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Jimenez JV, Tang MJ, Wilson MW, Morrison AH, Ackrivo J, Choi PJ. Initiation of noninvasive ventilation in patients with amyotrophic lateral sclerosis. Muscle Nerve 2024; 70:1099-1103. [PMID: 39243146 DOI: 10.1002/mus.28250] [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: 04/17/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION/AIMS Noninvasive ventilation (NIV) has been shown to improve survival and symptom burden in patients with amyotrophic lateral sclerosis (ALS). However, limited data exist regarding the clinical and physiological parameters at the time of NIV initiation. This study aimed to describe the clinical characteristics and respiratory physiological markers in a cohort of ALS patients with chronic respiratory failure. METHODS This is a single-center retrospective cohort study of patients with ALS assessed for NIV initiation between February 2012 and January 2021. NIV was initiated based on insurance eligibility criteria: daytime hypercapnia, defined by partial pressure of carbon dioxide (PaCO2) >45 mm Hg using diurnal transcutaneous CO2 (TcCO2) as a surrogate, a maximal inspiratory pressure (MIP) <60 cmH2O or forced vital capacity (FVC) <50% predicted normal. RESULTS We identified 335 patients with ALS and chronic respiratory failure referred to an outpatient home ventilation clinic for NIV initiation. The mean age was 64 years ±11; 151 (45%) were female, 326 (97%) were white, and 100 (29%) had bulbar-onset ALS. At the time of NIV initiation, the mean FVC was 64% ± 19%, the mean MIP; 41 cmH2O ± 17, and diurnal TcCO2; 40 ± 6 mmHg. The most common reasons for NIV initiation were MIP <60 cmH2O (58%) and multiple concomitant indications (28%). Within 1 year of NIV initiation, 126 (37%) patients were deceased. DISCUSSION We found that impairment in inspiratory force was the most common reason for NIV initiation and often preceded significant declines in FVC.
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Affiliation(s)
- Jose Victor Jimenez
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Michael J Tang
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Mathew W Wilson
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexander H Morrison
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jason Ackrivo
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philip J Choi
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Division of Pulmonary, and Critical Care and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
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Georges M, Perez T, Rabec C, Jacquin L, Finet-Monnier A, Ramos C, Patout M, Attali V, Amador M, Gonzalez-Bermejo J, Salachas F, Morelot-Panzini C. [Proposals from a French expert panel for respiratory care in ALS patients]. Rev Mal Respir 2024; 41:620-637. [PMID: 39019674 DOI: 10.1016/j.rmr.2024.06.006] [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: 06/27/2021] [Accepted: 02/25/2022] [Indexed: 07/19/2024]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive diaphragm weakness and deteriorating lung function. Bulbar involvement and cough weakness contribute to respiratory morbidity and mortality. ALS-related respiratory failure significantly affects quality of life and is the leading cause of death. Non-invasive ventilation (NIV), which is the main recognized treatment for alleviating the symptoms of respiratory failure, prolongs survival and improves quality of life. However, the optimal timing for the initiation of NIV is still a matter of debate. NIV is a complex intervention. Multiple factors influence the efficacy of NIV and patient adherence. The aim of this work was to develop practical evidence-based advices to standardize the respiratory care of ALS patients in French tertiary care centres. METHODS For each proposal, a French expert panel systematically searched an indexed bibliography and prepared a written literature review that was then shared and discussed. A combined draft was prepared by the chairman for further discussion. All of the proposals were unanimously approved by the expert panel. RESULTS The French expert panel updated the criteria for initiating NIV in ALS patients. The most recent criteria were established in 2005. Practical advice for NIV initiation were included and the value of each tool available for NIV monitoring was reviewed. A strategy to optimize NIV parameters was suggested. Revisions were also suggested for the use of mechanically assisted cough devices in ALS patients. CONCLUSION Our French expert panel proposes an evidence-based review to update the respiratory care recommendations for ALS patients in daily practice.
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Affiliation(s)
- M Georges
- Service des maladies respiratoires et des soins intensifs, centre de référence pour les maladies pulmonaires rares de l'adulte, hôpital universitaire de Dijon-Bourgogne, Dijon, France; Université de Bourgogne-Franche-Comté, Dijon, France; Centre des sciences du goût et de l'alimentation, UMR 6265, CNRS 1234, INRA, université de Bourgogne-Franche-Comté, Dijon, France.
| | - T Perez
- Service des maladies respiratoires, hôpital universitaire de Lille, Lille, France; Centre d'infection et d'immunité de Lille, Inserm U1019-UMR9017, université de Lille-Nord de France, Lille, France
| | - C Rabec
- Service des maladies respiratoires et des soins intensifs, centre de référence pour les maladies pulmonaires rares de l'adulte, hôpital universitaire de Dijon-Bourgogne, Dijon, France; Université de Bourgogne-Franche-Comté, Dijon, France
| | - L Jacquin
- Société ResMed SAS, Saint-Priest, France
| | - A Finet-Monnier
- Service des maladies neuromusculaires et de la SLA, hôpital universitaire de la Timone, Marseille, France
| | - C Ramos
- CRMR SLA-MNM, hôpital Pasteur 2, hôpital universitaire de Nice, Nice, France
| | - M Patout
- Département R3S, service des pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France
| | - V Attali
- Département R3S, service des pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France
| | - M Amador
- Service de neurologie, centre SLA de Paris, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - J Gonzalez-Bermejo
- Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France; Département R3S, service de pneumologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Salachas
- Service de neurologie, centre SLA de Paris, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - C Morelot-Panzini
- Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France; Département R3S, service de pneumologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Kanj AN, Niven AS, Cowl CT, Yadav H. Rethinking the Role of Race in Lung Function: The Shift to Race-Neutral Spirometry Interpretation. Mayo Clin Proc 2024; 99:1547-1552. [PMID: 39093270 PMCID: PMC11449646 DOI: 10.1016/j.mayocp.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/25/2024] [Accepted: 05/24/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Alexander S Niven
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Clayton T Cowl
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Segerstrom SC, Kasarskis EJ. The Seattle Amyotrophic Lateral Sclerosis (ALS) Patient Project Database: observational, longitudinal, dyadic characterization of people with ALS and their partners. Health Psychol Behav Med 2024; 12:2396137. [PMID: 39239358 PMCID: PMC11376292 DOI: 10.1080/21642850.2024.2396137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 08/16/2024] [Indexed: 09/07/2024] Open
Abstract
Introduction The median survival time in ALS is approximately 3 years, but survival times range from less than a year to more than 10 years and much variance in disease course remains to be explained. As is true for physical outcomes, there is considerable variance in QOL, which is influenced by psychological health, coping, and social support, among other psychosocial factors. The Seattle ALS Patient Project Database (SALSPPD) provides a unique opportunity for researchers to address established and novel hypotheses about disease progression and QOL in ALS. Methods The SALSPPD is a longitudinal dataset of people with ALS (n = 143) and their partners (spouses, significant others, or caregivers; n = 123) from clinics and community-based ALS support groups. Participants were interviewed in their homes every 3 months for up to 18 months between March 1987 and August 1989. Follow-up phone calls were completed in 1990, 1994, and 2008, primarily to ascertain disease outcomes. Results The provided data dictionary includes details of the over 500 variables measured in the study, which have been subsetted into domain datasets. Domains address physical, psychological, social, and behavioral status on the person with ALS and their partners. Missing data were coded according to their mechanism. Data are available in two formats: The person-level (wide) databases and the time-level (long) databases. Discussion The SALSPPD will provide a rich resource to scientists interested in the natural history of ALS, psychosocial effects on ALS outcomes and vice versa, and psychosocial and disease outcomes of treatments.
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Affiliation(s)
- Suzanne C Segerstrom
- School of Human Development and Family Sciences, Oregon State University, Corvallis, OR, USA
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Edward J Kasarskis
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
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Viccaro F, Lecci A, Baccolini V, Sciurti A, Piamonti D, Inghilleri M, D'Antoni L, Palange P. Prediction of cough effectiveness in amyotrophic lateral sclerosis patients assessed by ultrasuond of the diaphragm during the cough expiration phase. Respir Physiol Neurobiol 2024; 327:104299. [PMID: 38879100 DOI: 10.1016/j.resp.2024.104299] [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: 04/11/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024]
Abstract
Assessing cough effectiveness, using Cough Peak Flow, is crucial for patients with Neuromuscular Diseases, such as Amyotrophic Lateral Sclerosis. Impaired cough function can contribute to respiratory decline and failure. The goal of the study is to determine the correlation between diaphragmatic excursion and cough expiratory phase, potentially utilizing ultrasonographic indices to estimate Cough Peak Flow in these patients. Twenty-two patients were enrolled in this study. The upward displacement of the diaphragm was measured with ultrasonography during voluntary cough expiration and Cough Peak Flow was simultaneously measured. A multivariable linear regression model was built to quantify the association between Cough Peak Flow and diaphragm expiratory excursion. There is significative relationship between Cough Peak Flow and diaphragm excursion with a Pearson's r coefficient of 0.86 observed in the patients group. Multiple linear regression analysis for Cough Peak Flow (Adjusted R2 = 0.86) revealed significant associations between Cough Peak Flow and expiratory excursion (adjusted β-coefficient: 64.78, 95 %, CI: 51.50-78.07, p<0.001) and sex (adjusted β-coefficient: -69.06; 95 % CI: -109.98 to -28.15, p=0.001). Our results predict the cough effectiveness by using M-mode diaphragmatic sonography with a potentially significant impact on therapeutic choices.
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Affiliation(s)
- Fausta Viccaro
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Pulmonary Division, Policlinico Umberto I Hospital, Rome, Italy
| | - Altea Lecci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Pulmonary Division, Policlinico Umberto I Hospital, Rome, Italy.
| | - Valentina Baccolini
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Antonio Sciurti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Daniel Piamonti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Pulmonary Division, Policlinico Umberto I Hospital, Rome, Italy
| | - Maurizio Inghilleri
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Letizia D'Antoni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Pulmonary Division, Policlinico Umberto I Hospital, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Pulmonary Division, Policlinico Umberto I Hospital, Rome, Italy
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Sheers NL, Andersen T, Chatwin M. Airway Clearance in Neuromuscular Disease. Sleep Med Clin 2024; 19:485-496. [PMID: 39095145 DOI: 10.1016/j.jsmc.2024.04.009] [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] [Indexed: 08/04/2024]
Abstract
High-quality respiratory care and airway clearance is essential for people with neuromuscular disease (pwNMD) as respiratory tract infections are a major cause of morbidity and mortality. This review expands on published guidelines by highlighting the role of cough peak flow along with other options for cough evaluation, and discusses recent key research findings which have influenced the practice of respiratory therapy for pwNMD.
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Affiliation(s)
- Nicole L Sheers
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia; The Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.
| | - Tiina Andersen
- The Department of Health and Functioning, Western Norway University of Applied Science, Postboks 7030, 5020 Bergen, Norway; Thoracic Department, Haukeland University Hospital, Postboks 1400, 5021 Bergen, Norway
| | - Michelle Chatwin
- NMCC, The National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London WC1N 3BG, UK; Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, Part of Guys and St Thomas' NHS Foundation Trust, London SW3 6NP, UK
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7
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Hogden A, Labra J, Power E. Enabling decision-making: what assists people with motor neurone disease when they consider gastrostomy insertion? Disabil Rehabil 2024:1-8. [PMID: 39193938 DOI: 10.1080/09638288.2024.2395473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 08/11/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024]
Abstract
PURPOSE This study explores the views of people living with Motor Neurone Disease (MND) when they consider Percutaneous Endoscopic Gastrostomy (PEG) insertion, to understand their priorities and how their decisions were informed or supported. MATERIALS AND METHODS The study took place in single multidisciplinary specialised MND clinic in New South Wales, Australia. Nine people with MND (5 male and 4 female; age range 52-73 years; disease duration 6-99 months) who were considering, or had recently undergone PEG insertion, participated. Semi-structured interviews were conducted with participants to examine individual's experience of decision-making about PEG. The data were synthesised and analysed thematically. RESULTS Three main themes and two sub-themes captured participant views on their decision-making. The first, "What matters most to me," comprised optimising quality of life and maintaining family membership. The second theme explored "Understanding PEG and the clinical pathway." The third theme was "Thoughts on using a decision aid." CONCLUSIONS This study provides a foundation for future studies examining the longer-term outcomes of accepting, delaying or declining PEG. Insights from this study may be applicable to decision-making for any aspect of MND care where the outcomes or benefits are uncertain.
