into 4 groups, according to the King's staging system. Structural and functional brain connectivity matrices were obtained using diffusion tensor and resting-state fMRI data, respectively. Whole-brain network-based statistics (NBS) analysis and comparisons of intraregional and inter-regional connectivity values using analysis of covariance models were performed between groups. Correlations between MRI and clinical/cognitive measures were tested using Pearson coefficient. RESULTS One hundred four patients with ALS and 61 age-matched and sex-matched HCs were included. NBS and regional connectivity analyses demonstrated a progressive decrease of intranetwork and internetwork structural connectivity of sensorimotor regions at increasing ALS stages in our cohort, compared with HCs. By contrast, functional connectivity showed divergent patterns between King's stages 3 (increase in basal ganglia and temporal circuits [p = 0.04 and p = 0.05, respectively]) and 4 (frontotemporal decrease [p = 0.03]), suggesting a complex interplay between opposite phenomena in late stages of the disease. Intraregional sensorimotor structural connectivity was correlated with ALS Functional Rating Scale-revised (ALSFRS-r) score (r = 0.31, p < 0.001) and upper motor neuron burden (r = -0.25, p = 0.01). Inter-regional frontal-sensorimotor structural connectivity was also correlated with ALSFRS-r (r = 0.24, p = 0.02). No correlations with cognitive measures were found. DISCUSSION MRI of the brain allows to demonstrate and quantify increasing disruption of structural connectivity involving the sensorimotor networks in ALS, mirroring disease stages. Frontotemporal functional disconnection seems to characterize only advanced disease phases. Our findings support the utility of MRI connectomics to stratify patients and stage brain pathology in ALS in a reproducible way, which may mirror clinical progression.
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Affiliation(s)
- Edoardo G Spinelli
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alma Ghirelli
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Basaia
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisa Canu
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Veronica Castelnovo
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Camilla Cividini
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tommaso Russo
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paride Schito
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuri M Falzone
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Agosta
- From the Neuroimaging Research Unit (E.G.S., A.G., S.B., E.C., V.C., C.C., M.F., F.A.), Division of Neuroscience, and Neurology Unit (E.G.S., A.G., T.R., P.S., Y.M.F., M.F., F.A.), IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (E.G.S., A.G., T.R., M.F., F.A.); Neurorehabilitation Unit (N.R., M.F.), and Neurophysiology Service (M.F.), IRCCS San Raffaele Scientific Institute, Milan, Italy
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10
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Shimizu H, Nishimura Y, Shiide Y, Akimoto M, Yashiro M, Ueda M, Hirai M, Yoshino H, Mizutani T, Kanai K, Kano O, Kimura H, Sekino H, Ito K. Pharmacokinetics of Edaravone Oral Suspension in Patients With Amyotrophic Lateral Sclerosis. Clin Ther 2023; 45:1251-1258. [PMID: 37953075 DOI: 10.1016/j.clinthera.2023.09.025] [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: 06/28/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Edaravone is a neuroprotective agent approved as an intravenous treatment for amyotrophic lateral sclerosis (ALS). The intravenous administration of edaravone places a burden on patients and there is a clinical need for oral agents for the treatment of ALS. This report aimed to assess the pharmacokinetics and safety of an edaravone oral suspension in patients with ALS after oral and percutaneous endoscopic gastrostomy (PEG) tube administration. METHODS Two single-dose, open-label phase 1 clinical studies were conducted. Edaravone oral suspension (105 mg of edaravone in 5 mL aqueous suspension) was administered orally and via PEG tube to 9 and 6 Japanese patients with ALS, respectively. Plasma and urinary pharmacokinetics of unchanged edaravone and its metabolites (sulfate and glucuronide conjugates) were determined. Safety was also evaluated. FINDINGS After reaching maximum plasma concentration, the mean plasma concentration-time of unchanged edaravone showed a triphasic elimination. Mean plasma concentration-time profiles of the metabolites were higher than those of unchanged edaravone. The mean urinary excretion ratios were higher for the glucuronide conjugate than for either unchanged edaravone or the sulfate conjugate. In patients administered edaravone orally, a single adverse event occurred (blood urine present), which was mild and improved without medical intervention. No adverse drug reactions or serious adverse events were reported. In patients administered edaravone via PEG tube, 5 treatment-emergent adverse events were reported in 3 patients; none were related to the study drug. No adverse drug reactions were reported. IMPLICATIONS In patients with ALS, a single dose of edaravone oral suspension was well absorbed and mainly eliminated in urine as the glucuronide conjugate. No safety concerns emerged. Pharmacokinetics were similar to those previously reported in healthy participants following oral administration. This indicates that effective drug concentrations were achieved and edaravone can be successfully administered both orally and via a PEG tube in patients with ALS. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04176224 (oral administration) and NCT04254913 (PEG tube administration), www. CLINICALTRIALS gov.
