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van Eijk RPA, van den Berg LH, Lu Y. Cultivating Patient Preferences in ALS Clinical Trials: Reliability and Prognostic Value of the Patient-Ranked Order of Function. Neurology 2024; 103:e209502. [PMID: 38875513 DOI: 10.1212/wnl.0000000000209502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The Patient-Ranked Order of Function (PROOF) is a novel approach to account for patient-reported preferences in the evaluation of treatments of amyotrophic lateral sclerosis (ALS). In this study, we assess the reliability and prognostic value of different sets of patient-reported preferences that can be used for the PROOF end point. METHODS Data were obtained through online surveys over the course of 12 months using the population-based registry of the Netherlands. Patients were asked to score functional domains of the ALS Functional Rating Scale (ALSFRS-R) and rank the order of importance of each domain. Two weeks after the initial invite, the questionnaire was repeated to evaluate test-retest reliability. Vital status was extracted from the municipal population register. RESULTS In total, 611 patients with ALS were followed up for survival and 382 patients were included in the test-retest reliability study. All versions of PROOF, using different sets of preferences, resulted in excellent reliability (intraclass correlation coefficients ranged from 0.89 [95% CI 0.87-0.91] to 0.97 [95% CI 0.97-0.98], all p < 0.001), without systematic differences between baseline and week 2 (mean rank difference range -1 to -3 [95% CI range -8 to 2], all p > 0.20). Preferences about future events were more variable than preferences about current symptoms. All versions of PROOF strongly predicted overall survival (hazard ratios per 10th rank percentile ranged from 0.80 to 0.83 [95% CI range 0.76-0.87], all p < 0.001) and had a more even separation of survival curves between rank-stratified subgroups compared with the ALSFRS-R total score. DISCUSSION In a large cohort of patients, we show how patient-reported preferences can be measured and integrated reliably with the ALSFRS-R without leading to systematic bias. Patient preferences may provide unique prognostic information in addition to what is already measured conventionally. This could provide a more comprehensive understanding of how medical interventions effectively address the patient's concerns and improve what matters most to them.
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Affiliation(s)
- Ruben P A van Eijk
- From the UMC Utrecht Brain Center (R.P.A.v.E., L.H.v.d.B.), University Medical Center Utrecht, the Netherlands; and Department of Biomedical Data Science (Y.L.), Stanford University, CA
| | - Leonard H van den Berg
- From the UMC Utrecht Brain Center (R.P.A.v.E., L.H.v.d.B.), University Medical Center Utrecht, the Netherlands; and Department of Biomedical Data Science (Y.L.), Stanford University, CA
| | - Ying Lu
- From the UMC Utrecht Brain Center (R.P.A.v.E., L.H.v.d.B.), University Medical Center Utrecht, the Netherlands; and Department of Biomedical Data Science (Y.L.), Stanford University, CA
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Michielsen A, van Veenhuijzen K, Janse van Mantgem MR, van Es MA, Veldink JH, van Eijk RPA, van den Berg LH, Westeneng HJ. Association Between Hypothalamic Volume and Metabolism, Cognition, and Behavior in Patients With Amyotrophic Lateral Sclerosis. Neurology 2024; 103:e209603. [PMID: 38875517 DOI: 10.1212/wnl.0000000000209603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Dysfunction of energy metabolism, cognition, and behavior are important nonmotor symptoms of amyotrophic lateral sclerosis (ALS), negatively affecting survival and quality of life, but poorly understood. Neuroimaging is ideally suited to studying nonmotor neurodegeneration in ALS, but few studies have focused on the hypothalamus, a key region for regulating energy homeostasis, cognition, and behavior. We evaluated, therefore, hypothalamic neurodegeneration in ALS and explored the relationship between hypothalamic volumes and dysregulation of energy metabolism, cognitive and behavioral changes, disease progression, and survival. METHODS Patients with ALS and population-based controls were included for this cross-sectional and longitudinal MRI study. The hypothalamus was segmented into 5 subregions and their volumes were calculated. Linear (mixed) models, adjusted for age, sex, and total intracranial volume, were used to compare hypothalamic volumes between groups and to analyze associations with metabolism, cognition, behavior, and disease progression. Cox proportional hazard models were used to investigate the relationship of hypothalamic volumes with survival. Permutation-based corrections for multiple hypothesis testing were applied to all analyses to control the family-wise error rate. RESULTS Data were available for 564 patients with ALS and 356 controls. The volume of the anterior superior subregion of the hypothalamus was smaller in patients with ALS than in controls (β = -0.70 [-1.15 to -0.25], p = 0.013). Weight loss, memory impairments, and behavioral disinhibition were associated with a smaller posterior hypothalamus (β = -4.79 [-8.39 to -2.49], p = 0.001, β = -10.14 [-15.88 to -4.39], p = 0.004, and β = -12.09 [-18.83 to -5.35], p = 0.003, respectively). Furthermore, the volume of this subregion decreased faster over time in patients than in controls (β = -0.25 [0.42 to -0.09], p = 0.013), and a smaller volume of this structure was correlated with shorter survival (hazard ratio = 0.36 [0.21-0.61], p = 0.029). DISCUSSION We obtained evidence for hypothalamic involvement in ALS, specifically marked by atrophy of the anterior superior subregion. Moreover, we found that atrophy of the posterior hypothalamus was associated with weight loss, memory dysfunction, behavioral disinhibition, and survival, and that this subregion deteriorated faster in patients with ALS than in controls. These findings improve our understanding of nonmotor involvement in ALS and could contribute to the identification of new treatment targets for this devastating disease.