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Affiliation(s)
- Anne Hogden
- School of Public Health, Faculty of Medicine & Health, University of New South Wales, Kensington, Australia
| | | | - Emma Power
- Speech Pathology, Graduate School of Health, University of Technology Sydney, Ultimo, Australia
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Silva ST, Costa IM, Souza AA, Pondofe K, Melo LP, Resqueti VR, Valentim R, Gonçalves F, Ribeiro TS. Physical therapy for the management of global function, fatigue and quality of life in amyotrophic lateral sclerosis: systematic review and meta-analyses. BMJ Open 2024; 14:e076541. [PMID: 39182937 PMCID: PMC11404137 DOI: 10.1136/bmjopen-2023-076541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVES To critically evaluate the effectiveness of physical therapy interventions in improving global function, quality of life and fatigue in individuals with amyotrophic lateral sclerosis (ALS). DESIGN Systematic review and meta-analyses. DATA SOURCES MEDLINE, EMBASE, Cochrane Library (CENTRAL) and Physiotherapy Evidence Database (PEDro) were searched through 31 January 2023. ELIGIBILITY CRITERIA We included randomised clinical trials (RCTs) that compared physical therapy interventions that act on global function, fatigue and quality of life in individuals with ALS with any other non-physiotherapeutic methods and techniques, placebo or non-intervention. The primary outcome measure was the evaluation of global function. Secondary outcomes were quality of life, fatigue and adverse events. DATA EXTRACTION AND SYNTHESIS Two independent authors used a researcher-developed extraction form and the Rayyan software to search, screen and code included studies. The risk of bias was assessed using the PEDro scale. Meta-analyses were conducted employing random effects. Outcomes were succinctly presented in Grading of Recommendations, Assessment, Development and Evaluation evidence profiles. RESULTS Our searches identified 39 415 references. After study selection, three studies were included in the review. Such studies involved 62 participants with a mean age of 54.6 years. In the evaluated trials, 40 were male, while 22 participants were female. Regarding the type of onset of the disease, 58 participants had spinal onset of ALS, and four had bulbar. CONCLUSIONS Physical therapy intervention may improve the global function of individuals with ALS in the short term; however, clinically, it was inconclusive. In terms of quality of life and fatigue, physical therapy intervention is not more effective than control in the short term. Adverse events are not increased by physical therapy intervention in the short term. Due to significant methodological flaws, small sample sizes, wide CIs and clinical interpretation, our confidence in the effect estimate is limited. PROSPERO REGISTRATION NUMBER CRD42021251350.
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Affiliation(s)
- Stephano Tomaz Silva
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Isabela Macedo Costa
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Aline Alves Souza
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Karen Pondofe
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Luciana Protásio Melo
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Vanessa R Resqueti
- Fisioterapia, Laboratório de Inovação Tecnológica em Reabilitação e PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Ricardo Valentim
- Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Filipe Gonçalves
- Portuguese Association of Amyotrophic Lateral Sclerosis, Faculty of Health Sciences, University of A Coruna, A Coruna, Spain
| | - Tatiana Souza Ribeiro
- Department of Physical Therapy and Laboratory of Technological Innovation in Health, Federal University of Rio Grande do Norte, Natal, Brazil
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Bai W, Liu H, Ding J, Zhang H, Johnson CE, Cook A. Palliative care needs and utilisation of specialist services for people diagnosed with motor neuron disease: a national population-based study. BMJ Open 2024; 14:e082628. [PMID: 39122386 PMCID: PMC11331903 DOI: 10.1136/bmjopen-2023-082628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION There is a growing emphasis on the importance of the availability of specialist palliative care for people with motor neuron disease (MND). However, the palliative care needs of this population and the utilisation of different specialist services remain poorly defined. OBJECTIVES To (1) describe clinical characteristics, symptom burden and functional levels of patients dying with MND on their admission to palliative care services; (2) determine factors associated with receiving inpatient or community palliative care services. DESIGN An observational study based on point-of-care assessment data from the Australian Palliative Care Outcomes Collaboration. PARTICIPANTS A total of 1308 patients who received palliative care principally because of MND between 1 January 2013 and 31 December 2020. MEASURES Five validated clinical instruments were used to assess each individual's function, distress from symptoms, symptom severity and urgency and acuity of their condition. RESULTS Most patients with MND had no or mild symptom distress, but experienced a high degree of functional impairment. Patients who required 'two assistants for full care' relative to those who were 'independent' (OR=11.53, 95% CI: 4.87 to 27.26) and those in 'unstable' relative to 'stable' palliative care phases (OR=16.74, 95% CI: 7.73 to 36.24) were more likely to use inpatient versus community-based palliative care. Associations between the use of different palliative care services and levels of symptom distress were not observed in this study. CONCLUSIONS Patients with MND were more likely to need assistance for decreased function and activities of daily living, rather than symptom management. This population could have potentially been cared for in the palliative phase in a community setting if greater access to supportive services were available in this context.
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Affiliation(s)
- Wenhui Bai
- Department of Nursing, Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Huiqin Liu
- Health Management Center, Department of Cardiology, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Jinfeng Ding
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Hongmei Zhang
- Department of Nursing, Henan Provincial Key Medicine Laboratory of Nursing, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Claire E Johnson
- The Palliative Aged Care Outcomes Program, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Angus Cook
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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Schito P, Manera U, Russo T, Cremona G, Riboldi E, Tettamanti A, Agosta F, Quattrini A, Chiò A, Filippi M, Calvo A, Riva N. Use of the combination of spirometry, arterial blood gas analysis and overnight oximetry to predict the outcomes of patients affected by motor neuron disease: The Milan-Torin respiratory score (Mi-To-RS). Eur J Neurol 2024; 31:e16316. [PMID: 38716751 PMCID: PMC11235821 DOI: 10.1111/ene.16316] [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: 08/07/2023] [Revised: 02/23/2024] [Accepted: 04/10/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND PURPOSE The use of multiple tests, including spirometry, arterial blood gas (ABG) analysis and overnight oximetry (OvOx), is highly recommended to monitor the respiratory function of patients with motor neuron disease (MND). In this study, we propose a composite score to simplify the respiratory management of MND patients and better stratify their prognosis. MATERIALS AND METHODS We screened the clinical charts of 471 non-ventilated MND patients referred to the Neuro-rehabilitation Unit of the San Raffaele Scientific Institute of Milan (January 2001-December 2019), collecting spirometric, ABG and OvOx parameters. To evaluate the prognostic role of each measurement, univariate Cox regression for death/tracheostomy was performed, and the variables associated with survival were selected to design a scoring system. Univariate and multivariate Cox regression analyses were then carried out to evaluate the prognostic role of the score. Finally, results were replicated in an independent cohort from the Turin ALS Center. RESULTS The study population included 450 patients. Six measurements were found to be significantly associated with survival and were selected to design a scoring system (maximum score = 8 points). Kaplan-Meier analysis showed significant stratification of survival and time to non-invasive mechanical ventilation adaptation according to score values, and multivariate analysis confirmed the independent effect of the respiratory score on survival of each cohort. CONCLUSION Forced vital capacity, ABG and OvOx parameters provide complementary information for the respiratory management and prognosis of MND patients and the combination of these parameters into a single score might help neurologists predict prognosis and guide decisions on the timing of the implementation of different diagnostic or therapeutic approaches.
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Affiliation(s)
- Paride Schito
- Neurorehabilitation, Neurology Unit and Neurophysiology UnitSan Raffaele Scientific InstituteMilanItaly
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology (INSPE)San Raffaele Scientific InstituteMilanItaly
| | - Umberto Manera
- “Rita Levi Montalcini” Department of Neuroscience, ALS CentreUniversity of TurinTorinoItaly
| | - Tommaso Russo
- Neurorehabilitation, Neurology Unit and Neurophysiology UnitSan Raffaele Scientific InstituteMilanItaly
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology (INSPE)San Raffaele Scientific InstituteMilanItaly
| | - George Cremona
- Unit of Respiratory MedicineIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Elisa Riboldi
- Department of Rehabilitation and Functional RecoveryIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Andrea Tettamanti
- Department of Rehabilitation and Functional RecoveryIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Federica Agosta
- Neuroimaging Research Unit, Division of Neuroscience, Institute of Experimental NeurologySan Raffaele Scientific InstituteMilanItaly
- San Raffaele Scientific InstituteVita‐Salute San Raffaele UniversityMilanItaly
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology (INSPE)San Raffaele Scientific InstituteMilanItaly
| | - Adriano Chiò
- “Rita Levi Montalcini” Department of Neuroscience, ALS CentreUniversity of TurinTorinoItaly
| | - Massimo Filippi
- Neurorehabilitation, Neurology Unit and Neurophysiology UnitSan Raffaele Scientific InstituteMilanItaly
- Neuroimaging Research Unit, Division of Neuroscience, Institute of Experimental NeurologySan Raffaele Scientific InstituteMilanItaly
- San Raffaele Scientific InstituteVita‐Salute San Raffaele UniversityMilanItaly
| | - Andrea Calvo
- “Rita Levi Montalcini” Department of Neuroscience, ALS CentreUniversity of TurinTorinoItaly
| | - Nilo Riva
- Neurorehabilitation, Neurology Unit and Neurophysiology UnitSan Raffaele Scientific InstituteMilanItaly
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology (INSPE)San Raffaele Scientific InstituteMilanItaly
- Present address:
3rd Neurology Unit and Motor Neuron Disease CentreFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
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Koch T, Fabian R, Weinhold L, Koch F, Barakat S, Castro‐Gomez S, Grehl T, Bernsen S, Weydt P. Cardiac troponin T as a serum biomarker of respiratory impairment in amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2024; 11:2063-2072. [PMID: 38923228 PMCID: PMC11330226 DOI: 10.1002/acn3.52126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/26/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE Informative biomarkers are an urgent need in the management of amyotrophic lateral sclerosis. Serum cardiac troponin T is elevated in the majority of amyotrophic lateral sclerosis patients and increases with disease progression. We sought to establish the informative value of cardiac troponin T with regard to respiratory function, a major prognostic factor in amyotrophic lateral sclerosis. METHODS In this retrospective observation, we analyzed two independent hospital-based cohorts (d = discovery cohort; v = validation cohort) regarding serum cardiac troponin T (nd = 298; nv = 49), serum neurofilament light chain (nd = 117; nv = 17), and respiratory tests (nd = 93; nv = 49). RESULTS Serum cardiac troponin T, in contrast to serum neurofilament levels, was associated with the respiratory domain of the revised amyotrophic lateral sclerosis functional rating scale and with pulmonary function parameters, namely forced vital capacity % (r = -0.45, p = 0.001) and slow vital capacity % (r = -0.50, p = 0.001). Serum cardiac troponin T reliably discriminated benchmarks of slow vital capacity <80% (AUC 0.73, 95% CI 0.62-0.84) and <50% (AUC 0.80, 95% CI 0.68-0.93), forced vital capacity <80% (AUC 0.72, 95% CI 0.61-0.83) and <50% (AUC 0.79, 95% CI 0.67-0.91). INTERPRETATION Our findings position cardiac Troponin T as a valuable serum biomarker in amyotrophic lateral sclerosis, complementing neurofilaments and expanding the understanding of underlying physiological mechanisms. In clinical practice, serum cardiac troponin T can flag benchmarks of compromised respiratory function.
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Affiliation(s)
- Teresa Koch
- Department of Neuromuscular Diseases, Center for NeurologyUniversity Hospital BonnBonn53127Germany
| | - Rachel Fabian
- Department of Neuromuscular Diseases, Center for NeurologyUniversity Hospital BonnBonn53127Germany
| | - Leonie Weinhold
- Department for Medical Biometry, Informatics and EpidemiologyUniversity Hospital BonnBonn53127Germany
| | - Franz‐W. Koch
- Department of PulmologyNeukölln HospitalBerlinGermany
| | - Saman Barakat
- Department of Neuromuscular Diseases, Center for NeurologyUniversity Hospital BonnBonn53127Germany
| | - Sergio Castro‐Gomez
- Department of Parkinson, Sleep and Movement Disorders, Center for NeurologyUniversity Hospital BonnBonn53127Germany
- Institute of Physiology IIUniversity Hospital BonnBonn53115Germany
| | - Torsten Grehl
- Department of NeurologyAlfried ‐ Krupp‐HospitalEssenGermany
| | - Sarah Bernsen
- Department of Neuromuscular Diseases, Center for NeurologyUniversity Hospital BonnBonn53127Germany
- German Center for Neurodegenerative Diseases (DZNE)Bonn53127Germany
| | - Patrick Weydt
- Department of Neuromuscular Diseases, Center for NeurologyUniversity Hospital BonnBonn53127Germany
- Department of Parkinson, Sleep and Movement Disorders, Center for NeurologyUniversity Hospital BonnBonn53127Germany
- German Center for Neurodegenerative Diseases (DZNE)Bonn53127Germany
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12
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Mamarabadi M, Fafoutis E, Geronimo A, Walsh S, Simmons Z. Sodium phenylbutyrate-taurursodiol access, adherence and adverse event in patients with amyotrophic lateral sclerosis: Experience at one center in the United States. Muscle Nerve 2024; 70:204-209. [PMID: 38828849 DOI: 10.1002/mus.28175] [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: 02/07/2024] [Revised: 04/30/2024] [Accepted: 05/23/2024] [Indexed: 06/05/2024]
Abstract
INTRODUCTION/AIMS Sodium phenylbutyrate-taurursodiol (PB-TURSO) was recently approved for treating amyotrophic lateral sclerosis (ALS). Third-party payors' coverage policies are evolving, and adverse events are just being fully assessed. The goals of this study were to evaluate patients' experiences in obtaining and continuing PB-TURSO and assess adverse events and medication adherence. METHODS Medical records of 109 ALS patients who were considered PB-TURSO candidates by the treating physician at a tertiary ALS clinic from October 2022 to May 2023 were reviewed. Data was recorded for demographics, clinical, and insurance information. A survey was e-mailed to patients asking about out-of-pocket expenses for PB-TURSO, financial assistance, medication start and (if applicable) stop dates, and reasons for discontinuation. RESULTS Insurance information was available for 91 patients [57 males (62%); mean age 64.8 years (range 25.7-88)]. Of 79 who applied for insurance approval, 71 (90%) were approved; however, 19 required 1-3 appeals. Among 73 patients with available data about medication status, 54 started PB-TURSO and 19 did not, most commonly due to personal choice or out-of-pocket expenses. About 44% of patients (24/54) stopped taking PB-TURSO, primarily due to adverse events. Monthly out-of-pocket expenses varied from $0 to $3500 and 36 patients qualified for financial assistance. Administrative and nursing staff devoted 7.2 hours/week to the insurance authorization process. DISCUSSION Most patients received insurance approval for PB-TURSO, but one-fourth required appeals. Some out-of-pocket costs were very high. Investment of staff time was substantial. These findings have implications for insurance coverage of, and adherence to, future ALS treatments.