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Affiliation(s)
| | | | - Youichi Shiide
- Mitsubishi Tanabe Pharma Corporation, Chiyoda-ku, Tokyo, Japan
| | - Makoto Akimoto
- Mitsubishi Tanabe Pharma Corporation, Chiyoda-ku, Tokyo, Japan
| | - Makiko Yashiro
- Mitsubishi Tanabe Pharma Corporation, Chiyoda-ku, Tokyo, Japan
| | - Masaki Ueda
- Mitsubishi Tanabe Pharma Corporation, Chiyoda-ku, Tokyo, Japan
| | - Manabu Hirai
- Mitsubishi Tanabe Pharma Corporation, Chiyoda-ku, Tokyo, Japan
| | | | | | - Kazuaki Kanai
- Department of Neurology, School of Medicine, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Osamu Kano
- Department of Neurology, Toho University Faculty of Medicine, Ota-ku, Tokyo, Japan
| | - Hideki Kimura
- Tokyo Metropolitan Neurological Hospital, Fuchu, Tokyo, Japan
| | - Hisakuni Sekino
- Sekino Clinical Pharmacology Clinic, Toshima-ku, Tokyo, Japan
| | - Kimiko Ito
- Department of Neurology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
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11
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Swidler J, Olson T, Edelstein AL, Granning J, Haddad C, Uhrlaub M, Wicks P. A new diagnostic entity must enable earlier treatment in gene carriers. Brain 2023; 146:e77-e79. [PMID: 37202873 DOI: 10.1093/brain/awad164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/23/2023] [Indexed: 05/20/2023] Open
Affiliation(s)
- Jean Swidler
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
| | - Tucker Olson
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
| | - Amy L Edelstein
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
| | - Julie Granning
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
| | | | - Mindy Uhrlaub
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
| | - Paul Wicks
- Genetic ALS & FTD: End the Legacy, Philadelphia, PA 19107, USA
- Wicks Digital Health, Lichfield, WS13 6AQ, UK
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12
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Dučić T, Koch JC. Synchrotron-Based Fourier-Transform Infrared Micro-Spectroscopy of Cerebrospinal Fluid from Amyotrophic Lateral Sclerosis Patients Reveals a Unique Biomolecular Profile. Cells 2023; 12:1451. [PMID: 37296572 PMCID: PMC10253168 DOI: 10.3390/cells12111451] [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: 03/14/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease, with the most common adult-onset neurodegenerative disorder affecting motoneurons. Although disruptions in macromolecular conformation and homeostasis have been described in association with ALS, the underlying pathological mechanisms are still not completely understood, and unambiguous biomarkers are lacking. Fourier Transform Infrared Spectroscopy (FTIR) of cerebrospinal fluid (CSF) is appealing to extensive interest due to its potential to resolve biomolecular conformation and content, as this approach offers a non-invasive, label-free identification of specific biologically relevant molecules in a few microliters of CSF sample. Here, we analyzed the CSF of 33 ALS patients compared to 32 matched controls using FTIR spectroscopy and multivariate analysis and demonstrated major differences in the molecular contents. A significant change in the conformation and concentration of RNA is demonstrated. Moreover, significantly increased glutamate and carbohydrates are found in ALS. Moreover, key markers of lipid metabolism are strongly altered; specifically, we find a decrease in unsaturated lipids and an increase in peroxidation of lipids in ALS, whereas the total amount of lipids compared to proteins is reduced. Our study demonstrates that FTIR characterization of CSF could represent a powerful tool for ALS diagnosis and reveals central features of ALS pathophysiology.
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Affiliation(s)
- Tanja Dučić
- CELLS−ALBA, Carrer de la Llum 2-26, Cerdanyola del Valles, 08290 Barcelona, Spain
| | - Jan Christoph Koch
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
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