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Affiliation(s)
- Annebelle Michielsen
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Kevin van Veenhuijzen
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Mark R Janse van Mantgem
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Michael A van Es
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Jan H Veldink
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Henk-Jan Westeneng
- From the Department of Neurology (A.M., K.V.V., M.R.J.V.M., M.A.V.E., J.H.V., R.P.A.V.E., L.H.V.D.B., H.-J.W.), UMC Utrecht Brain Center, and Biostatistics & Research Support (R.P.A.V.E.), Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
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Peters S, Bouma F, Hoek G, Janssen N, Vermeulen R. Air pollution exposure and mortality from neurodegenerative diseases in the Netherlands: A population-based cohort study. ENVIRONMENTAL RESEARCH 2024; 259:119552. [PMID: 38964584 DOI: 10.1016/j.envres.2024.119552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Long-term exposure to ambient air pollution has been linked with all-cause mortality and cardiovascular and respiratory diseases. Suggestive associations between ambient air pollutants and neurodegeneration have also been reported, but due to the small effect and relatively rare outcomes evidence is yet inconclusive. Our aim was to investigate the associations between long-term air pollution exposure and mortality from neurodegenerative diseases. METHODS A Dutch national cohort of 10.8 million adults aged ≥30 years was followed from 2013 until 2019. Annual average concentrations of air pollutants (ultra-fine particles (UFP), nitrogen dioxide (NO2), fine particles (PM2.5 and PM10) and elemental carbon (EC)) were estimated at the home address at baseline, using land-use regression models. The outcome variables were mortality due to amyotrophic lateral sclerosis (ALS), Parkinson's disease, non-vascular dementia, Alzheimer's disease, and multiple sclerosis (MS). Hazard ratios (HR) were estimated using Cox models, adjusting for individual and area-level socio-economic status covariates. RESULTS We had a follow-up of 71 million person-years. The adjusted HRs for non-vascular dementia were significantly increased for NO2 (1.03; 95% confidence interval (CI) 1.02-1.05) and PM2.5 (1.02; 95%CI 1.01-1.03) per interquartile range (IQR; 6.52 and 1.47 μg/m3, respectively). The association with PM2.5 was also positive for ALS (1.02; 95%CI 0.97-1.07). These associations remained positive in sensitivity analyses and two-pollutant models. UFP was not associated with any outcome. No association with air pollution was found for Parkinson's disease and MS. Inverse associations were found for Alzheimer's disease. CONCLUSION Our findings, using a cohort of more than 10 million people, provide further support for associations between long-term exposure to air pollutants (PM2.5 and particularly NO2) and mortality of non-vascular dementia. No associations were found for Parkinson and MS and an inverse association was observed for Alzheimer's disease.
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Affiliation(s)
- Susan Peters
- Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM, Utrecht, the Netherlands.
| | - Femke Bouma
- Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM, Utrecht, the Netherlands
| | - Gerard Hoek
- Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM, Utrecht, the Netherlands
| | - Nicole Janssen
- National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, the Netherlands
| | - Roel Vermeulen
- Institute for Risk Assessment Sciences, Utrecht University, Yalelaan 2, 3584 CM, Utrecht, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, the Netherlands
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Van Es MA. Amyotrophic lateral sclerosis; clinical features, differential diagnosis and pathology. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:1-47. [PMID: 38802173 DOI: 10.1016/bs.irn.2024.04.011] [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
Amyotrophic lateral sclerosis (ALS) is a late-onset syndrome characterized by the progressive degeneration of both upper motor neurons (UMN) and lower motor neurons (LMN). ALS forms a clinical continuum with frontotemporal dementia (FTD), in which there are progressive language deficits or behavioral changes. The genetics and pathology underlying both ALS and FTD overlap as well, with cytoplasmatic misvocalization of TDP-43 as the hallmark. ALS is diagnosed by exclusion. Over the years several diagnostic criteria have been proposed, which in essence all require a history of slowly progressive motor symptoms, with UMN and LMN signs on neurological examination, clear spread of symptoms through the body, the exclusion of other disorder that cause similar symptoms and an EMG that it is compatible with LMN loss. ALS is heterogeneous disorder that may present in multitude ways, which makes the diagnosis challenging. Therefore, a systematic approach in the diagnostic process is required in line with the most common presentations. Subsequently, assessing whether there are cognitive and/or behavioral changes within the spectrum of FTD and lastly determining the cause is genetic. This chapter, an outline on how to navigate this 3 step process.
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Affiliation(s)
- Michael A Van Es
- Department of Neurology, Brain Center UMC Utrecht, Utrecht, The Netherlands.
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Van Wijk IF, Van Eijk RPA, Van Boxmeer L, Westeneng HJ, Van Es MA, Van Rheenen W, Van Den Berg LH, Eijkemans MJC, Veldink JH. Assessment of risk of ALS conferred by the GGGGCC hexanucleotide repeat expansion in C9orf72 among first-degree relatives of patients with ALS carrying the repeat expansion. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:188-196. [PMID: 37861203 DOI: 10.1080/21678421.2023.2272187] [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: 07/26/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVES We aimed to estimate the age-related risk of ALS in first-degree relatives of patients with ALS carrying the C9orf72 repeat expansion. METHODS We included all patients with ALS carrying a C9orf72 repeat expansion in The Netherlands. Using structured questionnaires, we determined the number of first-degree relatives, their age at death due to ALS or another cause, or age at time of questionnaire. The cumulative incidence of ALS among first-degree relatives was estimated, while accounting for death from other causes. Variability in ALS risk between families was evaluated using a random effects hazards model. We used a second, distinct approach to estimate the risk of ALS and FTD in the general population, using previously published data. RESULTS In total, 214 of the 2,486 (9.2%) patients with ALS carried the C9orf72 repeat expansion. The mean risk of ALS at age 80 for first-degree relatives carrying the repeat expansion was 24.1%, but ranged between individual families from 16.0 to 60.6%. Using the second approach, we found the risk of ALS and FTD combined was 28.7% (95% CI 17.8%-54.3%) for carriers in the general population. CONCLUSIONS On average, our estimated risk of ALS in the C9orf72 repeat expansion was lower compared to historical estimates. We showed, however, that the risk of ALS likely varies between families and one overall penetrance estimate may not be sufficient to describe ALS risk. This warrants a tailor-made, patient-specific approach in testing. Further studies are needed to assess the risk of FTD in the C9orf72 repeat expansion.
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Affiliation(s)
- Iris F Van Wijk
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Ruben P A Van Eijk
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Loes Van Boxmeer
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Henk-Jan Westeneng
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Michael A Van Es
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Wouter Van Rheenen
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Leonard H Van Den Berg
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Marinus J C Eijkemans
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
| | - Jan H Veldink
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands and
- Research support and Biostatistics, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, Netherlands
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van Eijk RPA, van den Berg LH, Roes KCB, Tian L, Lai TL, Nelson LM, Li C, Scowcroft A, Garcia-Segovia J, Lu Y. Hybrid Controlled Clinical Trials Using Concurrent Registries in Amyotrophic Lateral Sclerosis: A Feasibility Study. Clin Pharmacol Ther 2023; 114:883-892. [PMID: 37422655 DOI: 10.1002/cpt.2994] [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: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
Hybrid designs with both randomized arms and an external control cohort preserve key features of randomization and utilize external information to augment clinical trials. In this study, we propose to leverage high-quality, patient-level concurrent registries to enhance clinical trials and illustrate the impact on trial design for amyotrophic lateral sclerosis. The proposed methodology was evaluated in a randomized, placebo-controlled clinical trial. We used patient-level information from a well-defined, population-based registry, that was running parallel to the randomized clinical trial, to identify concurrently nonparticipating, eligible patients who could be matched with trial participants, and integrate them into the statistical analysis. We assessed the impact of the addition of the external controls on the treatment effect estimate, precision, and time to reach a conclusion. During the runtime of the trial, a total of 1,141 registry patients were alive; 473 (41.5%) of them fulfilled the eligibility criteria and 133 (11.7%) were enrolled in the study. A matched control population could be identified among the nonparticipating patients. Augmenting the randomized controls with matched external controls could have avoided unnecessary randomization of 17 patients (-12.8%) as well as reducing the study duration from 30.1 months to 22.6 months (-25.0%). Matching eligible external controls from a different calendar period led to bias in the treatment effect estimate. Hybrid trial designs utilizing a concurrent registry with rigorous matching can minimize bias due to a mismatch in calendar time and differences in standard of care, and may accelerate the development of new treatments.