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Affiliation(s)
- Mansoureh Mamarabadi
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eleni Fafoutis
- Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Andrew Geronimo
- Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Susan Walsh
- ALS United Mid-Atlantic, Ambler, Pennsylvania, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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13
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Lipanot BJ, Bosslet G. Five Questions to Help Prompt End-of-Life Planning in Neuromuscular Disease. Semin Respir Crit Care Med 2024. [PMID: 39029508 DOI: 10.1055/s-0044-1787994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Patients with neuromuscular disease are living longer lives but continue to have significant and often unpredictable morbidity and mortality. End-of-life planning for these patients is thus an essential part of their medical care. This planning should include the following topics: health care surrogates, swallowing and nutrition, daytime respiratory support, and all aspects of when end of life is near. Adult-onset and early-onset diseases may require different approaches to these topics. All patients with neuromuscular disease will benefit from these discussions to best reach patient-centered goals. We present health care providers these five questions and explanations as a guide.
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Affiliation(s)
- Benjamin J Lipanot
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gabriel Bosslet
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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14
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Pearson K, Dobak S. Current practices in the nutrition management of people with amyotrophic lateral sclerosis (ALS): a survey of U.S. ALS care teams. Amyotroph Lateral Scler Frontotemporal Degener 2024:1-8. [PMID: 38963090 DOI: 10.1080/21678421.2024.2374382] [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: 04/29/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To assess current practices of U.S. professionals providing outpatient ALS nutrition care. METHODS A cross-sectional survey assessing nutrition care practices was distributed in February/March 2023 through electronic mailing lists of relevant professional organizations. RESULTS Of the 87 professionals completing the survey, 85.1% were registered dietitians and 50.6% had five or fewer years of experience in ALS care. Many (44.2%) professionals reported receiving no training on the nutrition care of people with ALS (PALS), and 40.2% reported having no other ALS dietitians in their close network. Methods utilized to estimate calorie and protein requirements in PALS varied widely. Although 95.4% of respondents reported that their clinic's dietitian participates in feeding tube discussions, many practitioners may be waiting until ALS symptoms negatively impact PALS' breathing, eating, swallowing, or weight to begin discussing feeding tubes. Additionally, few professionals reported institutional practices conducive for refeeding syndrome prevention or monitoring. CONCLUSIONS Many professionals providing outpatient nutrition care to PALS possess limited experience, received insufficient training, and are not connected to other ALS dietitians. Specific nutrition care practices, including nutrient need estimation, vary widely among health professionals. Practices surrounding feeding tube discussions and refeeding syndrome may be suboptimal at many institutions. These findings highlight the need for initiatives that educate and connect practitioners providing nutrition care to PALS.
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Affiliation(s)
- Keith Pearson
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Nutrition and Dietetics, Samford University, Homewood, AL, USA, and
| | - Stephanie Dobak
- Jefferson Weinberg ALS Center, Thomas Jefferson University, Philadelphia, PA, USA
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15
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Fullam T, Hunt SL, Han M, Denesia J, Chandrashekhar S, Jawdat O, Piccione E, Fernandes JA, Statland J. Outcomes after intervention for enteral nutrition in patients with amyotrophic lateral sclerosis in multidisciplinary clinics. Muscle Nerve 2024; 70:94-100. [PMID: 38695638 DOI: 10.1002/mus.28103] [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: 12/04/2023] [Revised: 04/16/2024] [Accepted: 04/21/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION/AIMS Patients with amyotrophic lateral sclerosis (ALS) are susceptible to malnutrition, with appropriate management of nutritional interventions an active area of investigation. We sought to determine the impact of gastrostomy tube placement in ALS patients, exploring the correlation between forced vital capacity (FVC), malnutrition, and perioperative complications. METHODS A retrospective review was performed of clinically diagnosed ALS patients treated at two multidisciplinary clinics (University of Kansas, University of Nebraska) from January 2009 to September 2020 who were referred for gastrostomy. Data collected included demographics, disease characteristics, and key gastrostomy related dates/outcomes. RESULTS Two hundred thirty-nine patients were included with a median age of 65 years and median of 589 days from symptom onset to gastrostomy (interquartile range, 404-943). The population was predominantly Non-Hispanic White with bulbar-onset ALS. 30-day mortality was 4% and 30-day morbidity was 13%. Weight loss, body mass index, and predicted FVC at placement showed no increased 30-day morbidity or mortality association. Bulbar-onset ALS patients exhibited higher overall mortality postplacement than limb onset (odds ratio: 1.85, 95% confidence interval: 1.03-3.33). There was a 5% incidence of symptoms suggestive of refeeding syndrome. DISCUSSION Rates of major/minor complications and 30-day mortality related to gastrostomy placement in our population were similar compared with prior studies in ALS. The lack of difference in outcomes based on FVC at procedure may suggest this is not predictive of outcome, or perhaps, high-quality perioperative respiratory management. Alternative reasons may account for the increased morbidity and mortality of gastrostomy placement in the ALS population.
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Affiliation(s)
- Timothy Fullam
- Department of Neurology, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Suzanne L Hunt
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Madison Han
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jacob Denesia
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Swathy Chandrashekhar
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Omar Jawdat
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ezequiel Piccione
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - J Americo Fernandes
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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16
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Gray E, Menadue C, Piper A, Wong K, Kiernan M, Yee B. Hypercapnia is not excluded by normoxia in neuromuscular disease patients: implications for oximetry. ERJ Open Res 2024; 10:00927-2023. [PMID: 39010884 PMCID: PMC11247367 DOI: 10.1183/23120541.00927-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/16/2024] [Indexed: 07/17/2024] Open
Abstract
Background Pulse oximetry is widely used in the assessment of chronic respiratory failure in neuromuscular disease (NMD) patients. Chronic respiratory failure is the major cause of morbidity and mortality, necessitating early diagnosis and intervention. Guidelines suggest that an arterial blood gas (ABG) measurement is indicated if oxygen saturation (S pO2 ) is ≤94% in the absence of lung disease. However, hypercapnia with normoxia (S pO2 ≥95%) has been observed on ABGs of patients with NMD, in particular those with motor neurone disease. Methods A single-centre retrospective audit of room-air ABGs in stable hypercapnic chronic respiratory failure patients from 1990 to 2020 was performed. Patients with parenchymal lung disease were excluded. Patients were grouped into three main categories: non-NMD, other NMD and motor neurone disease. Findings 297 ABGs with hypercapnia from 180 patients with extrinsic restrictive lung disease were analysed. No patients with non-NMD, 54% of patients with other NMD and 36% of motor neurone disease patients demonstrated hypercapnia with normoxia (Chi-squared 61.33; p<0.001). The potential mechanism is proposed to be a difference in calculated respiratory quotient. If the alveolar-arterial gradient is assumed to be normal, the calculated respiratory quotient was significantly higher in motor neurone disease patients and other NMD patients compared with non-NMD patients (estimated marginal mean 0.99, 95% CI 0.94-1.03; 0.86 0.76-0.96; 0.73, 0.63-0.83, respectively; p<0.001) by mixed-model analysis. Interpretation Hypercapnia is not excluded with normal oximetry in NMD patients and may be due to an elevated respiratory quotient. This has implications in the diagnosis and monitoring of respiratory insufficiency in NMD patients with oximetry alone.
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Affiliation(s)
- Emma Gray
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical Medical School, The University of Sydney, Camperdown, Australia
| | - Collette Menadue
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Amanda Piper
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Keith Wong
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical Medical School, The University of Sydney, Camperdown, Australia
- Sleep Research Group, Woolcock Institute of Medical Research, Glebe, Australia
| | - Matthew Kiernan
- Central Clinical Medical School, The University of Sydney, Camperdown, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Australia
- Brain and Mind Centre, The University of Sydney, Camperdown, Australia
| | - Brendon Yee
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical Medical School, The University of Sydney, Camperdown, Australia
- Sleep Research Group, Woolcock Institute of Medical Research, Glebe, Australia
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17
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Rabadi MH, Russell KA, Xu C. Veterans with familial ALS and bulbar and respiratory presentations at onset had shorter survival. Sci Prog 2024; 107:368504241262902. [PMID: 39096043 PMCID: PMC11298063 DOI: 10.1177/00368504241262902] [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] [Indexed: 08/04/2024]
Abstract
OBJECTIVE We sought to characterize the clinical prognostic factors in veterans with amyotrophic lateral sclerosis (ALS) followed in our ALS clinic. BACKGROUND ALS is a rare, progressive neurodegenerative condition associated with decreased survival compared to that in the normal population. METHOD The electronic medical records of 105 veterans diagnosed with ALS who are followed in our ALS clinic between 2010 and 2021 were reviewed. Approval from the institutional review board was obtained from the study protocol. Demographic and clinical variables included age at symptom onset, age at initial evaluation, survival (from symptom onset to death), gender, site of onset (appendicular, bulbar, and respiratory), initial amyotrophic lateral sclerosis functional-related score-revised (ALSFRS-R), total functional independence measure (TFIM) scores, initial forced vital capacity (FVC), and interventions (Riluzole, gastrostomy, noninvasive ventilation [NIV], and tracheostomy). Normally distributed data was expressed as mean ± standard deviation. Fischer's exact analysis of the distribution differences of categorical data. The Kaplan-Meier plot analyzed the time-to-event. RESULTS The mean (SD) age at symptom onset was 62.0 (11.1) years, age at diagnosis was 65 (11) years, with 72% of the patients being over 60 years at diagnosis. The median survival time from symptom onset was 4.12 (3) years. Limb-onset ALS (appendicular) was the most frequent (52%) followed by bulbar-onset ALS (43%). The mean ALSFRS-R and TFIM scores were 31 (8) and 91 (25), respectively. Family history (familial), bulbar, and respiratory presentation at diagnosis were associated with shorter survival times. CONCLUSION This study suggests that of the clinical prognostic factors veterans with familial ALS, bulbar, and respiratory onset at presentations had shorter survival. The presence of Agent Orange, PEG placement, and NIV did not affect survival.
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Affiliation(s)
- Meheroz H Rabadi
- Department of Neurology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Department of Neurology, the Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Kimberly A Russell
- Department of Neurology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Chao Xu
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center (Statistician), Oklahoma City, OK, USA
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18
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Diao JA, He Y, Khazanchi R, Nguemeni Tiako MJ, Witonsky JI, Pierson E, Rajpurkar P, Elhawary JR, Melas-Kyriazi L, Yen A, Martin AR, Levy S, Patel CJ, Farhat M, Borrell LN, Cho MH, Silverman EK, Burchard EG, Manrai AK. Implications of Race Adjustment in Lung-Function Equations. N Engl J Med 2024; 390:2083-2097. [PMID: 38767252 PMCID: PMC11305821 DOI: 10.1056/nejmsa2311809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Adjustment for race is discouraged in lung-function testing, but the implications of adopting race-neutral equations have not been comprehensively quantified. METHODS We obtained longitudinal data from 369,077 participants in the National Health and Nutrition Examination Survey, U.K. Biobank, the Multi-Ethnic Study of Atherosclerosis, and the Organ Procurement and Transplantation Network. Using these data, we compared the race-based 2012 Global Lung Function Initiative (GLI-2012) equations with race-neutral equations introduced in 2022 (GLI-Global). Evaluated outcomes included national projections of clinical, occupational, and financial reclassifications; individual lung-allocation scores for transplantation priority; and concordance statistics (C statistics) for clinical prediction tasks. RESULTS Among the 249 million persons in the United States between 6 and 79 years of age who are able to produce high-quality spirometric results, the use of GLI-Global equations may reclassify ventilatory impairment for 12.5 million persons, medical impairment ratings for 8.16 million, occupational eligibility for 2.28 million, grading of chronic obstructive pulmonary disease for 2.05 million, and military disability compensation for 413,000. These potential changes differed according to race; for example, classifications of nonobstructive ventilatory impairment may change dramatically, increasing 141% (95% confidence interval [CI], 113 to 169) among Black persons and decreasing 69% (95% CI, 63 to 74) among White persons. Annual disability payments may increase by more than $1 billion among Black veterans and decrease by $0.5 billion among White veterans. GLI-2012 and GLI-Global equations had similar discriminative accuracy with regard to respiratory symptoms, health care utilization, new-onset disease, death from any cause, death related to respiratory disease, and death among persons on a transplant waiting list, with differences in C statistics ranging from -0.008 to 0.011. CONCLUSIONS The use of race-based and race-neutral equations generated similarly accurate predictions of respiratory outcomes but assigned different disease classifications, occupational eligibility, and disability compensation for millions of persons, with effects diverging according to race. (Funded by the National Heart Lung and Blood Institute and the National Institute of Environmental Health Sciences.).
