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Childs AM, Turner C, Astin R, Bianchi S, Bourke J, Cunningham V, Edel L, Edwards C, Farrant P, Heraghty J, James M, Massey C, Messer B, Michel Sodhi J, Murphy PB, Schiava M, Thomas A, Trucco F, Guglieri M. Development of respiratory care guidelines for Duchenne muscular dystrophy in the UK: key recommendations for clinical practice. Thorax 2024; 79:476-485. [PMID: 38123347 DOI: 10.1136/thorax-2023-220811] [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: 08/04/2023] [Accepted: 10/17/2023] [Indexed: 12/23/2023]
Abstract
Significant inconsistencies in respiratory care provision for Duchenne muscular dystrophy (DMD) are reported across different specialist neuromuscular centres in the UK. The absence of robust clinical evidence and expert consensus is a barrier to the implementation of care recommendations in public healthcare systems as is the need to increase awareness of key aspects of care for those living with DMD. Here, we provide evidenced-based and/or consensus-based best practice for the respiratory care of children and adults living with DMD in the UK, both as part of routine care and in an emergency. METHODOLOGY Initiated by an expert working group of UK-based respiratory physicians (including British Thoracic Society (BTS) representatives), neuromuscular clinicians, physiotherapist and patient representatives, draft guidelines were created based on published evidence, current practice and expert opinion. After wider consultation with UK respiratory teams and neuromuscular services, consensus was achieved on these best practice recommendations for respiratory care in DMD. RESULT The resulting recommendations are presented in the form of a flow chart for assessment and monitoring, with additional guidance and a separate chart setting out key considerations for emergency management. The recommendations have been endorsed by the BTS. CONCLUSIONS These guidelines provide practical, reasoned recommendations for all those managing day-to-day and acute respiratory care in children and adults with DMD. The hope is that this will support patients and healthcare professionals in accessing high standards of care across the UK.
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Affiliation(s)
- Anne-Marie Childs
- Department of Paediatric Neurosciences, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Catherine Turner
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Ronan Astin
- Division of Medical Specialties, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen Bianchi
- Academic Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Bourke
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Lisa Edel
- Respiratory Neuromuscular Physiotherapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christopher Edwards
- Leeds Centre for Children's Respiratory Medicine, Leeds Children's Hospital, Leeds General Infirmary, Leeds, UK
| | | | - Jane Heraghty
- Department of Paediatrics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Meredith James
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Charlotte Massey
- Queen Square Centre for Neuromuscular Diseases, University College London NHS Foundation Trust, London, UK
- Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Ben Messer
- North East Assisted Ventilation Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jassi Michel Sodhi
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Patrick Brian Murphy
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Marianela Schiava
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ajit Thomas
- Department of Respiratory Medicine, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Federica Trucco
- Dubowitz Neuromuscular Centre, University College London, London, UK
- Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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2
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Xie VX, Harrar D, Murnick J, Bharucha-Goebel D, Sen K. Starfield Pattern on Brain MRI in a Patient with Duchenne Muscular Dystrophy. Neuropediatrics 2024; 55:146-147. [PMID: 37532227 DOI: 10.1055/a-2146-6989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Vivien X Xie
- Division of Neurology, Children's National Hospital, Washington, District of Columbia, United States
| | - Dana Harrar
- Division of Neurology, Children's National Hospital, Washington, District of Columbia, United States
| | - Jonathan Murnick
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia, United States
| | - Diana Bharucha-Goebel
- Division of Neurology, Children's National Hospital, Washington, District of Columbia, United States
| | - Kuntal Sen
- Division of Neurodevelopmental Pediatrics and Neurogenetics, Children's National Hospital, Washington, District of Columbia, United States
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3
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Woods WA, Harmon WG, Webb LW, Robinson GG, McCulloch MA. Emergency department care of patients with Duchenne muscular dystrophy. Am J Emerg Med 2022; 60:101-105. [PMID: 35933945 DOI: 10.1016/j.ajem.2022.07.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022] Open
Abstract
Patients with Duchenne muscular dystrophy are living longer and are increasingly seen in Emergency Departments. Though the most common cause of death remains progressive respiratory failure, increased life expectancies have unmasked the significance of progressive myocardial dysfunction, now associated with nearly 40% of mortalities in the DMD population. Cardiac complications such as arrhythmias and cardiomyopathy are becoming ever more widely recognized. Emergency physicians may encounter DMD patients with untreated, undiagnosed or worsening of known heart disease. This review will initially familiarize the emergency physician with the pathophysiology and lifetime trajectory of care for these patients before describing specific emergency department evaluation and treatment.