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Affiliation(s)
- Ruben P A van Eijk
- Department of Biomedical Data Science and Centre for Innovative Study Design, School of Medicine, Stanford University, Stanford, California, USA
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Kit C B Roes
- Section Biostatistics, Department of Health Evidence, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Lu Tian
- Department of Biomedical Data Science and Centre for Innovative Study Design, School of Medicine, Stanford University, Stanford, California, USA
| | - Tze L Lai
- Department of Biomedical Data Science and Centre for Innovative Study Design, School of Medicine, Stanford University, Stanford, California, USA
| | - Lorene M Nelson
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, USA
| | - Chenyu Li
- Department of Biomedical Data Science and Centre for Innovative Study Design, School of Medicine, Stanford University, Stanford, California, USA
| | | | | | - Ying Lu
- Department of Biomedical Data Science and Centre for Innovative Study Design, School of Medicine, Stanford University, Stanford, California, USA
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California, USA
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de Jongh AD, van Eijk RPA, Bakker LA, Bunte TM, Beelen A, van der Meijden C, van Es MA, Visser-Meily JMA, Kruitwagen ET, Veldink JH, van den Berg LH. Development of a Rasch-Built Amyotrophic Lateral Sclerosis Impairment Multidomain Scale to Measure Disease Progression in ALS. Neurology 2023; 101:e602-e612. [PMID: 37311649 PMCID: PMC10424842 DOI: 10.1212/wnl.0000000000207483] [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: 12/08/2022] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Current scales used in amyotrophic lateral sclerosis (ALS) attempt to summarize different functional domains or "dimensions" into 1 overall score, which may not accurately characterize the individual patient's disease severity or prognosis. The use of composite score risks declaring treatments ineffective if not all dimensions of ALS disease progression are affected equally. We aimed to develop the ALS Impairment Multidomain Scale (AIMS) to comprehensively characterize disease progression and increase the likelihood of identifying effective treatments. METHODS The Revised ALS Functional Rating Scale (ALSFRS-R) and a preliminary questionnaire, based on literature review and patient input, were completed online by patients from the Netherlands ALS registry at bimonthly intervals over a period of 12 months. A 2-week test-retest, factor analysis, Rasch analysis, and a signal-to-noise optimization strategy were performed to create a multidomain scale. Reliability, longitudinal decline, and associations with survival were evaluated. The sample size required to detect a 35% reduction in progression rate over 6 or 12 months was assessed for a clinical trial that defines the ALSFRS-R or AIMS subscales as a primary endpoint family. RESULTS The preliminary questionnaire, consisting of 110 questions, was completed by 367 patients. Three unidimensional subscales were identified, and a multidomain scale was constructed with 7 bulbar, 11 motor, and 5 respiratory questions. Subscales fulfilled Rasch model requirements, with excellent test-retest reliability of 0.91-0.94 and a strong relationship with survival (p < 0.001). Compared with the ALSFRS-R, signal-to-noise ratios were higher as patients declined more uniformly per subscale. Consequently, the estimated sample size reductions achieved with the AIMS compared with those achieved with the ALSFRS-R were 16.3% and 25.9% for 6-month and 12-month clinical trials, respectively. DISCUSSION We developed the AIMS, consisting of unidimensional bulbar, motor, and respiratory subscales, which may characterize disease severity better than a total score. AIMS subscales have high test-retest reliability, are optimized to measure disease progression, and are strongly related to survival time. The AIMS can be easily administered and may increase the likelihood of identifying effective treatments in ALS clinical trials.
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Affiliation(s)
- Adriaan D de Jongh
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Ruben P A van Eijk
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Leonhard A Bakker
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Tommy M Bunte
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Anita Beelen
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Conny van der Meijden
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Michael A van Es
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Johanna M A Visser-Meily
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Esther T Kruitwagen
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Jan H Veldink
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands
| | - Leonard H van den Berg
- From the Department of Neurology (A.D.d.J., R.P.A.v.E., L.A.B., T.M.B., M.A.v.E., J.H.V., L.H.v.d.B.), UMC Utrecht Brain Center, University Medical Center Utrecht; Department of Neurology (A.D.d.J.), Tergooi Hospital, Blaricum; Biostatistics & Research Support (R.P.A.v.E.), Julius Center for Health Sciences and Primary Care, Department of Rehabilitation, Physical Therapy Science and Sports (L.A.B., A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, and Center of Excellence for Rehabilitation Medicine (A.B., J.M.A.V.-M., E.T.K.), UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation; and ALS Patients Connected (C.v.d.M.), Bilthoven, the Netherlands.