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Affiliation(s)
- James A Diao
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Yixuan He
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Rohan Khazanchi
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Max Jordan Nguemeni Tiako
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Jonathan I Witonsky
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Emma Pierson
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Pranav Rajpurkar
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Jennifer R Elhawary
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Luke Melas-Kyriazi
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Albert Yen
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Alicia R Martin
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Sean Levy
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Chirag J Patel
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Maha Farhat
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Luisa N Borrell
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Michael H Cho
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Edwin K Silverman
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Esteban G Burchard
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
| | - Arjun K Manrai
- From the Department of Biomedical Informatics, Harvard Medical School (J.A.D., P.R., L.M.-K., C.J.P., M.F., A.K.M.), the Computational Health Informatics Program, Boston Children's Hospital (J.A.D., A.K.M.), the Analytic and Translational Genetics Unit (Y.H., A.R.M.) and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.F.), Massachusetts General Hospital, Harvard Internal Medicine-Pediatrics Combined Residency Program, Brigham and Women's Hospital, Boston Children's Hospital, and Boston Medical Center (R.K.), the François-Xavier Bagnoud Center for Health and Human Rights, Harvard University (R.K.), the Department of Medicine (M.J.N.T.) and the Channing Division of Network Medicine and the Division of Pulmonary and Critical Care Medicine, Department of Medicine (M.H.C., E.K.S.), Brigham and Women's Hospital, and the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center (S.L.), Boston, and the Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge (Y.H., A.R.M.) - all in Massachusetts; the Departments of Pediatrics (J.I.W.), Medicine (J.R.E., E.G.B.), and Bioengineering and Therapeutic Sciences (J.R.E., E.G.B.), University of California, San Francisco, San Francisco; the Department of Computer Science, Cornell University, Ithaca (E.P.), and the Department of Population Health Sciences, Weill Cornell Medical College (E.P.), and the Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (L.N.B.), New York - all in New York; the Department of Engineering Science, University of Oxford, Oxford, United Kingdom (L.M.-K.); and the Medical Scientist Training Program, University of Illinois at Chicago, Chicago (A.Y.)
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Laurido-Soto OJ, Faust IM, Nielsen SS, Racette BA. Adherence to practice parameters in Medicare beneficiaries with amyotrophic lateral sclerosis. PLoS One 2024; 19:e0304083. [PMID: 38829866 PMCID: PMC11146737 DOI: 10.1371/journal.pone.0304083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE Physician adherence to evidence-based clinical practice parameters impacts outcomes of amyotrophic lateral sclerosis (ALS) patients. We sought to investigate compliance with the 2009 practice parameters for treatment of ALS patients in the United States, and sociodemographic and provider characteristics associated with adherence. METHODS In this population-based, retrospective cohort study of incident ALS patients in 2009-2014, we included all Medicare beneficiaries age ≥20 with ≥1 International Classification of Diseases, Ninth Revision, Clinical Modification ALS code (335.20) in 2009 and no prior years (N = 8,575). Variables of interest included race/ethnicity, sex, age, urban residence, Area Deprivation Index (ADI), and provider specialty (neurologist vs. non-neurologist). Outcomes were use of practice parameters, which included feeding tubes, non-invasive ventilation (NIV), riluzole, and receiving care from a neurologist. RESULTS Overall, 42.9% of patients with ALS received neurologist care. Black beneficiaries (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.67), older beneficiaries (OR 0.964, 95% CI 0.961-0.968 per year), and those living in disadvantaged areas (OR 0.70, 95% CI 0.61-0.80) received less care from neurologists. Overall, only 26.7% of beneficiaries received a feeding tube, 19.2% NIV, and 15.3% riluzole. Neurologist-treated patients were more likely to receive interventions than other ALS patients: feeding tube (OR 2.80, 95% CI 2.52-3.11); NIV (OR 10.8, 95% CI 9.28-12.6); and riluzole (OR 7.67, 95% CI 6.13-9.58), after adjusting for sociodemographics. These associations remained marked and significant when we excluded ALS patients who subsequently received a code for other diseases that mimic ALS. CONCLUSIONS ALS patients treated by neurologists received care consistent with practice parameters more often than those not treated by a neurologist. Black, older, and disadvantaged beneficiaries received less care consistent with the practice parameters.
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Affiliation(s)
- Osvaldo J. Laurido-Soto
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Irene M. Faust
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, United States of America
| | - Susan Searles Nielsen
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Brad A. Racette
- Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, United States of America
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Van Damme P, Al‐Chalabi A, Andersen PM, Chiò A, Couratier P, De Carvalho M, Hardiman O, Kuźma‐Kozakiewicz M, Ludolph A, McDermott CJ, Mora JS, Petri S, Probyn K, Reviers E, Salachas F, Silani V, Tysnes O, van den Berg LH, Villanueva G, Weber M. European Academy of Neurology (EAN) guideline on the management of amyotrophic lateral sclerosis in collaboration with European Reference Network for Neuromuscular Diseases (ERN EURO-NMD). Eur J Neurol 2024; 31:e16264. [PMID: 38470068 PMCID: PMC11235832 DOI: 10.1111/ene.16264] [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: 12/07/2023] [Revised: 02/06/2024] [Accepted: 02/15/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND This update of the guideline on the management of amyotrophic lateral sclerosis (ALS) was commissioned by the European Academy of Neurology (EAN) and prepared in collaboration with the European Reference Network for Neuromuscular Diseases (ERN EURO-NMD) and the support of the European Network for the Cure ALS (ENCALS) and the European Organization for Professionals and Patients with ALS (EUpALS). METHODS Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the effectiveness of interventions for ALS. Two systematic reviewers from Cochrane Response supported the guideline panel. The working group identified a total of 26 research questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available. RESULTS A guideline mapping effort revealed only one other ALS guideline that used GRADE methodology (a National Institute for Health and Care Excellence [NICE] guideline). The available evidence was scarce for many research questions. Of the 26 research questions evaluated, the NICE recommendations could be adapted for 8 questions. Other recommendations required updates of existing systematic reviews or de novo reviews. Recommendations were made on currently available disease-modifying treatments, multidisciplinary care, nutritional and respiratory support, communication aids, psychological support, treatments for common ALS symptoms (e.g., muscle cramps, spasticity, pseudobulbar affect, thick mucus, sialorrhea, pain), and end-of-life management. CONCLUSIONS This update of the guideline using GRADE methodology provides a framework for the management of ALS. The treatment landscape is changing rapidly, and further updates will be prepared when additional evidence becomes available.
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Affiliation(s)
- Philip Van Damme
- Department of Neurology, University Hospitals Leuven, Department of Neuroscience KU LeuvenCenter for Brain & Disease Research VIBLeuvenBelgium
| | - Ammar Al‐Chalabi
- Department of Basic and Clinical NeuroscienceMaurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Peter M. Andersen
- Department of Clinical Science, NeurosciencesUmeå UniversityUmeåSweden
| | - Adriano Chiò
- Rita Levi Montalcini Department of NeuroscienceUniversity of TurinTurinItaly
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di TorinoTurinItaly
| | | | - Mamede De Carvalho
- Faculdade de MedicinaInstituto de Medicina Molecular, Universidade de Lisboa, Centro Académico de Medicina de LisboaLisbonPortugal
| | - Orla Hardiman
- Academic Unit of NeurologyTrinity Biomedical Sciences Institute, Trinity College DublinDublinIreland
| | | | - Albert Ludolph
- Department of Neurology, Ulm University, German Center for Neurodegenerative Diseases (DZNE)UlmGermany
| | | | - Jesus S. Mora
- ALS Unit, Department of NeurologyHospital Universitario San RafaelMadridSpain
| | - Susanne Petri
- Department of Neurology, Hannover Medical SchoolHannoverGermany
| | | | - Evy Reviers
- EUpALS (European Organization for Professionals and Patients with ALS) and ALS Liga BelgiëLeuvenBelgium
| | - François Salachas
- Neurology Department, Paris ALS Center, Groupe Hospitalier Pitié‐Salpêtrière, AP‐HPParisFrance
| | - Vincenzo Silani
- Department of Neuroscience and Laboratory of NeuroscienceIRCCS Istituto Auxologico ItalianoMilanItaly
- Department of Pathophysiology and Transplantation, Dino Ferrari CenterUniversità degli Studi di MilanoMilanItaly
| | - Ole‐Bjørn Tysnes
- Department of NeurologyHaukeland University HospitalBergenNorway
| | - Leonard H. van den Berg
- Department of Neurology, UMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | | | - Markus Weber
- Neuromuscular Diseases Unit/ALS ClinicSt. GallenSwitzerland
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Kim HS, Woo H, Choi SJ, Baek JG, Ryu JS, Shin HI, Park KS, Beom J. Factors associated with adherence to noninvasive positive pressure ventilation in amyotrophic lateral sclerosis. PLoS One 2024; 19:e0302515. [PMID: 38748695 PMCID: PMC11095767 DOI: 10.1371/journal.pone.0302515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/05/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION This cohort study aimed to investigate the factors associated with noninvasive positive pressure ventilation adherence and assess the long-term effects of noninvasive positive pressure ventilation adherence in patients with amyotrophic lateral sclerosis (ALS). METHODS The medical records of patients with ALS admitted to a tertiary hospital for noninvasive positive pressure ventilation initiation were retrospectively reviewed. Pulmonary function parameters, variables of blood gas analysis, the site of symptom onset, the time from onset and diagnosis to noninvasive positive pressure ventilation application, ALS Functional Rating Scale-Revised, neurophysiological index, and the length of hospital stay were evaluated. The adherence to noninvasive positive pressure ventilation was defined as the use of noninvasive positive pressure ventilation for ≥ 2 h/day or ≥ 4 h/day. The correlations between noninvasive positive pressure ventilation adherence or length of hospital stay and other clinical parameters were analyzed. RESULTS Fifty-one patients with ALS were included in the study. The time from onset and diagnosis to NIPPV application was reduced by 16 months in the adherent group than that in the non-adherent group; however, the parameters of blood gas analysis and pulmonary function tests did not differ significantly between the groups. Furthermore, the neurophysiological index of the abductor digiti minimi muscle was higher by 4.05 in the adherent group than that in the non-adherent group. The adherence to noninvasive positive pressure ventilation prolonged tracheostomy-free survival compared to that of non-adherence. Desaturation events, lower forced vital capacity, last pCO2, bicarbonate, and base excess, and higher differences in pCO2, were associated with an increase in the length of hospital stay. CONCLUSIONS Noninvasive positive pressure ventilation application shortly after symptom onset and ALS diagnosis in patients with CO2 retention and reduced forced vital capacity can be considered for successful adherence. Adherence to noninvasive positive pressure ventilation may result in reduced tracheostomy conversion rates and prolonged tracheostomy-free survival.
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Affiliation(s)
- Hee Soo Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hyeonseong Woo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Seok-Jin Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Gyu Baek
- Department of Neurology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
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22
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White S, O’Cathain A, Halliday V, Bradburn M, McDermott CJ. Supporting people with Motor Neuron Disease (MND) to make decisions about gastrostomy feeding tube placement: a survey of UK healthcare professionals' practice and beliefs. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:290-298. [PMID: 38337170 PMCID: PMC11262427 DOI: 10.1080/21678421.2024.2314061] [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: 10/17/2023] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Understand the practice and beliefs of healthcare professionals (HCPs) supporting the decision-making of people with MND (pwMND) about gastrostomy placement, including identifying differences between professions. METHODS An online cross-sectional survey disseminated to HCPs who support the decision-making of pwMND about gastrostomy placement. RESULTS A total of 139 participants completed the survey including representation from a range of healthcare professions. A third (36/101, 36%) initiated discussions about gastrostomy later in practice than they believed was ideal. In relation to the outcome of declining compared to accepting gastrostomy, participants were more likely to discuss aspiration (80% vs. 68%), choking (76% vs. 58%) and prognosis (36% vs. 22%). Participants believed gastrostomies should be placed after a mean 8.1% weight loss since symptom-onset. More participants favored gastrostomy placement before pwMND presented with respiratory symptoms (45%) compared to onset of dysphagia (11%). Half believed pwMND placed gastrostomies too late. Participants were more likely to 'often'/'always' recommend pwMND to have a gastrostomy (23%) than continue without (7%) or decline (4%) gastrostomy, when believing these were the best option for pwMND. Nurses and dietitians discussed the broadest range of information, while doctors were more likely to discuss mortality risk and prognosis. CONCLUSION There is variation in HCPs practice and beliefs about initiating discussions, the sharing of information and recommendations, and timing, about gastrostomy placement. The information shared varies by profession and there is evidence of sub-optimal communication between HCPs. Further research is required to understand how these findings may impact on the decision-making of pwMND about gastrostomy.
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Affiliation(s)
- Sean White
- Division of Neuroscience, The University of Sheffield, Sheffield, UK
| | - Alicia O’Cathain
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK, and
| | - Vanessa Halliday
- School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
| | - Michael Bradburn
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK, and
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23
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Parra-Cantu C, Martinez-Thompson JM, Linch FB, Welch TL, Chou CZ, Pattinson AK, Staff NP, Neisen M. Radiologically Inserted Gastrostomy Tube Placement Guided by the Assessment and Primary Palliative Care Provided by an Amyotrophic Lateral Sclerosis Multidisciplinary Clinic: A Single-Arm Retrospective Clinical Study. Am J Hosp Palliat Care 2024; 41:516-526. [PMID: 37266922 DOI: 10.1177/10499091231180553] [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] [Indexed: 06/03/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with a median survival of about 3 years. An ALS multidisciplinary team can provide primary palliative care and improve outcomes and quality of life for patients. Feeding tube insertion may be considered for patients with significant weight loss, or respiratory insufficiency. While radiologically inserted gastrostomy (RIG) tube placement may be an option, further studies are required to determine its best timing and appropriateness. This study's objectives were to evaluate the feasibility and outcomes of RIG tube placement in ALS patients over a 90-day follow-up period through the assessment and primary palliative care provided by the multidisciplinary team. This retrospective study reviewed the placement of 16 or 18 French RIG-tube without intubation or endoscopy for 36 ALS patients at a single center between April 2019 and December 2021. Measures included ALS Functional Rating Scale-Revised (ALSFRS-R) scores to determine the ALS stage. Demographic, clinical, procedural, and follow-up data were reviewed. Results showed that the RIG tube placement had a low rate of minor adverse events (11%) and no major procedure-related adverse events. The mean ALSFRS-R score at the time of procedure in subjects who died within 90 days was lower than of those alive beyond 90 days (P = .04). This study found that RIG-tube placement is a safe and effective way to manage dysphagia in ALS patients and highlights the importance of educating members of the multidisciplinary clinic in palliative care principles to determine the appropriateness of RIG tube placement.