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Affiliation(s)
- William A Woods
- Department of Emergency Medicine, University of Virginia, Charlottesville, VA, United States of America; Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America.
| | - William G Harmon
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Lauren W Webb
- Department of Emergency Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Grant G Robinson
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Michael A McCulloch
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
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4
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Abney AJ, Monash B, Trappey B, Olson APJ. A traumatic traveler. J Hosp Med 2022; 17:54-58. [PMID: 32195652 DOI: 10.12788/jhm.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/16/2019] [Accepted: 01/04/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Ancil J Abney
- Departments of Pediatrics and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Bradley Monash
- Departments of Pediatrics and Medicine, University of California San Francisco, San Francisco, California
| | - Bernard Trappey
- Departments of Pediatrics and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Andrew P J Olson
- Departments of Pediatrics and Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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Chouteau WA, Burrows C, Wittekind SG, Rutter MM, Bange JE, Sabla GE, Rybalsky I, Tian C. Emergency Planning as Part of Healthcare Transition Preparation for Patients with Duchenne Muscular Dystrophy. J Pediatr Nurs 2021; 61:298-304. [PMID: 34450470 DOI: 10.1016/j.pedn.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Emergency care planning is an important component of healthcare transition, particularly for patients with medical complexity. Duchenne muscular dystrophy (DMD) is a complex, progressive pediatric-onset disease affecting multiple organ systems including impairment of cardiac and pulmonary function, high risk for fractures, fat embolism, adrenal crisis and malignant hyperthermia. Appropriate interdisciplinary emergency management is critical for survival for these patients. The purpose of this quality improvement project was to develop a process to reliably share an individualized emergency care plan (ECP) with patients and their families as part of a larger plan to develop an integrated transition program. METHODS An interdisciplinary team of nurses and clinicians used the principles of quality improvement to develop a reliable process to assure patients with DMD received an individualized, multidisciplinary ECP at routine interdisciplinary clinic visits. Additionally, the project used surveys to assess patient and family satisfaction with the letter and whether it improved their knowledge of emergency care. RESULTS Sixty-two patients were seen during the study timeframe. All received an ECP. Sixty-two surveys were sent and twenty-three surveys were returned. Of those that responded, the majority stated the ECP increased their knowledge of emergency care. CONCLUSION ECPs can be developed and disseminated to patients with DMD and their caregivers. This tool can potentially promote timely and appropriate emergency care for these patients with unique and complex medical needs.
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Affiliation(s)
- Wendy A Chouteau
- Neurology, Cincinnati Children's Hospital, OH, United States of America.
| | - Carolyn Burrows
- Pulmonary Medicine, Cincinnati Children's Hospital, OH, United States of America.
| | - Samuel G Wittekind
- Cardiology, Cincinnati Children's Hospital, OH, United States of America.
| | - Meilan M Rutter
- Endocrinology, Cincinnati Children's Hospital, OH, United States of America.
| | - Jean E Bange
- Neurology, Cincinnati Children's Hospital, OH, United States of America.
| | - Gregg E Sabla
- Pulmonary Medicine, Cincinnati Children's Hospital, OH, United States of America.
| | - Irina Rybalsky
- Neurology, Cincinnati Children's Hospital, OH, United States of America.
| | - Cuixia Tian
- Neurology, Cincinnati Children's Hospital, OH, United States of America.