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van Eenennaam RM, Kruithof W, Beelen A, Bakker LA, van Eijk RPA, Maessen M, Baardman JF, Visser-Meily JMA, Veldink JH, van den Berg LH. Frequency of euthanasia, factors associated with end-of-life practices, and quality of end-of-life care in patients with amyotrophic lateral sclerosis in the Netherlands: a population-based cohort study. Lancet Neurol 2023; 22:591-601. [PMID: 37353279 DOI: 10.1016/s1474-4422(23)00155-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis is a progressive and lethal neurodegenerative disease that is at the forefront of debates on regulation of assisted dying. Since 2002, when euthanasia was legally regulated in the Netherlands, the frequency of this end-of-life practice has increased substantially from 1·7% of all deaths in 1990 and 2005 to 4·5% in 2015. We aimed to investigate whether the frequency of euthanasia in patients with amyotrophic lateral sclerosis had similarly increased since 2002, and to assess the factors associated with end-of-life practices and the quality of end-of-life care in patients with this disease. METHODS Using data from the Netherlands ALS registry, we did a population-based cohort study of clinicians and informal caregivers of patients with amyotrophic lateral sclerosis to assess factors associated with end-of-life decision making and the quality of end-of-life care. We included individuals who were diagnosed with amyotrophic lateral sclerosis according to the revised El-Escorial criteria, and who died between Jan 1, 2014, and Dec 31, 2016. We calculated the frequency of euthanasia in patients with amyotrophic lateral sclerosis from reports made to euthanasia review committees (ERCs) between 2012 and 2020. Results were compared with clinic-based survey studies conducted in 1994-2005. End-of-life practices were end-of-life decisions by a clinician when hastening of death was considered as the potential, probable, or definite effect comprising euthanasia, physician-assisted suicide, ending of life without explicit request, forgoing life-prolonging treatment, and intensified alleviation of symptoms. FINDINGS Between Jan 1, 2012, and Dec 31, 2020, 4130 reports of death from amyotrophic lateral sclerosis were made to ERCs, of which 1014 were from euthanasia or physician-assisted suicide (mean frequency 25% [SD 3] per year). Sex and gender data were unavailable from the ERC registry. Of 884 patients with amyotrophic lateral sclerosis who died between Jan 1, 2014, and Dec 31, 2016, their treating clinician was identified for 731 and a caregiver was identified for 741, of whom 356 (49%) and 450 (61%), respectively, agreed to participate in the population-based survey study. According to clinicians, end-of-life practices were chosen by 280 (79%) of 356 patients with amyotrophic lateral sclerosis who died. The frequency of euthanasia in patients with amyotrophic lateral sclerosis in 2014-16 (141 [40%] of 356 deaths in patients with amyotrophic lateral sclerosis) was higher than in 1994-98 (35 [17%] of 203) and 2000-05 (33 [16%] of 209). Median survival of patients with amyotrophic lateral sclerosis from diagnosis was 15·9 months (95% CI 12·6-17·6) for those who chose euthanasia and 16·1 months (13·4-19·1) for those who did not choose euthanasia (hazard ratio 1·07, 95% CI 0·85-1·34; p=0·58). According to caregivers, compared with other end-of-life practices, patients with amyotrophic lateral sclerosis choosing euthanasia commonly reported reasons to hasten death as no chance of improvement (53 [56%] of 94 patients who chose euthanasia vs 28 [39%] of 72 patients who chose other end-of-life practices), loss of dignity (47 [50%] vs 15 [21%]), dependency (34 [36%] vs five [7%]), and fatigue or extreme weakness (41 [44%] vs 14 [20%]). According to caregivers, people with amyotrophic lateral sclerosis-whether they chose euthanasia or did not-were satisfied with the general quality (83 [93%] of 89 patients who chose euthanasia vs 73 [86%] of 85 patients who did not) and availability (85 [97%] of 88 vs 81 [91%] of 90) of end-of-life care. INTERPRETATION The proportion of patients with amyotrophic lateral sclerosis who chose euthanasia in the Netherlands has increased since 2002. The choice of euthanasia was not associated with disease or patient characteristics, depression or hopelessness, or the availability or quality of end-of-life care. The choice of euthanasia had no effect on overall survival. Future studies could focus on the effect of discussing end-of-life options on quality of life as part of multidisciplinary care throughout the course of the disease, to reduce feelings of loss of autonomy and dignity in patients living with amyotrophic lateral sclerosis. FUNDING Netherlands ALS Foundation.
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Affiliation(s)
- Remko M van Eenennaam
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Willeke Kruithof
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Leonhard A Bakker
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Maud Maessen
- University Center for Palliative Care, Inselspital University Hospital Bern, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Joost F Baardman
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Johanna M A Visser-Meily
- Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands; De Hoogstraat Rehabilitation, Utrecht, Netherlands
| | - Jan H Veldink
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, Netherlands.
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Yamashita S, Tawara N, Hara K, Ueda M. Gender differences in clinical features at the initial examination of late-onset amyotrophic lateral sclerosis. J Neurol Sci 2023; 451:120697. [PMID: 37295193 DOI: 10.1016/j.jns.2023.120697] [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: 04/12/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that mainly affects motor neurons in the brain and spinal cord. With the advent of aging societies, the proportion of elderly patients with ALS is expected to increase. METHODS We retrospectively compared the clinical characteristics at the initial examination of patients with onset of ALS at age 74 years or younger (early onset) and those aged 75 years or older at onset (late-onset) at a single regional ALS diagnostic center in Japan. RESULTS The phenotype of late-onset ALS differed between males and females, with late-onset females having more bulbar-onset ALS and significantly lower body mass index, late-onset males having more frequent bulbar and respiratory symptoms at the initial examination, and significantly lower forced vital capacity at the initial examination in both groups compared to early onset patients. CONCLUSION For late-onset patients, maintenance of skeletal muscle mass by early intervention for bulbar and respiratory symptoms may be useful for prolonging survival; however, a prospective analysis is warranted.
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Affiliation(s)
- Satoshi Yamashita
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Neurology, International University of Health and Welfare Narita Hospital, Narita, Japan.
| | - Nozomu Tawara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kentaro Hara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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10
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Mata S, Bussotti M, Del Mastio M, Barilaro A, Piersanti P, Lombardi M, Cincotta M, Torricelli S, Leccese D, Sperti M, Rodolico GR, Nacmias B, Sorbi S. Epidemiology of amyotrophic lateral sclerosis in the north east Tuscany in the 2018–2021 period. eNeurologicalSci 2023; 31:100457. [PMID: 37008534 PMCID: PMC10063398 DOI: 10.1016/j.ensci.2023.100457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/14/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Background The incidence of Amyotrophic Lateral Sclerosis (ALS) varies among different geographical areas and seems to increase over time. This study aimed to examine the epidemiologic data of ALS in the north-east Tuscany and compare the results with those of similar surveys. Methods Data from ALS cases diagnosed in Florence and Prato Hospitals were prospectively collected from 1st June 2018 to 31st May 2021. Results The age- and sex-adjusted incidence rate of ALS in cases per 100,000 population was 2.71 (M/F ratio: 1.21), significantly higher as compared to that reported in the 1967-1976 decade in the same geographical area (0.714). The age- and sex-adjusted incidence rate among resident strangers was similar to that of the general population (2.69). A slightly higher incidence rate (4.36) was observed in the north-east area of Florence province, which includes the Mugello valley. The mean prevalence was of 7.17/100,00. The mean age at diagnosis was 69.7 years, with a peak between 70 and 79 years among men and a smoother age curve among women. Conclusions ALS epidemiological features in north-east Tuscany are in line with other Italian and European Centers. The dramatic increase of the local disease burden over the last decades probably reflects better ascertainment methods and health system.