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Affiliation(s)
| | | | - Forrest B Linch
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Tasha L Welch
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Claudia Z Chou
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | - Adele K Pattinson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Nathan P Staff
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Melissa Neisen
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
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24
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Filipe CB, Carreira NR, Reis-Pina P. Optimizing breathlessness management in amyotrophic lateral sclerosis: insights from a comprehensive systematic review. BMC Palliat Care 2024; 23:100. [PMID: 38622643 PMCID: PMC11020819 DOI: 10.1186/s12904-024-01429-z] [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: 01/11/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Breathlessness is a prevalent symptom affecting the quality of life (QOL) of Amyotrophic Lateral Sclerosis (ALS) patients. This systematic review explored the interventions for controlling breathlessness in ALS patients, emphasizing palliative care (PALC), non-invasive ventilation (NIV), opioids, and non-pharmacological strategies. METHODS A comprehensive search of PubMed, Cochrane Library, and Web of Science databases was conducted. Eligibility criteria encompassed adults with ALS or motor neuron disease experiencing breathlessness. Outcomes included QOL and symptom control. Study designs comprised qualitative studies, cohort studies, and randomized controlled trials. RESULTS Eight studies were included, most exhibiting low bias risk, comprising one randomized controlled trial, three cohort studies, two comparative retrospective studies, and two qualitative studies (interviews). Most studies originated from Europe, with one from the United States of America. The participants totaled 3423, with ALS patients constituting 95.6%. PALC consultations significantly improved symptom assessment, advance care planning, and discussions about goals of care. NIV demonstrated efficacy in managing breathlessness, with considerations for device limitations. Opioids were effective, though predominantly studied in non-ALS patients. Non-pharmacological strategies varied in efficacy among patients. CONCLUSION The findings underscore the need for individualized approaches in managing breathlessness in ALS. PALC, NIV, opioids, and non-pharmacological strategies each play a role, with unique considerations. Further research, especially ALS-specific self-management studies, is warranted.
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Affiliation(s)
- Catarina Bico Filipe
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal
| | - Nuno Reis Carreira
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal
- North Lisboa Hospital Centre, Santa Maria Hospital, Lisboa, Portugal
| | - Paulo Reis-Pina
- Faculty of Medicine, University of Lisbon, Avenida Professor Egas Moniz, Lisboa, 1649-028, Portugal.
- Bento Menni Palliative Care Unit, Sintra, Portugal.
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25
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Swash M. Timing initiation of non-invasive ventilation in management of ALS. J Neurol Sci 2024; 459:122972. [PMID: 38522244 DOI: 10.1016/j.jns.2024.122972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Michael Swash
- Department of Neurology, Royal London Hospital and Barts and the London School of Medicine, QMUL, London, UK; Institute of Neuroscience, University of Lisbon, Portugal.
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26
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Geronimo A, Simmons Z. Remote pulmonary function testing allows for early identification of need for non-invasive ventilation in a subset of persons with ALS. J Neurol Sci 2024; 459:122971. [PMID: 38522245 DOI: 10.1016/j.jns.2024.122971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/24/2024] [Accepted: 03/17/2024] [Indexed: 03/26/2024]
Abstract
The traditional ALS multidisciplinary clinical practice of quarterly respiratory assessment may leave some individuals in danger of developing untreated respiratory insufficiency between visits or beginning non-invasive ventilation (NIV) later than would be optimal. Remote, or home-based, pulmonary function testing (rPFT) allows patients with ALS to perform regular respiratory testing at more frequent intervals in the home. The aim of this study was to determine the clinical benefit of weekly rPFT compared to standard, quarterly in-clinic respiratory assessments: the number of individuals with earlier identification of NIV need, the magnitude of this advance notice, and the individual factors predicting benefit. Participants with ALS (n = 39) completed rPFT training via telemedicine and then completed one year of weekly self-guided assessments in the home. Over this period, 17 individuals exhibited remotely-measured FVC dropping below 50% of predicted, the value often used for recommendation of NIV initiation. In 13 individuals with clinical detection of this event, the median and range of advance notice of need for NIV was 53 (-61-294) days. Prescription of NIV occurred for 21 individuals on the study, six of whom began NIV as a result of remote testing, prior to indication of need as determined by in-person assessments. Weekly home assessments appeared to be of greatest clinical value in a subset of patients with low baseline respiratory test values and rapid respiratory decline. This has potential implications for clinical management of ALS as well as the conduct of clinical trials that rely on respiratory endpoints.
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Affiliation(s)
- Andrew Geronimo
- Departments of Neurology and Neurosurgery, Penn State College of Medicine, Hershey, PA 17033, United States of America.
| | - Zachary Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, PA 17033, United States of America
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27
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Yang J, Zhao Y, Soares M, Needham M, Begley A, Calton E. Clinical prognostic factors predicting survival of motor neuron disease patients with gastrostomy: A retrospective analysis. Muscle Nerve 2024; 69:440-447. [PMID: 38353364 DOI: 10.1002/mus.28064] [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: 08/21/2023] [Revised: 01/19/2024] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION/AIMS Enteral feeding via gastrostomy is a key intervention to prevent significant weight loss in Motor Neuron Disease (MND). The aim of this study was to explore demographic, clinical, and nutritional factors associated with survival time in MND patients with gastrostomy. METHODS The retrospective study analyzed 94 MND patients (n = 58 bulbar-onset and n = 36 limb-onset) who underwent gastrostomy between 2015 and 2021. The primary outcome was the survival time from gastrostomy insertion to death. Independent variables of interest explored were: age at gastrostomy insertion, disease onset type, known genetic cause, use of riluzole, non-invasive ventilation (NIV) use, forced vital capacity prior to gastrostomy, weight loss from diagnosis to gastrostomy insertion, and body mass index (BMI) at the time of gastrostomy insertion. RESULTS The median survival time from gastrostomy to death was 357 days (± 29.3, 95%CI: 299.5, 414.5). Kaplan-Meier method and log-rank test revealed patients with lower body mass index <18.5 kg/m2 at the time of gastrostomy insertion (p = .023) had shorter survival. Cox proportional hazards model with multivariable adjustment revealed that older age (p = .008), and greater weight loss from diagnosis to gastrostomy (p = .003) were associated with shorter survival time post gastrostomy. Limb onset (p = .023), NIV use not being required (p = .008) and daily NIV use when required and tolerated (p = .033) were associated with longer survival. DISCUSSION Preventing or minimizing weight loss from MND diagnosis and encouraging NIV use when clinically indicated are modifiable factors that may prolong the survival of MND patients with gastrostomy.
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Affiliation(s)
- Jie Yang
- Curtin School of Population Health, Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
- Department of Nutrition and Dietetics, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Yun Zhao
- Curtin School of Population Health, Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
| | - Mario Soares
- Curtin School of Population Health, Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
| | - Merrilee Needham
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Faculty of Medicine University of Notre Dame, Perth, Western Australia, Australia, CMMIT Murdoch University, Perth, Western Australia, Australia
| | - Andrea Begley
- Curtin School of Population Health, Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
| | - Emily Calton
- Curtin School of Population Health, Faculty of Health Science, Curtin University, Perth, Western Australia, Australia
- School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- South Metropolitan Health Service, Harry Perkins Institute, Perth, Western Australia, Australia
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28
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Son B, Lee J, Ryu S, Park Y, Kim SH. Timing and impact of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis: a comprehensive analysis. Sci Rep 2024; 14:7103. [PMID: 38531942 DOI: 10.1038/s41598-024-56752-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
Dysphagia is common in amyotrophic lateral sclerosis (ALS) patients, often requiring percutaneous endoscopic gastrostomy (PEG) for enteral nutrition. We retrospectively analyzed data from 188 Korean patients with ALS who underwent PEG tube insertion at five-time points: symptom onset (t1), diagnosis (t2), recommended time for gastrostomy (t3), PEG insertion (t4), and one-year post-insertion (t5). The recommended time point for gastrostomy (T-rec for gastrostomy) was defined as the earlier time point between a weight loss of more than 10% and advanced dysphagia indicated by the ALSFRS-R swallowing subscore of 2 or less. The T-rec for gastrostomy was reached at 22 months after symptom onset, followed by PEG insertion at 30 months, resulting in an 8-month delay. During the delay, the ALSFRS-R declined most rapidly at 1.7 points/month, compared to 0.8 points/month from symptom onset to diagnosis, 0.7 points/month from diagnosis to T-rec for gastrostomy, and 0.6 points/month after the PEG insertion. It is crucial to discuss PEG insertion before significant weight loss or severe dysphagia occurs and minimize the delay between the recommended time for gastrostomy and the actual PEG insertion. A stratified and individualized multidisciplinary team approach with careful symptom monitoring and proactive management plans, including early PEG insertion, should be prioritized to improve patient outcomes.
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Affiliation(s)
- Bugyeong Son
- Cell Therapy Center, Hanyang University Seoul Hospital, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea
| | - Jisu Lee
- Department of Food and Nutrition, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea
| | - Soorack Ryu
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Yongsoon Park
- Department of Food and Nutrition, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea.
| | - Seung Hyun Kim
- Cell Therapy Center, Hanyang University Seoul Hospital, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea.
- Department of Neurology, Hanyang University Seoul Hospital, 222-1 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Korea.
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29
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Kotsia E, Chroni E, Alexandropoulou A, Mills C, Veltsista D, Kefalopoulou ZM, Michou E. Dysphagia Assessments as Criteria in the 'Decision-Making Process' for Percutaneous Endoscopic Gastrostomy Placement in People with Amyotrophic Lateral Sclerosis: A Systematic Review. Dysphagia 2024:10.1007/s00455-024-10686-2. [PMID: 38517530 DOI: 10.1007/s00455-024-10686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/09/2024] [Indexed: 03/24/2024]
Abstract
To review the assessment methods of dysphagia as a criterion for the decision-making process for Percutaneous Endoscopic Gastrostomy (PEG) placement in patients with Amyotrophic Lateral Sclerosis (ALS). Systematic review. A search was conducted in three databases (EMBASE, CINAHL, PUBMED) in December 2022 and updated in July 2023. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools. Systematic review registration number in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42022385461. The searches identified 240 records. The 10 eligible studies included 2 case reports, 4 retrospective studies, 3 prospective studies, and 1 cohort observational study. Study quality was low, with most studies having moderate to high risk of bias. Dysphagia is a common criterion for decision-making. Dysphagia assessment is usually in the form of either self-reports, objective instrumental assessments, or both. Dysphagia is a common criterion for the decision-making process, yet is missing in clinical guidelines. Establishing the optimal means of dysphagia assessment is important for timely decision-making procedures, so that life-threatening consequences of dysphagia are minimized.
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Affiliation(s)
- Ermioni Kotsia
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
| | - Elizabeth Chroni
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Anna Alexandropoulou
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Claire Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dimitra Veltsista
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | | | - Emilia Michou
- School of Medicine, Unit of Neuromuscular Diseases University Hospital of Patras, University of Patras, Patras, Greece.
- Department of Speech and Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece.
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.
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30
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Khamaysa M, Lefort M, Pélégrini-Issac M, Lackmy-Vallée A, Mendili MME, Preuilh A, Devos D, Bruneteau G, Salachas F, Lenglet T, Amador MM, Le Forestier N, Hesters A, Gonzalez J, Rolland AS, Desnuelle C, Chupin M, Querin G, Georges M, Morelot-Panzini C, Marchand-Pauvert V, Pradat PF. Quantitative brainstem and spinal MRI in amyotrophic lateral sclerosis: implications for predicting noninvasive ventilation needs. J Neurol 2024; 271:1235-1246. [PMID: 37910250 DOI: 10.1007/s00415-023-12045-x] [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: 08/23/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Respiratory complications resulting from motor neurons degeneration are the primary cause of death in amyotrophic lateral sclerosis (ALS). Predicting the need for non-invasive ventilation (NIV) in ALS is important for advance care planning and clinical trial design. The aim of this study was to assess the potential of quantitative MRI at the brainstem and spinal cord levels to predict the need for NIV during the first six months after diagnosis. METHODS Forty-one ALS patients underwent MRI and spirometry shortly after diagnosis. The need for NIV was monitored according to French health guidelines for 6 months. The performance of four regression models based on: clinical variables, brainstem structures volumes, cervical spinal measurements, and combined variables were compared to predict the need for NIV within this period. RESULTS Both the clinical model (R2 = 0.28, AUC = 0.85, AICc = 42.67, BIC = 49.8) and the brainstem structures' volumes model (R2 = 0.30, AUC = 0.85, AICc = 40.13, BIC = 46.99) demonstrated good predictive performance. In addition, cervical spinal cord measurements model similar performance (R2 = 0.338, AUC = 0.87, AICc = 37.99, BIC = 44.49). Notably, the combined model incorporating predictors from all three models yielded the best performance (R2 = 0.60, AUC = 0.959, AICc = 36.38, BIC = 44.8). These findings are supported by observed positive correlations between brainstem volumes, cervical (C4/C7) cross-sectional area, and spirometry-measured lung volumes. CONCLUSIONS Our study shows that brainstem volumes and spinal cord area are promising measures to predict respiratory intervention needs in ALS.