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Marulanda J, Boraschi-Diaz I, Beauparlant P, Crine P, Rauch F. Skeletal Effects of Bone-Targeted TGFbeta Inhibition in a Mouse Model of Duchenne Muscular Dystrophy. Life (Basel) 2021; 11:life11080791. [PMID: 34440535 PMCID: PMC8401157 DOI: 10.3390/life11080791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a severe progressive muscle disease that is frequently associated with secondary osteoporosis. Previous studies have shown that TGFbeta inactivating antibody improves the muscle phenotype in mdx mice, a model of DMD. In the present study, we assessed the skeletal effects of treatment with a bone-targeted TGFbeta antibody (PCT-011) in mdx mice. Micro-computed tomography showed that 8 weeks of intraperitoneal administration of PCT-011 (10 mg per kg body mass, 3 times per week) was associated with more than twofold higher trabecular bone volume at the distal femur, which was explained by a higher trabecular number. At the femoral midshaft, PCT-011 exposure increased cortical thickness but did not significantly affect the results of three-point bending tests. Histomorphometric analyses of the lumbar vertebra 4 showed that PCT-011 treatment led to a lower bone formation rate. In conclusion, treatment with the TGFbeta antibody PCT-011 had a positive effect on bone development in mdx mice. Inhibiting TGFbeta activity thus appears to be a promising approach to treat bone fragility in the context of DMD.
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Affiliation(s)
- Juliana Marulanda
- Shriners Hospital for Children-Canada, Montreal, QC H4A 0A9, Canada; (J.M.); (I.B.-D.)
- Department of Pediatrics, McGill University, Montreal, QC H3A 0G4, Canada
| | - Iris Boraschi-Diaz
- Shriners Hospital for Children-Canada, Montreal, QC H4A 0A9, Canada; (J.M.); (I.B.-D.)
- Department of Pediatrics, McGill University, Montreal, QC H3A 0G4, Canada
| | | | - Philippe Crine
- PreciThera Inc., Montreal, QC H3A 2R7, Canada; (P.B.); (P.C.)
| | - Frank Rauch
- Shriners Hospital for Children-Canada, Montreal, QC H4A 0A9, Canada; (J.M.); (I.B.-D.)
- Department of Pediatrics, McGill University, Montreal, QC H3A 0G4, Canada
- Correspondence:
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Choong Wong S, Joseph S, Capaldi N, Marco MD, Dunne J, Guglieri M, Horrocks I, Straub V, Faisal Ahmed S. A survey of the feasibility of developing osteoporosis clinical trials in Duchenne muscular dystrophy: Survey of the opinion of young people with Duchenne muscular dystrophy, families and clinicians. Clin Trials 2020; 18:39-50. [PMID: 33012180 DOI: 10.1177/1740774520958395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Given the extent of osteoporosis in people with Duchenne muscular dystrophy treated with glucocorticoids and the limited evidence of bone-protective therapies, clinical trials are needed. We conducted surveys to obtain the opinion of young people with Duchenne muscular dystrophy, parents/guardians and neuromuscular clinicians on the feasibility of osteoporosis clinical trials in this population. METHODS Online surveys were sent to three groups: (a) people with a confirmed diagnosis of Duchenne muscular dystrophy (≥14 years), (b) parents and guardians and (c) neuromuscular clinicians in the UK NorthStar Clinical Network. Surveys (a) and (b) were distributed via the UK Duchenne muscular dystrophy Registry. RESULTS Survey respondents included 52 people with Duchenne muscular dystrophy with a median age of 17 years (range: 14, 40) and 183 parents/guardians. Fourteen out of 23 (61%) NorthStar centres responded. Of the 52 people with Duchenne muscular dystrophy, 13 (25%) were very concerned about their bone health and 21 (40%) were slightly concerned. Of the 183 parents/guardians, 75 (41%) were very concerned about their son's bone health and 90 (49%) were slightly concerned. Fractures and quality of life were the top two main outcome measures identified by people with Duchenne muscular dystrophy. Fractures and bone density were the top two main outcome measures identified by parents/guardians and neuromuscular clinicians. Thirty percent of people with Duchenne muscular dystrophy and 40% of parents/guardians would not take part if an osteoporosis trial involved a placebo that was administered parenterally. Only 2 of the 14 NorthStar centres (14%) would enrol people with Duchenne muscular dystrophy if a parenteral placebo was used in an osteoporosis trial in Duchenne muscular dystrophy. CONCLUSION There is great awareness of bone health and the need for bone-protective trials among people with Duchenne muscular dystrophy and their carers. However, a proportion of people with Duchenne muscular dystrophy and parents are reluctant to participate in a placebo-controlled osteoporosis trial that included a parenteral therapy. A larger proportion of health care experts are unwilling to enrol their patients in such a trial. Our finding is relevant for the design of bone-protective studies in Duchenne muscular dystrophy.