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Bos JW, Groen EJN, Budding K, Delemarre EM, Goedee HS, Knol EF, van den Berg LH, van der Pol WL. Multifocal motor neuropathy is not associated with altered innate immune responses to endotoxin. J Neurol Sci 2023; 451:120692. [PMID: 37422959 DOI: 10.1016/j.jns.2023.120692] [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: 01/24/2023] [Revised: 04/19/2023] [Accepted: 05/22/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Antibody- and complement-mediated peripheral nerve inflammation are central in the pathogenesis of MMN. Here, we studied innate immune responses to endotoxin in patients with MMN and controls to further our understanding of MMN risk factors and disease modifiers. METHODS We stimulated whole blood of 52 patients with MMN and 24 controls with endotoxin and collected plasma. With a multiplex assay, we determined levels of the immunoregulating proteins IL-1RA, IL-1β, IL-6, IL-10, IL-21, TNF-α, IL-8 and CD40L in unstimulated and LPS-stimulated plasma. We compared baseline and stimulated protein levels between patients and controls and correlated concentrations to clinical parameters. RESULTS Protein level changes after stimulation were comparable between groups (p > 0.05). IL-1RA, IL-1β, IL-6 and IL-21 baseline concentrations showed a positive correlation with monthly IVIg dosage (all corrected p-values < 0.016). Patients with anti-GM1 IgM antibodies showed a more pronounced IL-21 increase after stimulation (p 0.048). CONCLUSIONS Altered endotoxin-induced innate immune responses are unlikely to be a susceptibility factor for MMN.
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Affiliation(s)
- Jeroen W Bos
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Ewout J N Groen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Kevin Budding
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Eveline M Delemarre
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Edward F Knol
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
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Spencer PS, Palmer VS, Kisby GE, Lagrange E, Horowitz BZ, Valdes Angues R, Reis J, Vernoux JP, Raoul C, Camu W. Early-onset, conjugal, twin-discordant, and clusters of sporadic ALS: Pathway to discovery of etiology via lifetime exposome research. Front Neurosci 2023; 17:1005096. [PMID: 36860617 PMCID: PMC9969898 DOI: 10.3389/fnins.2023.1005096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/09/2023] [Indexed: 02/17/2023] Open
Abstract
The identity and role of environmental factors in the etiology of sporadic amyotrophic lateral sclerosis (sALS) is poorly understood outside of three former high-incidence foci of Western Pacific ALS and a hotspot of sALS in the French Alps. In both instances, there is a strong association with exposure to DNA-damaging (genotoxic) chemicals years or decades prior to clinical onset of motor neuron disease. In light of this recent understanding, we discuss published geographic clusters of ALS, conjugal cases, single-affected twins, and young-onset cases in relation to their demographic, geographic and environmental associations but also whether, in theory, there was the possibility of exposure to genotoxic chemicals of natural or synthetic origin. Special opportunities to test for such exposures in sALS exist in southeast France, northwest Italy, Finland, the U.S. East North Central States, and in the U.S. Air Force and Space Force. Given the degree and timing of exposure to an environmental trigger of ALS may be related to the age at which the disease is expressed, research should focus on the lifetime exposome (from conception to clinical onset) of young sALS cases. Multidisciplinary research of this type may lead to the identification of ALS causation, mechanism, and primary prevention, as well as to early detection of impending ALS and pre-clinical treatment to slow development of this fatal neurological disease.
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Affiliation(s)
- Peter S. Spencer
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, United States,*Correspondence: Peter S. Spencer,
| | - Valerie S. Palmer
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Glen E. Kisby
- College of Osteopathic Medicine of the Pacific Northwest, Western University of Health Sciences, Lebanon, OR, United States
| | - Emmeline Lagrange
- Department of Neurology, Reference Center of Neuromuscular Disease and ALS Consultations, Grenoble University Hospital, Grenoble, France
| | - B. Zane Horowitz
- Department of Emergency Medicine, Oregon-Alaska Poison Center, Oregon Health and Science University, Portland, OR, United States
| | - Raquel Valdes Angues
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States
| | - Jacques Reis
- University of Strasbourg, Faculté de Médecine, Strasbourg, France
| | - Jean-Paul Vernoux
- Normandie Université, UNICAEN, Unité de Recherche Aliments Bioprocédés Toxicologie Environnements, Caen, France
| | - Cédric Raoul
- INM, University of Montpellier, INSERM, Montpellier, France
| | - William Camu
- ALS Reference Center, Montpellier University Hospital and University of Montpellier, INSERM, Montpellier, France
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Nona RJ, Xu Z, Robinson GA, Henderson RD, McCombe PA. Age of Onset and Length of Survival of Queensland Patients with Amyotrophic Lateral Sclerosis: Details of Subjects with Early Onset and Subjects with Long Survival. NEURODEGENER DIS 2022; 22:104-121. [PMID: 36587610 PMCID: PMC10627495 DOI: 10.1159/000528875] [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: 06/16/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The aims of the study were to document the characteristics of amyotrophic lateral sclerosis (ALS) patients in Queensland, to examine factors influencing age of onset, and survival, and to study those with early-onset (<45 years) disease and those with long (>5 years) survival. METHODS We studied subjects seen at the ALS Clinic at the Royal Brisbane and Women's Hospital. We recorded sex, age of onset, region of onset, length of survival, presence of family history, type of disease, and evidence of cognitive involvement. We analysed the influence of these features on age of onset and survival. We analysed the features of patients with early onset of disease and patients with long survival. RESULTS There were 855 ALS patients (505 males) in the cohort. The age of onset was lower in males than females, in patients with a family history of ALS compared to those without, and in patients with spinal onset compared to bulbar onset. Early-onset disease was seen in 10% of patients, and had a greater proportion of males, spinal onset, and classical ALS phenotype compared to late-onset disease. Survival was shorter in females, in patients with bulbar onset, and in patients with classical ALS. Long survival was seen in 18% of patients. Patients with long survival had younger age of onset, greater proportion of males, spinal onset, and fewer patients with classical ALS. CONCLUSION Our study confirms that ALS is more prevalent in males and that spinal onset is more common than bulbar onset. Males have earlier onset but longer survival. We found that overall, patients with classical ALS have worse survival than ALS variants, but some patients who were considered to have classical ALS had long survival. This study confirms the similarity of ALS in our region to ALS in other geographical regions.