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Affiliation(s)
- M Khamaysa
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M Lefort
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M Pélégrini-Issac
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - A Lackmy-Vallée
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M M El Mendili
- APHM, Hôpital Timone, CEMEREM, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - A Preuilh
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - D Devos
- Département de Neurologie, Centre Référent SLA, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
- Départment de Pharmacologie Médicale, Université de Lille, INSERM UMRS_1172 LilNCog, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
| | - G Bruneteau
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - F Salachas
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - T Lenglet
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
- Faculté de Médecine de Nice, Département de Neurologie, Université Cote d'Azur, Nice, France
- Département de Neurophysiologie, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Md M Amador
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - N Le Forestier
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
- Département de Recherche en Éthique, EA 1610: Etudes des Sciences et Techniques, Université Paris Sud/Paris Saclay, Paris, France
| | - A Hesters
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - J Gonzalez
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - A-S Rolland
- Départment de Pharmacologie Médicale, Université de Lille, INSERM UMRS_1172 LilNCog, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
| | - C Desnuelle
- Faculté de Médecine de Nice, Département de Neurologie, Université Cote d'Azur, Nice, France
| | - M Chupin
- CATI, Plateforme d'Imagerie Neurologique Multicentrique, Paris, France
| | - G Querin
- APHP, Service de Neuromyologie, Hôpital Pitié-Salpêtrière, Centre Référent Pour les Maladies Neuromusculaires Rares, Paris, France
- Institut de Myologie, Plateforme d'essais cliniques I-Motion, Hôpital Pitié-Salpêtrière, Paris, France
| | - M Georges
- Département des Maladies Respiratoires et Soins Intensifs, Centre de Référence pour les Maladies Pulmonaires Rares, Hôpital Universitaire de Dijon-Bourgogne, Dijon, France
- Université de Bourgogne Franche-Comté, Dijon, France
- Centre des Sciences du Goût et de l'Alimentation, UMR 6265 CNRS 1234 INRA, Université de Bourgogne Franche-Comté, Dijon, France
| | - C Morelot-Panzini
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
- Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - V Marchand-Pauvert
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - P-F Pradat
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France.
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France.
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, C-TRIC, Altnagelvin Hospital, Derry, Londonderry, UK.
- Institut pour la Recherche sur la Moelle Epinière et l'encephale (IRME), 15 rue Duranton, 75015, Paris, France.
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Phillips J, Dixon S, Koehler T, Kluger B. Advance Care Planning Among Patients With Amyotrophic Lateral Sclerosis: Patient Perspectives on Goals of Care Conversations. Am J Hosp Palliat Care 2024; 41:295-301. [PMID: 37128837 DOI: 10.1177/10499091231172901] [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] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Little is known regarding circumstances surrounding advanced care planning (ACP) for patients with amyotrophic lateral sclerosis (ALS). We aim to describe preferences, and perspectives surrounding ACP in patients with ALS. METHODS We conducted a survey of patients with ALS. Survey questions were related to advance directive completion and ACP discussions regarding end-of-life (EoL) choices. RESULTS 49 surveys were included. Patients have given thought to advance directives, goals of care, and EoL treatments within months of diagnosis (Median: 1 month; IQR: .6 - 3 months). Twenty-seven opened dialogue with spouses, 24 with family members, 19 with health professionals and 16 with their lawyer. Eighty percent were comfortable discussing advance directives and power of attorney while fewer (70%) are less comfortable regarding specific aspects of care such as CPR or invasive ventilation. Only one barrier to discussion was identified with one patient reporting they did not wish to talk about the topic. There was no significant correlation between timing of diagnosis and whether an EoL discussion had occurred (τb = .23, P = .14: n = 42). Level of feeling informed was significantly associated with making EoL decisions for CPR, legal arrangements for a decision maker and completion of living will or AD. CONCLUSION In this small cohort, a substantial proportion of ALS patients initiated EoL conversations early. When feeling informed, patients were more likely to make specific EoL choices. Findings suggest an opportunity for providers to help facilitate conversations, ensuring patient wishes.
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Affiliation(s)
- Joel Phillips
- Department of Neurology, Trinity Health Saint Mary's, Grand Rapids, MI, USA
- Department of Palliative and Supportive Care, Trinity Health Saint Mary's, Grand Rapids, MI, USA
| | - Stacy Dixon
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Benzi Kluger
- Departments of Neurology and Medicine, University of Rochester, Rochester, NY, USA
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Manera U, Torrieri MC, Moglia C, Canosa A, Vasta R, Palumbo F, Matteoni E, Cabras S, Grassano M, Bombaci A, Mattei A, Bellocchia M, Tabbia G, Ribolla F, Chiò A, Calvo A. Calculated Maximal Volume Ventilation (cMVV) as a Marker of Early Respiratory Failure in Amyotrophic Lateral Sclerosis (ALS). Brain Sci 2024; 14:157. [PMID: 38391731 PMCID: PMC10887238 DOI: 10.3390/brainsci14020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Respiratory failure assessment is among the most debatable research topics in amyotrophic lateral sclerosis (ALS) clinical research due to the wide heterogeneity of its presentation. Among the different pulmonary function tests (PFTs), maximal voluntary ventilation (MVV) has shown potential utility as a diagnostic and monitoring marker, able to capture early respiratory modification in neuromuscular disorders. In the present study, we explored calculated MVV (cMVV) as a prognostic biomarker in a center-based, retrospective ALS population belonging to the Piemonte and Valle d'Aosta registry for ALS (PARALS). A Spearman's correlation analysis with clinical data and PFTs showed a good correlation of cMVV with forced vital capacity (FVC) and a moderate correlation with some other features such as bulbar involvement, ALSFRS-R total score, blood oxygen (pO2), carbonate (HCO3-), and base excess (BE), measured with arterial blood gas analysis. Both the Cox proportional hazard models for survival and the time to non-invasive ventilation (NIV) measurement highlighted that cMVV at diagnosis (considering cMVV(40) ≥ 80) is able to stratify patients across different risk levels for death/tracheostomy and NIV indication, especially considering patients with FVC% ≥ 80. In conclusion, cMVV is a useful marker of early respiratory failure in ALS, and is easily derivable from standard PFTs, especially in asymptomatic ALS patients with normal FVC measures.
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Affiliation(s)
- Umberto Manera
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | | | - Cristina Moglia
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Antonio Canosa
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Institute of Cognitive Sciences and Technologies, Consiglio Nazionale delle Ricerche C.N.R., 00185 Rome, Italy
| | - Rosario Vasta
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesca Palumbo
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Enrico Matteoni
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Sara Cabras
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Maurizio Grassano
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessandro Bombaci
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessio Mattei
- S.C. Pneumologia, S. Croce and Carle Hospital, 12100 Cuneo, Italy
| | - Michela Bellocchia
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Giuseppe Tabbia
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Fulvia Ribolla
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Adriano Chiò
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Institute of Cognitive Sciences and Technologies, Consiglio Nazionale delle Ricerche C.N.R., 00185 Rome, Italy
| | - Andrea Calvo
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
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Cabona C, Ferraro PM, Scialò C, Bandettini Di Poggio M, Novi G, Gemelli C, Vignolo M, Rao F, Capovilla M, Marogna M, Mandich P, Origone P, Schenone A, Caponnetto C. Clinical epidemiology of amyotrophic lateral sclerosis in Liguria, Italy: a ten year follow up study. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:104-111. [PMID: 37737151 DOI: 10.1080/21678421.2023.2260842] [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: 07/03/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE This article presents an updated analysis of the LIGALS register, a prospective study conducted over a ten-year period (2009-2018) in Liguria, Italy, aimed at evaluating the incidence, prevalence, clinical presentation, and management of amyotrophic lateral sclerosis (ALS). METHODS We calculated the mean annual crude incidence rate of ALS, assessed the point prevalence of ALS on January 1, 2018, and analyzed demographic factors, clinical characteristics, and clinical management strategies. Data analysis included Cox regression analysis to identify predictors of survival. RESULTS The mean annual crude incidence rate of ALS was 3.16/100,000 per year (CI 95%) while the point prevalence of ALS on January 1, 2018, was 9.31/100,000 population (CI 95%). Among the patients, 6.5% were familial ALS, while 93.5% were sporadic cases. Clinical management strategies, including percutaneous endoscopic gastrostomy (PEG) and noninvasive ventilation (NIV), were employed. The study observed a stable frequency of NIV initiation and PEG placement over time, with a growing trend toward earlier PEG positioning. The mean survival from symptom onset was 39 months, whereas from diagnosis, it was 26 months. Cox regression analysis identified several predictors of survival, including gender, age at onset and diagnosis, site of onset, diagnostic category, phenotype, and diagnostic delay. CONCLUSIONS This comprehensive analysis provides valuable insights into the long-term trends in ALS epidemiology and clinical management in Liguria, Italy. It underscores the importance of continued research efforts in understanding and addressing the challenges posed by ALS, particularly in terms of early diagnosis and optimizing clinical interventions to improve patient outcomes.
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Affiliation(s)
| | | | - Carlo Scialò
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | | | - Giovanni Novi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | | | - Fabrizio Rao
- Centro Clinico NeMO, Ospedale la Colletta, Arenzano, Italy
| | | | - Maura Marogna
- Azienda Sanitaria Locale 3 Genovese, Genova, Italy, and
| | - Paola Mandich
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
| | - Paola Origone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
| | - Angelo Schenone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
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Alqallaf A, Cates DW, Render KP, Patel KA. Sodium Phenylbutyrate and Taurursodiol: A New Therapeutic Option for the Treatment of Amyotrophic Lateral Sclerosis. Ann Pharmacother 2024; 58:165-173. [PMID: 37269231 DOI: 10.1177/10600280231172802] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To review the safety and efficacy of sodium phenylbutyrate and taurursodiol (SP + T) in slowing progression of amyotrophic lateral sclerosis (ALS) compared with pre-existing therapies. DATA SOURCES A PubMed (from January 1, 2009, to April 13, 2023) and ClinicalTrials.gov search conducted using sodium phenylbutyrate, taurursodiol, AMX0035, riluzole, and edaravone. Additional articles were identified by hand from references. DATA SELECTION AND DATA EXTRACTION This included English-language articles evaluating SP + T efficacy or safety in humans for decreasing neuronal death and slowing the progression of ALS. DATA SYNTHESIS In one phase II clinical trial that encompassed an open-label extension phase, disease severity, assessed by the rate of decline in overall score on the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised with higher scores indicating more functional ability, was -1.24 points per month with active drug and -1.66 points per month with placebo (difference, 0.42 points per month; 95% CI, 0.03-0.81; P = 0.03). Post hoc analysis found survival benefit of median 4.8 months with active medication compared with placebo. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON WITH EXISTING DRUGS SP + T is a new US Food and Drug Administration-approved oral suspension for the treatment of ALS. Patients who received active medication through the phase II trial showed decreased rates of disease progression. Overall, SP + T could be considered a potential agent for the treatment of ALS which has a high unmet need. CONCLUSION SP + T is an option for the treatment of ALS; however, additional data regarding efficacy in phase III trials with long-term safety profile considerations, as well as trials to compare current therapy with SP + T, are needed.
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Morishima R, Shimizu T, Kimura H, Bokuda K, Saotome T, Nakayama Y, Takahashi K. High doses of opioids usage for amyotrophic lateral sclerosis patients with non-invasive ventilation. Acta Neurol Belg 2024; 124:101-107. [PMID: 37543533 DOI: 10.1007/s13760-023-02344-5] [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: 04/20/2023] [Accepted: 07/19/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION While opioids have been found to be useful in relieving suffering in amyotrophic lateral sclerosis (ALS), there is a lack of evidence concerning how and how much to use them in practice. This study was conducted to clarify how opioids were used for patients with ALS. METHODS We performed a retrospective case-based analysis at a single tertiary neurology center in Tokyo from 2010 to 2018. We enrolled patients with ALS who had died before the end of 2018. We examined the opioid dosage equivalent of morphine hydrochloride and patients' clinical backgrounds, focusing on ventilatory support. RESULTS Morphine was administered in 110 patients with ALS, and 84 were followed up until their death. Of these 84 patients, 57 (69.9%) did not use mechanical ventilation until death (no-MV group), and 21 (22.9%) utilized only non-invasive ventilation (NIV group). Final morphine dosage in the NIV group was significantly higher (mean 65.7 mg [SD 54.6], range 10-200 mg) than in the no-MV group (mean 31.7 mg [SD 26.9], range 0-120 mg; p = 0.015, Welch's t-test). The NIV group needed psychotropic drugs more frequently than the no-MV group (62% [n = 13] vs. 35% [n = 20]). CONCLUSION Patients in the NIV group used opioids for a statistically significantly longer time and at a higher dose than those in the no-MV group. Symptom control with opioids alone may be difficult, and the development of multifaceted evaluation and care is desirable.
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Affiliation(s)
- Ryo Morishima
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan.
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan.