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Affiliation(s)
- Sze Choong Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK
| | - Shuko Joseph
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK.,Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Nadia Capaldi
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK
| | - Marina Di Marco
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK.,Scottish Muscle Network, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jennifer Dunne
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Michela Guglieri
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Iain Horrocks
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Volker Straub
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, UK
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Yoon SH, Grynpas MD, Mitchell J. Growth Hormone Increases Bone Toughness and Decreases Muscle Inflammation in Glucocorticoid-Treated Mdx Mice, Model of Duchenne Muscular Dystrophy. J Bone Miner Res 2019; 34:1473-1486. [PMID: 31188496 DOI: 10.1002/jbmr.3718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 01/03/2023]
Abstract
The absence of functional dystrophin with mutations of the dystrophin-encoding gene in Duchenne muscular dystrophy (DMD) results in muscle inflammation and degeneration, as well as bone fragility. Long-term glucocorticoid therapy delays the muscular disease progression but suppresses growth hormone secretion, resulting in short stature and further deleterious effects on bone strength. This study evaluated the therapeutic potential of daily growth hormone therapy in growing mdx mice as a model of DMD. Growth hormone treatment on its own or in combination with glucocorticoids significantly improved muscle histology and function and decreased markers of inflammation in mdx mice. Glucocorticoid treatment thinned cortical bone and decreased bone strength and toughness. Despite the minimal effects of growth hormone on bone microarchitecture, it significantly improved biomechanical properties of femurs and vertebrae, even in the presence of glucocorticoid treatment. Together these studies suggest that the use of growth hormone in DMD should be considered for improvements to muscle and bone health. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Sung-Hee Yoon
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Health System, Toronto, Canada
| | - Marc D Grynpas
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Health System, Toronto, Canada
| | - Jane Mitchell
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
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Abstract
Fat embolism (FE) occurs frequently after trauma and during orthopaedic procedures involving manipulation of intramedullary contents. Classically characterized as a triad of pulmonary distress, neurologic symptoms, and petechial rash, the clinical entity of FE syndrome is much less common. Both mechanical and biochemical pathophysiologic theories have been proposed with contributions of vascular obstruction and the inflammatory response to embolized fat and trauma. Recent studies have described the relationship of embolized marrow fat with deep venous thrombosis and postsurgical cognitive decline, but without clear treatment strategies. Because treatment is primarily supportive, our focus must be on prevention. In trauma, early fracture stabilization decreases the rate of FE syndrome; however, questions remain regarding the effect of reaming and management of bilateral femur fractures. In arthroplasty, computer navigation and alternative cementation techniques decrease fat embolization, although the clinical implications of these techniques are currently unclear, illustrating the need for ongoing education and research with an aim toward prevention.
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Abstract
Obesity is a common problem in children and adolescents with neuromuscular disease. The available literature on obesity in cerebral palsy, spina bifida, and Duchenne muscular dystrophy as it relates to orthopedic treatment is reviewed, including the demographics and measurement of obesity as well as the mechanisms of obesity in these individuals. In addition, the effect of obesity on function, patient evaluation, and orthopedic treatment are reviewed.
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Fat Embolism Syndrome in Duchenne Muscular Dystrophy Patients: Early Recognition and Aggressive Therapy. Case Rep Crit Care 2018; 2018:3686470. [PMID: 30009059 PMCID: PMC6008769 DOI: 10.1155/2018/3686470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 01/28/2023] Open
Abstract
We describe two pediatric patients with Duchenne muscular dystrophy that presented with acute neurologic deterioration and hypoxic respiratory failure requiring mechanical ventilation. These cases fulfill the clinical criteria for Fat Embolism Syndrome. Early recognition and aggressive supportive therapy with mechanical ventilation, right ventricular afterload reduction, and blood transfusion led to survival without any residual effects from the event. Fat Embolism Syndrome needs to be considered early in the course of patients with Duchenne muscular dystrophy who present with respiratory and neurological symptoms.
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