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Affiliation(s)
- Robert J. Nona
- Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
| | - Zhouwei Xu
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Gail A. Robinson
- Queensland Brain Institute and School of Psychology, University of Queensland, St Lucia, Queensland, Australia
| | - Robert D. Henderson
- Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Pamela A. McCombe
- Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
- Department of Neurology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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de Jongh AD, Braun N, Weber M, van Es MA, Masrori P, Veldink JH, van Damme P, van den Berg LH, van Eijk RPA. Characterising ALS disease progression according to El Escorial and Gold Coast criteria. J Neurol Neurosurg Psychiatry 2022; 93:865-870. [PMID: 35654584 DOI: 10.1136/jnnp-2022-328823] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/20/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Gold Coast criteria (GCC) have been proposed as a means of selecting patients for amyotrophic lateral sclerosis (ALS) clinical trials. We aimed to characterise disease progression according to the GCC. METHODS Data from population-based ALS registries from the Netherlands and Belgium were analysed. The GCC additionally define ALS as lower motor neuron (LMN) dysfunction in ≥2 body regions without upper motor neuron dysfunction. Therefore, the revised El Escorial criteria (rEEC) were supplemented with a 'Gold Coast ALS' category for patients with only LMN dysfunction in ≥2 body regions. We assessed survival time, ALS Functional Rating Scale (ALSFRS-R) progression rates and between-patient variability per diagnostic category. RESULTS We included 5957 ALS patients, of whom 600 (10.1%) fulfilled the GCC but not the rEEC, and 95 (1.6%) fulfilled only the rEEC. ALSFRS-R progression rates were similar for the rEEC (0.84 points/month) and GCC (0.81 points/month) with similar variability (standard deviation of 0.59 vs. 0.60) and median survival time (17.8 vs.18.7 months). Survival time and average progression rates varied (p<0.001) between categories. Per category, however, there was considerable between-patient variability with progression rates ranging from: -2.10 to -0.14 (definite), -1.94 to -0.06 (probable), -2.10 to -0.02 (probable laboratory supported), -1.79 to -0.02 (possible) and -1.31 to 0.08 (Gold Coast). CONCLUSIONS The GCC broaden the definition of ALS, allowing more patients to participate in trials, while minimally impacting population heterogeneity. Given the large variability per diagnostic category, selecting only specific categories for trials may not result in a more homogeneous study population.
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Affiliation(s)
- Adriaan D de Jongh
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Nathalie Braun
- Neuromuscular Diseases Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Markus Weber
- Neuromuscular Diseases Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Michael A van Es
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Pegah Masrori
- Department of Neurosciences, Laboratory for Neurobiology, KU Leuven and Center for Brain & Disease Research, VIB, Leuven Brain Institute, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Jan H Veldink
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Philip van Damme
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Ruben P A van Eijk
- Department of Neurology, University Medical Center Utrecht Brain Center Rudolf Magnus, Utrecht, The Netherlands .,Biostatistics & Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Park J, Kim JE, Song TJ. The Global Burden of Motor Neuron Disease: An Analysis of the 2019 Global Burden of Disease Study. Front Neurol 2022; 13:864339. [PMID: 35528743 PMCID: PMC9068990 DOI: 10.3389/fneur.2022.864339] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Up-to-date, accurate information on the disease burden of motor neuron disease (MND) is the cornerstone for evidence-based resource allocation and healthcare planning. We aimed to estimate the burden of MND globally from 1990 to 2019, as part of the Global Burden of Disease, Injuries and Risk Factor (GBD) study. Amyotrophic lateral sclerosis, progressive muscular atrophy, primary lateral sclerosis, pseudobulbar palsy, spinal muscular atrophy and hereditary spastic paraplegia- were included for analysis as MNDs. We measured age-standardized incidence, prevalence, death, and disability-adjusted life-years (DALYs) in 204 countries and territories worldwide from 1990 to 2019 using spatial Bayesian analyses. The effects of age, sex, and the sociodemographic index (measures of income per capita, education, and fertility) on incidence, prevalence, death, and disability-adjusted life-years due to MNDs were explored. According to 2019 GBD estimates, there were ~268,673 [95% uncertainty interval (UI), 213,893-310,663] prevalent cases and 63,700 (95% UI, 57,295-71,343) incident cases of MND worldwide. In 2019, MND caused 1,034,606 (95% UI, 979,910-1,085,401) DALYs and 39,081 (95% UI, 36,566-41,129) deaths worldwide. The age-standardized rates of prevalence, incidence, death, and DALYs for MNDs in 2019 were 3.37 (95% UI, 2.9-3.87) per 100,000 people, 0.79 (95% UI, 0.72-0.88) per 100,000 people, 0.48 (95% UI, 0.45-0.51) per 100,000 people, and 12.66 (95% UI, 11.98-13.29) per 100,000 people, respectively. The global prevalence and deaths due to MND in 2019 were increased (1.91% [95% UI, 0.61-3.42] and 12.39% [95% UI, 5.81-19.27], respectively) compared to 1990, without significant change in incidence. More than half of the prevalence and deaths due to MND occurred in three high-income regions (North America, Western Europe, and Australasia). In most cases, the prevalence, incidence, and DALYs of MNDs were high in regions with high sociodemographic index; however, in high-income East Asia, these were relatively low compared to similar sociodemographic index groups elsewhere. The burden of MND increased between 1990 and 2019. Its expected increase in the future highlights the importance of global and national healthcare planning using more objective evidence. Geographical heterogeneity in the MND burden might suggest the influences of sociodemographic status and genetic background in various regions.
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Affiliation(s)
- Jin Park
- Department of Neurology, Seoul Hospital Ewha Womans University College of Medicine, Seoul, South Korea
| | - Jee-Eun Kim
- Department of Neurology, Seoul Hospital Ewha Womans University College of Medicine, Seoul, South Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital Ewha Womans University College of Medicine, Seoul, South Korea
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16
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Andrew A, Zhou J, Gui J, Harrison A, Shi X, Li M, Guetti B, Nathan R, Tischbein M, Pioro E, Stommel E, Bradley W. Airborne lead and polychlorinated biphenyls (PCBs) are associated with amyotrophic lateral sclerosis (ALS) risk in the U.S. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 819:153096. [PMID: 35041949 PMCID: PMC10752436 DOI: 10.1016/j.scitotenv.2022.153096] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/09/2022] [Accepted: 01/09/2022] [Indexed: 06/14/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) risk is linked to environmental exposures. The National Emissions Inventory (NEI) database compiles mandatory reports of levels of airborne contaminants from a variety of stationary and mobile pollution sources across the U.S. The objective of this study was to identify airborne contaminants that may be associated with ALS etiology for future study. We geospatially estimated exposure to airborne contaminants as risk factors for ALS in a nationwide large de-identified medical claims database, the SYMPHONY Integrated Dataverse®. We extracted zip3 of residence at diagnosis of ~26,000 nationally distributed ALS patients and n = 3 non-ALS controls matched per case for age and sex. We individually aggregated the median levels of each of 268 airborne contaminants recorded in the NEI database for 2008 to estimate local residential exposure. We randomly broke the dataset into two independent groups to form independent discovery and validation cohorts. Contaminants associated with increased ALS risk in both the discovery and validation studies included airborne lead (false discovery rate (FDR) = 0.00077), and polychlorinated biphenyls (PCBs), such as heptachlorobiphenyl (FDR = 3.60E-05). Small aircraft were the largest source of airborne lead, while the PCB emissions came from certain power plants burning biomass, and from industrial boilers. Associations with residential history of lead exposure were confirmed in two additional cohorts (10 year top quartile in New Hampshire/Vermont OR 2.46 95% CI 1.46-2.80, and in Ohio OR 1.60 95% CI 1.28-1.98). The results of our geospatial analysis support neurotoxic airborne metals and PCBs as risk factors for ALS.