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
| | - Toshio Shimizu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hideki Kimura
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kota Bokuda
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Takako Saotome
- Department of Rehabilitation Medicine, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
- Palliative Care Team, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Yuki Nakayama
- Unit for Intractable Disease Care Unit, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo, 183-0042, Japan
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McHenry KL. Airway Clearance Strategies and Secretion Management in Amyotrophic Lateral Sclerosis. Respir Care 2024; 69:227-237. [PMID: 37816542 PMCID: PMC10898456 DOI: 10.4187/respcare.11215] [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] [Indexed: 10/12/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare, neurodegenerative motor neuron disease that affects voluntary muscle movement. Often, difficulty in coughing, breathing, and swallowing are sequela associated with the condition, and the presence of bulbar muscle predominant weakness results in deleterious effects on airway clearance and secretion management. This narrative review will provide practical guidance for clinicians treating this population. Cough insufficiency in this population typically manifests as a prolonged, slow, weak cough effort that impedes the clearability of secretions and airway protection. Dystussia and dysphagia frequently occur simultaneously in bulbar dysfunction, subsequently impacting respiratory health. Measures of respiratory strength should be obtained and monitored every 3-6 months, preferably in a multidisciplinary clinic setting. Cough augmentation, whether manual or mechanical techniques, should be sought as early in the disease progression as possible to adequately control secretions in the proximal airways. This airway clearance strategy can aid in the prevention and treatment of respiratory tract infections (RTIs), which can pose a significant clinical hurdle to those with ALS. The use of mechanical insufflation-exsufflation may be complicated by severe bulbar dysfunction rendering this technique ineffective. Though peripheral airway clearance strategies, such as high-frequency chest-wall compression, have the advantage of being less impacted by bulbar dysfunction, it is only recommended this modality be used in conjunction with, versus in lieu of, proximal strategies. Salivary secretion management includes the use of anticholinergics, botulinum toxin, and radiation therapy depending on severity and desire for relief.
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Affiliation(s)
- Kristen L McHenry
- Boise State University, Department of Respiratory Care, Boise, Idaho.
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Oh HJ, Lee WJ, Sung JJ, Hong YH. Individualized predictions for clinical milestone in amyotrophic lateral sclerosis: A multialgorithmic approach. Digit Health 2024; 10:20552076241260120. [PMID: 38832104 PMCID: PMC11146000 DOI: 10.1177/20552076241260120] [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] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024] Open
Abstract
Objective The phenotypic heterogeneity and complex disease trajectory complicate the ability to predict specific clinical milestone for individual patients with amyotrophic lateral sclerosis (ALS). Here we developed individualized prediction models to estimate the time to the loss of autonomy in swallowing function. Methods Utilizing the Pooled Resource Open-Access ALS Clinical Trials (PRO-ACT) database, we built three models of distinct time-to-event prediction algorithms: accelerated failure time (AFT), cox proportional hazard (COX) and random survival forest (RSF) for an individualized risk assessment of the swallowing milestone. The target variable was defined as the time to a decline in the ALSFRS-R swallowing item score to 1 or below, indicating a need for supplementary tube feeding. Results Internal cross-validation revealed the median concordance index (C-index) of 0.851 (IQR, 0.842-0.859) for AFT, 0.850 (0.841-0.859) for COX and 0.846 (0.839-0.854) for RSF, and all models demonstrated good distributional calibration with predicted and observed event probabilities closely matched across different time intervals. For external validation with a registry dataset with characteristics different from PRO-ACT, the discriminative power was replicated with comparable C-indices for all models, whereas the calibration revealed a left-skewed distribution suggesting a bias towards overestimation of event probabilities in real-world data. While all models were effective at stratifying patients, the results of RSF model, unlike AFT and COX, did not match well with the KM curves of the corresponding risk groups, supporting the importance of nuanced understanding of data structure and algorithmic properties. Conclusion Our models are implemented into a web application which could be applied to individualized counselling, management and clinical trial design for gastrostomy intervention. Further studies for model optimization will advance personalized care in patients with ALS.
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Affiliation(s)
- Hyeon-Ji Oh
- Seoul National University College of Medicine, Seoul, Republic of
Korea
| | - Won-Joon Lee
- Seoul National University College of Medicine, Seoul, Republic of
Korea
| | - Jung-Joon Sung
- Department of Neurology, Neuroscience Research Institute, Medical Research Council, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoon-Ho Hong
- Department of Neurology, Neuroscience Research Institute, Medical Research Council, Seoul National University College of Medicine, SNU Boramae Medical Center, Seoul, Republic of Korea
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Ludolph AC, Grandjean H, Reviers E, De Micheli V, Bianchi C, Cardosi L, Russ H, Silani V. The preferences of people with amyotrophic lateral sclerosis on riluzole treatment in Europe. Sci Rep 2023; 13:22497. [PMID: 38110502 PMCID: PMC10728064 DOI: 10.1038/s41598-023-49424-3] [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: 03/16/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023] Open
Abstract
The Patient Preference Survey aims to understand unmet needs related to riluzole management in people with Amyotrophic Lateral Sclerosis (ALS) and to identify which characteristics of a new formulation could better match their preferences. The survey involved 117 people with ALS (PALS) treated with riluzole in four European countries. The dysphagic PALS were least satisfied with the riluzole tablet and oral suspension and with ease in self-administration; up to 68% of respondents postponed or missed the treatment due to swallowing difficulties and need of caregiver assistance. Overall, 51% of tablet and 53% of oral suspension users regularly crushed or mixed riluzole with beverages, respectively; PALS who always manipulated riluzole showed low satisfaction with the formulation and considered the risk of choking and pneumonia the most worrisome event. The survey evaluated the driving factors in choosing/switching the therapy: 67% of PALS declared a low risk of choking. The research finally evaluated which attributes of a new formulation would be preferred: the most relevant were ease of use (4.3/5), convenient/portable packaging (4.0/5) and oral-dissolving properties without tongue motility (3.9/5). The Patient Preference Survey suggests that patients have several unmet needs and preferences that could be addressed by a different formulation, e.g. using oral film technologies.
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Affiliation(s)
- Albert C Ludolph
- Department of Neurology, German Center for Neurodegenerative Diseases (DZNE), University of Ulm, Ulm, Germany
| | | | - Evy Reviers
- European Organization for Professionals and Patients with ALS (EUpALS), Leuven, Belgium
| | | | | | | | - Hermann Russ
- Sirius Scientific Consulting AG, 8852, Altendorf, Switzerland.
| | - Vincenzo Silani
- Department of Neuroscience and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, Dino Ferrari Center, Università degli Studi di Milano, Milan, Italy
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Ansari U, Chen V, Sedighi R, Syed B, Muttalib Z, Ansari K, Ansari F, Nadora D, Razick D, Lui F. Role of the UNC13 family in human diseases: A literature review. AIMS Neurosci 2023; 10:388-400. [PMID: 38188011 PMCID: PMC10767061 DOI: 10.3934/neuroscience.2023029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
This literature review explores the pivotal roles of the Uncoordinated-13 (UNC13) protein family, encompassing UNC13A, UNC13B, UNC13C, and UNC13D, in the pathogenesis of various human diseases. These proteins, which are evolutionarily conserved and crucial for synaptic vesicle priming and exocytosis, have been implicated in a range of disorders, spanning from neurodegenerative diseases like amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) to immune-related conditions such as familial hemophagocytic lymphohistiocytosis (FHL). The involvement of UNC13A in neurotransmitter release and synaptic plasticity is linked to ALS and FTD, with genetic variations affecting disease progression. UNC13B, which is closely related to UNC13A, plays a role in autism spectrum disorders (ASD), epilepsy, and schizophrenia. UNC13C is implicated in oral squamous cell carcinoma (OSCC) and hepatocellular carcinoma (HCC), and has a neuroprotective role in Alzheimer's disease (AD). UNC13D has an essential role in immune cell function, making it a key player in FHL. This review highlights the distinct molecular functions of each UNC13 family member and their implications in disease contexts, shedding light on potential therapeutic strategies and avenues for future research. Understanding these proteins' roles offers new insights into the management and treatment of neurological and immunological disorders.
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Affiliation(s)
- Ubaid Ansari
- California Northstate University College of Medicine, USA
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Hamad AA, Amer BE, Al Mawla AM, Goufa E, Abdelwahab MM, Serag I. Clinical characteristics, course, and outcomes of amyotrophic lateral sclerosis overlapping with pregnancy: a systematic review of 38 published cases. Neurol Sci 2023; 44:4219-4231. [PMID: 37587387 PMCID: PMC10641051 DOI: 10.1007/s10072-023-06994-4] [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: 06/23/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Amyotrophic lateral sclerosis (ALS) is a rare and fatal neurodegenerative disease that can overlap with pregnancy, but little is known about its clinical characteristics, course, and outcomes in this context. This systematic review aimed to synthesize the current evidence on ALS overlapping with pregnancy. METHODS We comprehensively searched four databases on February 2, 2023, to identify case studies reporting cases of ALS overlapping with pregnancy. Joanna Brigs Institute tool was followed to assess the quality of the included studies. RESULTS Twenty-six articles reporting 38 cases were identified and included in our study. Out of the 38 cases, 18 were aged < 30 years. The onset of ALS was before pregnancy in 18 cases, during pregnancy in 16 cases, and directly after pregnancy in 4 cases. ALS progression course was rapid or severe in 55% of the cases during pregnancy, and this percentage reached 61% in cases with an onset of ALS before pregnancy. While ALS progression course after pregnancy was rapid or severe in 63% and stable in 37% of the cases. Most cases (95%) were able to complete the pregnancy and gave live birth. However, preterm delivery was common. For neonates, 86% were healthy without any complications. CONCLUSION While pregnancy with ALS is likely to survive and result in giving birth to healthy infants, it could be associated with rapid or severe progression of ALS and result in a worse prognosis, highlighting the importance of close monitoring and counselling for patients and healthcare providers.
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Affiliation(s)
| | - Basma Ehab Amer
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Benha University, Benha, Egypt
| | - Aya Mustafa Al Mawla
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Elarbi Goufa
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, University of Oran 1 - Ahmed Ben Bella, Oran, Algeria
| | - Maya Magdy Abdelwahab
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Ibrahim Serag
- Medical Research Group of Egypt, Negida Academy, Arlington, MA, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Nakamura R, Kurihara M, Kobashi S, Tamaki Y, Ogawa N, Kitamura A, Yamakawa I, Bamba S, Terashima T, Urushitani M. Ideal body weight-based determination of minimum oral calories beneficial to function and survival in ALS. Front Neurol 2023; 14:1286153. [PMID: 38020597 PMCID: PMC10663338 DOI: 10.3389/fneur.2023.1286153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction This study sought to identify the optimal caloric intake to improve function and survival in ALS patients by comparing oral intake per ideal body weight (IBW) and its discrepancy with total energy expenditure (TEE) using the Shimizu formula. Methods A retrospective analysis of 104 ALS patients was conducted, categorizing them based on their average intake during the first week after admission using two primary intake cutoffs: 25 kcal/kgIBW and 30 kcal/kgIBW. The variance between oral intake and TEE was also evaluated using -300 kcal and 0 kcal as reference points. Results Oral caloric intake per IBW and functional decline rate (rs = -0.35, p < 0.001), but the variance from TEE was not significantly correlated (-0.11, p = 0.27). Survival data showed that patients consuming less than 25 kcal/kgIBW had a median survival of 24 months, increasing to 38 months for those consuming between 25-30 kcal/kgIBW and 63 months for those consuming 30 kcal/kgIBW or more. Deviations from the TEE did not significantly affect survival (p = 0.36). Among patients consuming less than their TEE, those consuming less than 25 kcal/kgIBW had a shorter median survival (24 months) compared to their counterparts (46 months) (p = 0.022). Consumption of less than 25 kcal/kgBW emerged as a significant negative predictor of patient outcome, independent of factors such as age, gender or disease progression. Discussion Intakes of 25 kcal/kgIBW or more are correlated with improved ALS outcomes, and larger, multi-regional studies are recommended for deeper insights.
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Affiliation(s)
- Ryutaro Nakamura
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Mika Kurihara
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
| | - Shuhei Kobashi
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Yoshitaka Tamaki
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Nobuhiro Ogawa
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Akihiro Kitamura
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Isamu Yamakawa
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Shigeki Bamba
- Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
- Department of Fundamental Nursing, Shiga University of Medical Science, Otsu, Japan
| | - Tomoya Terashima
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
| | - Makoto Urushitani
- Department of Neurology, Shiga University of Medical Science, Otsu, Japan
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Abstract
Although the past two decades have produced exciting discoveries in the genetics and pathology of amyotrophic lateral sclerosis (ALS), progress in developing an effective therapy remains slow. This review summarizes the critical discoveries and outlines the advances in disease characterization, diagnosis, imaging, and biomarkers, along with the current status of approaches to ALS care and treatment. Additional knowledge of the factors driving disease progression and heterogeneity will hopefully soon transform the care for patients with ALS into an individualized, multi-prong approach able to prevent disease progression sufficiently to allow for a dignified life with limited disability.
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Affiliation(s)
- Hristelina Ilieva
- Jefferson Weinberg ALS Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Justin Kwan
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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Izenberg A. Amyotrophic Lateral Sclerosis and Other Motor Neuron Diseases. Continuum (Minneap Minn) 2023; 29:1538-1563. [PMID: 37851042 DOI: 10.1212/con.0000000000001345] [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: 10/19/2023]
Abstract
OBJECTIVE This article reviews the clinical spectrum of amyotrophic lateral sclerosis (ALS), its variant presentations, and the approach to diagnosis and management. This review includes a detailed discussion of current and emerging disease-modifying therapies and the management of respiratory and bulbar manifestations of disease. An updated review of ALS genetics and pathophysiology is also provided. This article also touches on several other important motor neuron diseases. LATEST DEVELOPMENTS A new set of simplified diagnostic criteria may help identify patients at earlier stages of the disease. A coformulation of sodium phenylbutyrate and tauroursodeoxycholic acid has been shown to have a significant benefit on disease progression and survival, leading to approval by regulatory authorities in the United States and Canada. An oral formulation of edaravone and an antisense oligonucleotide to a SOD1 gene variation (tofersen) have also recently been approved by the US Food and Drug Administration (FDA). Phase 3 trials of intrathecal mesenchymal stem cells failed to meet primary end points for efficacy. Updated American Academy of Neurology quality measures for the care of patients with ALS were published in 2023. ESSENTIAL POINTS There has been continued progress in ALS genetics, diagnosis, and disease-modifying therapies. However, we still lack a definitive biomarker or a treatment that can halt the progression or reverse the course of disease. The evolving understanding of the genetic and pathophysiologic underpinnings of disease offers promise for more effective and clinically meaningful treatments in the future.
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Dubbioso R, Spisto M, Hausdorff JM, Aceto G, Iuzzolino VV, Senerchia G, De Marco S, Marcuccio L, Femiano C, Iodice R, Salvatore E, Santangelo G, Trojano L, Moretta P. Cognitive impairment is associated with gait variability and fall risk in amyotrophic lateral sclerosis. Eur J Neurol 2023; 30:3056-3067. [PMID: 37335396 DOI: 10.1111/ene.15936] [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: 04/05/2023] [Revised: 06/08/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND In amyotrophic lateral sclerosis (ALS), gait abnormalities contribute to poor mobility and represent a relevant risk for falls. To date, gait studies in ALS patients have focused on the motor dimension of the disease, underestimating the cognitive aspects. METHODS Using a wearable gait analysis device, we compared gait patterns in ambulatory ALS patients with mild cognitive impairment (ALS MCI+; n = 18), and without MCI (ALS MCI-; n = 24), and healthy subjects (HS; n = 16) under two conditions: (1) normal gait (single task) and (2) walking while counting backward (dual task). Finally, we examined if the occurrence and number of falls in the 3 months following the baseline test were related to cognition. RESULTS In the single task condition, ALS patients, regardless of cognition, displayed higher gait variability than HS, especially for stance and swing time (p < 0.001). The dual task condition revealed additional differences in gait variability parameters between ALS MCI+ and ALS MCI- for cadence (p = 0.005), stance time (p = 0.04), swing time (p = 0.04) and stability index (p = 0.02). Moreover, ALS MCI+ showed a higher occurrence (p = 0.001) and number of falls (p < 0.001) at the follow-up. Regression analyses demonstrated that MCI condition predicted the occurrence of future falls (β = 3.649; p = 0.01) and, together with executive dysfunction, was associated with the number of falls (cognitive impairment: β = 0.63; p < 0.001; executive dysfunction: β = 0.39; p = 0.03), regardless of motor impairment at clinical examination. CONCLUSION In ALS, MCI is associated with exaggerated gait variability and predicts the occurrence and number of short-term falls.
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Affiliation(s)
- Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Myriam Spisto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
- Department of Psychology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rush Alzheimer's Disease Center and Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Gabriella Aceto
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Valentina Virginia Iuzzolino
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Gianmaria Senerchia
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Stefania De Marco
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
- Department of Psychology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme Institute, Benevento, Italy
| | - Cinzia Femiano
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme Institute, Benevento, Italy
| | - Rosa Iodice
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Elena Salvatore
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Gabriella Santangelo
- Department of Psychology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurological Rehabilitation Unit of Telese Terme Institute, Benevento, Italy
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Berlowitz DJ, Mathers S, Hutchinson K, Hogden A, Carey KA, Graco M, Whelan BM, Charania S, Steyn F, Allcroft P, Crook A, Sheers NL. The complexity of multidisciplinary respiratory care in amyotrophic lateral sclerosis. Breathe (Sheff) 2023; 19:220269. [PMID: 37830099 PMCID: PMC10567075 DOI: 10.1183/20734735.0269-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 10/14/2023] Open
Abstract
Motor neurone disease/amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder with no known cure, where death is usually secondary to progressive respiratory failure. Assisting people with ALS through their disease journey is complex and supported by clinics that provide comprehensive multidisciplinary care (MDC). This review aims to apply both a respiratory and a complexity lens to the key roles and areas of practice within the MDC model in ALS. Models of noninvasive ventilation care, and considerations in the provision of palliative therapy, respiratory support, and speech and language therapy are discussed. The impact on people living with ALS of both inequitable funding models and the complexity of clinical care decisions are illustrated using case vignettes. Considerations of the impact of emerging antisense and gene modifying therapies on MDC challenges are also highlighted. The review seeks to illustrate how MDC members contribute to collective decision-making in ALS, how the sum of the parts is greater than any individual care component or health professional, and that the MDC per se adds value to the person living with ALS. Through this approach we hope to support clinicians to navigate the space between what are minimum, guideline-driven, standards of care and what excellent, person-centred ALS care that fully embraces complexity could be. Educational aims To highlight the complexities surrounding respiratory care in ALS.To alert clinicians to the risk that complexity of ALS care may modify the effectiveness of any specific, evidence-based therapy for ALS.To describe the importance of person-centred care and shared decision-making in optimising care in ALS.
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Affiliation(s)
- David J. Berlowitz
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Australia
| | - Susan Mathers
- Calvary Health Care Bethlehem, Caulfield South, Australia
- School of Clinical Sciences, Monash University, Clayton, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- Central Coast Local Health District, Gosford, Australia
| | - Anne Hogden
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Kate A. Carey
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
| | - Marnie Graco
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
| | - Brooke-Mai Whelan
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Salma Charania
- Motor Neurone Disease Association of Queensland, Oxley, Australia
| | - Frederik Steyn
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Peter Allcroft
- Southern Adelaide Palliative Services, Flinders Medical Centre, Bedford Park, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - Ashley Crook
- Graduate School of Health, University of Technology Sydney, Chippendale, Australia
- Centre for MND Research and Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Nicole L. Sheers
- The University of Melbourne, Parkville, Australia
- Institute for Breathing and Sleep, Heidelberg, Australia
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Orr JE, Chen K, Vaida F, Schmickl CN, Laverty CG, Ravits J, Lesser D, Bhattacharjee R, Malhotra A, Owens RL. Effectiveness of long-term noninvasive ventilation measured by remote monitoring in neuromuscular disease. ERJ Open Res 2023; 9:00163-2023. [PMID: 37753280 PMCID: PMC10518857 DOI: 10.1183/23120541.00163-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/14/2023] [Indexed: 09/28/2023] Open
Abstract
Background and objective Patients with neuromuscular disease are often treated with home noninvasive ventilation (NIV) with devices capable of remote patient monitoring. We sought to determine whether long-term NIV data could provide insight into the effectiveness of ventilation over time. Methods We abstracted available longitudinal data for adults with neuromuscular disease in monthly increments from first available to most recent. Generalised linear mixed-effects modelling with subject-level random effects was used to evaluate trajectories over time. Results 1799 months of data across 85 individuals (median age 61, interquartile range (IQR) 46-71 years; 44% female; 49% amyotrophic lateral sclerosis (ALS)) were analysed, with a median (IQR) of 17 (8-35) months per individual. Over time, tidal volume increased and respiratory rate decreased. Dynamic respiratory system compliance decreased, accompanied by increased pressure support. Compared to volume-assured mode, fixed-pressure modes were associated with lower initial tidal volume, higher respiratory rate and lower pressures, which did not fully equalise with volume-assured mode over time. Compared with non-ALS patients, those with ALS had lower initial pressure support, but faster increases in pressure support over time, and ALS was associated wtih a more robust increase in respiratory rate in response to low tidal volume. Nonsurvivors did not differ from survivors in ventilatory trajectories over time, but did exhibit decreasing NIV use prior to death, in contrast with stable use in survivors. Conclusion NIV keeps breathing patterns stable over time, but support needs are dynamic and influenced by diagnosis and ventilation mode. Mortality is preceded by decreased NIV use rather than inadequate support during use.
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Affiliation(s)
- Jeremy E. Orr
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, San Diego, CA, USA
| | - Kenneth Chen
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, San Diego, CA, USA
| | - Florin Vaida
- School of Public Health, UC San Diego, San Diego, CA, USA
| | | | | | - John Ravits
- Department of Neurology, UC San Diego, San Diego, CA, USA
| | - Daniel Lesser
- Department of Pediatrics, UC San Diego, San Diego, CA, USA
| | | | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, San Diego, CA, USA
| | - Robert L. Owens
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego, San Diego, CA, USA
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Sulistyo A, Abrahao A, Freitas ME, Ritsma B, Zinman L. Enteral tube feeding for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2023; 8:CD004030. [PMID: 37579081 PMCID: PMC10413437 DOI: 10.1002/14651858.cd004030.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND Maintaining adequate nutrition is critical for people with amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND). Enteral tube feeding is offered to people experiencing difficulty swallowing (dysphagia) to prevent weight loss and aspiration pneumonia. Among the types of enteral tube feeding, percutaneous endoscopic gastrostomy (PEG) is the typical procedure offered to people with ALS and will be mainly discussed here. OBJECTIVES To examine the effectiveness of percutaneous endoscopic gastrostomy or other enteral tube feeding in people with ALS, compared to oral feeds without enteral tube feeding on: 1. survival; 2. nutritional status; 3. quality of life. To examine the incidence of minor and major complications of percutaneous endoscopic gastrostomy (PEG) and other enteral tube feeding procedures in people with ALS. SEARCH METHODS On 3 January 2020 and 6 February 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE. Embase, ClinicalTrials.gov and WHO ICTRP. We screened the results to identify randomized controlled studies on enteral tube feeding in ALS. We reviewed all references from the search in published articles to identify any additional references. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs, and cross-over trials evaluating the effectiveness and complications of PEG or other enteral tube feeding placement in ALS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We found no RCTs or quasi-RCTs comparing the effectiveness of enteral tube feeding versus oral feeds without enteral tube feeding. AUTHORS' CONCLUSIONS There are no RCTs or quasi-RCTs to indicate whether enteral tube feeding is effective compared to continuation of oral feeding for any of the outcome measures. Such RCTs are very unlikely to be performed for ethical reasons. RCTs evaluating the effect of different enteral tube insertion techniques and timings of tube placement on survival and quality of life of people with ALS dysphagia are feasible and warranted.
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Affiliation(s)
- Adrienne Sulistyo
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Agessandro Abrahao
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Maria Eliza Freitas
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Benjamin Ritsma
- Department of Physical Medicine & Rehabilitation, Queen's University, Providence Care Hospital, Kingston , Canada
| | - Lorne Zinman
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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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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Hansen-Flaschen J, Ackrivo J. Practical Guide to Management of Long-Term Noninvasive Ventilation for Adults With Chronic Neuromuscular Disease. Respir Care 2023; 68:1123-1157. [PMID: 36922023 PMCID: PMC10353174 DOI: 10.4187/respcare.10349] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/19/2022] [Indexed: 03/17/2023]
Abstract
Recent technological advances in respiratory support and monitoring have dramatically enhanced the utility of long-term noninvasive ventilation (NIV). Improved quality of life and prolonged survival have been demonstrated for several common chronic neuromuscular diseases. Many adults with progressive neuromuscular respiratory disease can now comfortably maintain normal ventilation at home to near total respiratory muscle paralysis without needing a tracheostomy. However, current practice in many communities falls short of that potential. Mastery of the new technology calls for detailed awareness of the respiratory cycle; expert knowledge of mechanical devices, facial interfaces, and quantitative monitoring tools for home ventilation; and a willingness to stay current in a rapidly expanding body of clinical research. The depth and breadth of the expertise required to manage home assisted ventilation has given rise to a new focused medical subspecialty in chronic respiratory failure at the interface between pulmonology, critical care, and sleep medicine. For clinicians seeking pragmatic "how to" guidance, this primer presents a comprehensive, physician-directed management approach to long-term NIV of adults with chronic neuromuscular respiratory disease. Bi-level devices, portable ventilators, ventilation modalities, terminology, and monitoring strategies are reviewed in detail. Building on that knowledge base, we present a step-by-step guide to initiation, refinement, and maintenance of home NIV tailored to patient-centered goals of therapy. The quantitative approach recommended incorporates routine monitoring of home ventilation using technologies that have only recently become widely available including cloud-based device telemonitoring and noninvasive measurements of blood gases. Strategies for troubleshooting and problem solving are included.
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Affiliation(s)
- John Hansen-Flaschen
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jason Ackrivo
- Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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50
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Khan A, Frazer-Green L, Amin R, Wolfe L, Faulkner G, Casey K, Sharma G, Selim B, Zielinski D, Aboussouan LS, McKim D, Gay P. Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest 2023; 164:394-413. [PMID: 36921894 DOI: 10.1016/j.chest.2023.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations. STUDY DESIGN AND METHODS An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations. RESULTS Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement. INTERPRETATION Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.
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Affiliation(s)
- Akram Khan
- Division of Pulmonary Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR.
| | | | - Reshma Amin
- Department of Respiratory Medicine, The Hospital for Sick Kids, Toronto
| | - Lisa Wolfe
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Kenneth Casey
- Department of Sleep Medicine, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Girish Sharma
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Bernardo Selim
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Zielinski
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - Douglas McKim
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, ON
| | - Peter Gay
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
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