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Affiliation(s)
- Angeline Andrew
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
| | - Jie Zhou
- Dartmouth College, Hanover, NH, United States of America
| | - Jiang Gui
- Dartmouth College, Hanover, NH, United States of America
| | - Antoinette Harrison
- Mitsubishi Tanabe Pharma America, Inc., Jersey City, NJ, United States of America
| | - Xun Shi
- Dartmouth College, Hanover, NH, United States of America
| | - Meifang Li
- Dartmouth College, Hanover, NH, United States of America
| | - Bart Guetti
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | | | - Maeve Tischbein
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Erik Pioro
- Cleveland Clinic, Cleveland, OH, United States of America
| | - Elijah Stommel
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Walter Bradley
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States of America
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17
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Kennedy P, Conroy É, Heverin M, Leroi I, Beelen A, van den Berg L, Hardiman O, Galvin M. Burden and benefit-A mixed methods study of informal Amyotrophic Lateral Sclerosis caregivers in Ireland and the Netherlands. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5704. [PMID: 35362219 PMCID: PMC9315024 DOI: 10.1002/gps.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 03/13/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Amyotrophic Lateral Sclerosis (ALS) is a systemic and terminal disorder of the central nervous system which causes paralysis of limbs, respiratory and bulbar muscles, impacting on physical, communication, cognitive and behavioural functioning. Informal caregivers play a key role in the care of people with ALS. This study aimed to explore experiences of burden along with any beneficial aspects of caregiving in ALS. An understanding of both burden and benefit is important to support the informal caregiver and the person with ALS. METHODS/DESIGN This exploratory mixed methods study characterizes two groups of informal caregivers in Ireland (n = 76) and the Netherlands (n = 58). In a semi-structured interview, quantitative data were collected in the form of standardized measures assessing psychological distress, quality of life and burden. Qualitative data were collected from an open ended question, in which caregivers identified positive aspects in their caregiving experience. These data types were purposefully mixed in the analysis and interpretation stages, to provide a greater depth of evidence through diverse research lenses. RESULTS The caregiver cohorts were predominantly female (69%) and spouse/partners (84%) of the person with ALS. Greater levels of self-assessed burden were found among the caregivers in the Netherlands (p < 0.05), and higher levels of quality of life among the cohort from Ireland (p < 0.05). Themes generated through qualitative analysis identified caregiver satisfaction, ability to meet the patient's needs and the (re) evaluation of meaning and existential aspects of life as positive aspects of caregiving. Existential factors were identified frequently by the caregivers in Ireland, and personal satisfaction and meeting their care recipient's needs by caregivers in the Netherlands. Three percent of all respondents reported there was nothing positive about caregiving. CONCLUSIONS Based on our findings, we suggest that both burden and the presence of positive factors should be evaluated and monitored. The possibility of concurrent positive and challenging experiences should be considered in the design and delivery of supportive interventions for informal caregivers.
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Affiliation(s)
- Polly Kennedy
- Academic Unit of NeurologySchool of MedicineTrinity College DublinDublinIreland
| | - Éilís Conroy
- Academic Unit of NeurologySchool of MedicineTrinity College DublinDublinIreland
| | - Mark Heverin
- Academic Unit of NeurologySchool of MedicineTrinity College DublinDublinIreland
| | - Iracema Leroi
- Department of Psychiatry St James' HospitalGlobal Brain Health InstituteTrinity College DublinDublinIreland
| | - Anita Beelen
- Center of Excellence for Rehabilitation MedicineUMC Utrecht Brain CenterUniversity Medical Center Utrecht, and De Hoogstraat RehabilitationUtrechtThe Netherlands
| | - Leonard van den Berg
- Department of NeurologyUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Orla Hardiman
- Academic Unit of NeurologySchool of MedicineTrinity College DublinDublinIreland
- Department of NeurologyBeaumont HospitalDublinIreland
| | - Miriam Galvin
- Academic Unit of NeurologySchool of MedicineTrinity College DublinDublinIreland
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18
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Burchardt JM, Mei XW, Ranger T, McDermott CJ, Radunovic A, Coupland C, Hippisley-Cox J. Analysis of incidence of motor neuron disease in England 1998-2019: use of three linked datasets. Amyotroph Lateral Scler Frontotemporal Degener 2022; 23:363-371. [PMID: 35103515 PMCID: PMC9344929 DOI: 10.1080/21678421.2021.2016837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: This study uses three linked datasets to provide an estimate of incidence of motor neuron disease (MND) in England from 1998 to 2019. Comparison is made to previous British studies. It examines age at diagnosis and ethnicity of those affected. Methods: The literature was searched for studies of MND incidence in Great Britain from 1995 to date. The QResearch and linked Hospital Episode Statistics and Death register databases were searched from 1998 to 2019 for cases of MND, and incidence calculated from 16.8 million adults and 112 million adult years of data. Results: We found 6437 adults with a diagnosis of MND giving an incidence of MND of 5.69/100,000 person years (95% CI 5.51–5.88); 6.57 (6.41–6.99) in men and 4.72 (4.49–4.97) in women when age-standardized to the 2011 UK population. The median age of diagnosis was 72 years. Peak incidence occurred in the 80–84 year age group in men and 75–79 in women. Age-standardized incidence was as high in Bangladeshi, Black Caribbean, Indian, other Asian and Pakistani people as in White people. Black African and Chinese people had a lower incidence. Conclusion: The use of three linked national datasets captured 33% more people than a primary care dataset alone. Patients were older than in previous studies and rates were high in all ethnic groups studied except Black African and Chinese people. We present the highest incidence of MND reported globally in the past 50 years. Methodological differences may in part explain differences with previous reports. The use of national datasets may have captured additional MND patients with serious comorbidities who have not seen a neurologist before death. A limitation of this approach is that unlike population registers, which minimize false positive diagnosis by neurologist review of each patient, we cannot review diagnosis for individuals as data are anonymized.
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Affiliation(s)
- Judith M Burchardt
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England
| | - Xue W Mei
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England
| | - Tom Ranger
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England
| | | | | | - Carol Coupland
- School of Medicine, University of Nottingham, Nottingham, England
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, England
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19
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Carey IM, Banchoff E, Nirmalananthan N, Harris T, DeWilde S, Chaudhry UAR, Cook DG. Prevalence and incidence of neuromuscular conditions in the UK between 2000 and 2019: A retrospective study using primary care data. PLoS One 2021; 16:e0261983. [PMID: 34972157 PMCID: PMC8719665 DOI: 10.1371/journal.pone.0261983] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the UK, large-scale electronic primary care datasets can provide up-to-date, accurate epidemiological information on rarer diseases, where specialist diagnoses from hospital discharges and clinic letters are generally well recorded and electronically searchable. Current estimates of the number of people living with neuromuscular disease (NMD) have largely been based on secondary care data sources and lacked direct denominators. OBJECTIVE To estimate trends in the recording of neuromuscular disease in UK primary care between 2000-2019. METHODS The Clinical Practice Research Datalink (CPRD) database was searched electronically to estimate incidence and prevalence rates (per 100,000) for a range of NMDs in each year. To compare trends over time, rates were age standardised to the most recent CPRD population (2019). RESULTS Approximately 13 million patients were actively registered in each year. By 2019, 28,230 active patients had ever received a NMD diagnosis (223.6), which was higher among males (239.0) than females (208.3). The most common classifications were Guillain-Barre syndrome (40.1), myasthenia gravis (33.7), muscular dystrophy (29.5), Charcot-Marie-Tooth (29.5) and inflammatory myopathies (25.0). Since 2000, overall prevalence grew by 63%, with the largest increases seen at older ages (≥65-years). However, overall incidence remained constant, though myasthenia gravis incidence has risen steadily since 2008, while new cases of muscular dystrophy fell over the same period. CONCLUSIONS Lifetime recording of many NMDs on primary care records exceed current estimates of people living with these conditions; these are important data for health service and care planning. Temporal trends suggest this number is steadily increasing, and while this may partially be due to better recording, it cannot be simply explained by new cases, as incidence remained constant. The increase in prevalence among older ages suggests increases in life expectancy among those living with NMDs may have occurred.
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Affiliation(s)
- Iain M. Carey
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | - Emma Banchoff
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | | | - Tess Harris
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | - Stephen DeWilde
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | - Umar A. R. Chaudhry
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
| | - Derek G. Cook
- Population Health Research Institute, St George’s, University of London, London, United Kingdom
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20
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Informal Caregivers in Amyotrophic Lateral Sclerosis: A Multi-Centre, Exploratory Study of Burden and Difficulties. Brain Sci 2021; 11:brainsci11081094. [PMID: 34439713 PMCID: PMC8394559 DOI: 10.3390/brainsci11081094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS)/motor neuron disease (MND) is a systemic and fatal neurodegenerative condition for which there is currently no cure. Informal caregivers play a vital role in supporting the person with ALS, and it is essential to support their wellbeing. This multi-centre, mixed methods descriptive exploratory study describes the complexity of burden and self-defined difficulties as described by the caregivers themselves. Quantitative and qualitative data were collected during face-to-face interviews with informal caregivers from centres in the Netherlands, England, and Ireland. Standardised measures assessed burden, quality of life, and psychological distress; furthermore, an open-ended question was asked about difficult aspects of caregiving. Most caregivers were female, spouse/partners, and lived with the person with ALS for whom they provided care. Significant differences between national cohorts were identified for burden, quality of life, and anxiety. Among the difficulties described were the practical issues associated with the caregiver role and emotional factors such as witnessing a patient’s health decline, relationship change, and their own distress. The mixed-methods approach allows for a more nuanced understanding of the burden and difficulties experienced. It is important to generate an evidence base to support the psychosocial wellbeing and brain health of informal caregivers.
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21
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Andrew AS, Pioro EP, Li M, Shi X, Gui J, Stommel EW, Butt TH, Peipert D, Henegan P, Tischbein M, Cazzolli P, Novak J, Quick A, Pugar KD, Sawlani K, Katirji B, Hayes TA, Horton DK, Mehta P, Bradley WG. The Incidence of Amyotrophic Lateral Sclerosis in Ohio 2016-2018: The Ohio Population-Based ALS Registry. Neuroepidemiology 2021; 55:196-205. [PMID: 33902051 DOI: 10.1159/000515103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/05/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a fatal, neuromuscular disease with no cure. ALS incidence rates have not been assessed specifically in Ohio, yet the state contains both metropolitan and rural areas with a variety of environmental factors that could contribute to disease etiology. We report the incidence of ALS in Ohio residents diagnosed from October 2016 through September 2018. METHODS We engaged practitioners from 9 Ohio sites to identify newly diagnosed ALS patients and to complete case report forms with demographic and clinical information. ALS was diagnosed according to the Awaji criteria and classified as either definite, probable, or possible. We developed a method to estimate missing cases using a Poisson regression model to impute cases in counties with evidence of undercounting. RESULTS We identified 333 newly diagnosed ALS patients residing in Ohio during the 2-year index period and found incidence rates varied in the 88 state counties. After incorporating the estimated 27% of missing cases, the corrected crude annual incidence was 1.96/100,000 person-years, and the age- and gender-standardized incidence was 1.71/100,000 person-years (standardized to the 2010 US census). DISCUSSION/CONCLUSION The estimated Ohio incidence of ALS is overall similar to that reported in other states in the USA. This study reveals a geospatial variation in incidence within the state, and areas with higher rates warrant future investigation.
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Affiliation(s)
- Angeline S Andrew
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Erik P Pioro
- Section of ALS and Related Disorders, Cleveland Clinic, Cleveland, Ohio, USA
| | - Meifang Li
- Department of Geography, Dartmouth College, Hanover, New Hampshire, USA
| | - Xun Shi
- Department of Geography, Dartmouth College, Hanover, New Hampshire, USA
| | - Jiang Gui
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Elijah W Stommel
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Tanya H Butt
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Daniel Peipert
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Patricia Henegan
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Maeve Tischbein
- Department of Neurology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - John Novak
- Ohio Health Physician Group, Westerville, Ohio, USA
| | - Adam Quick
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - K Doug Pugar
- Dayton Center for Neurological Disorders, Dayton, Ohio, USA
| | - Komal Sawlani
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Bashar Katirji
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - D Kevin Horton
- Centers for Disease Control and Prevention (CDC), Agency for Toxic Substances and Disease Registry (ATSDR), Atlanta, Georgia, USA
| | - Paul Mehta
- Centers for Disease Control and Prevention (CDC), Agency for Toxic Substances and Disease Registry (ATSDR), Atlanta, Georgia, USA
| | - Walter G Bradley
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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