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Goyal NA, Bonar K, Savic N, Beau Lejdstrom R, Wright J, Mellor J, McDermott C. Misdiagnosis of amyotrophic lateral sclerosis in clinical practice in Europe and the USA: a patient chart review and physician survey. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:16-25. [PMID: 37794794 DOI: 10.1080/21678421.2023.2260808] [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: 06/19/2023] [Accepted: 09/07/2023] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Delays in amyotrophic lateral sclerosis (ALS) diagnosis can result in compromised disease management and unnecessary costs. We examined the extent of ALS misdiagnosis in the US and Europe. METHODS Data were collected via the Adelphi ALS Disease Specific Programme™, a cross-sectional survey of physicians and a medical chart review of their consulting patients with ALS in France, Germany, Italy, Spain, the UK (EU5), and the US. Between July 2020 and March 2021, eligible physicians (primary speciality neurology, active involvement in managing patients with ALS) abstracted data from patients (≥18 years old) with confirmed ALS. RESULTS Overall, 138 physicians completed the survey (EU5 107, US 31), with data reviewed from 795 patient medical charts (EU5 568, US 227); 278 (35.0%) patients (EU5 183 [32.2%], US 95 [41.9%]) had received ≥1 initial misdiagnosis based on symptoms later attributed to ALS. Mean (SD) time from symptom onset to first healthcare professional consultation was 3.8 (5.2) months (EU5 4.3 [4.8] months, US 2.6 [5.8] months). Mean (SD) time from symptom onset to ALS diagnosis was 8.2 (12.5) months (EU5 9.6 [14.0] months, US 5.0 [6.8] months) and increased to 10.4 (17.9) for patients with a misdiagnosis (compared with 6.9 [7.2] for patients with no misdiagnosis). Physician-identified barriers to timely ALS diagnosis included the similarity of symptoms to other conditions and delayed referral to neurologists. CONCLUSIONS Misdiagnosis of ALS is frequent, with a protracted diagnostic pathway. Targeted education of patients and physicians about signs and symptoms and benefits of prompt referral to multidisciplinary care are needed.
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Affiliation(s)
- Namita A Goyal
- Department of Neurology, UC Irvine MDA-ALS and Neuromuscular Center, University of California, Irvine, USA
| | | | | | | | | | | | - Christopher McDermott
- Department of Neurology, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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Yu W, Yu F, Li M, Yang F, Wang H, Song H, Huang X. Quantitative association between lead exposure and amyotrophic lateral sclerosis: a Bayesian network-based predictive study. Environ Health 2024; 23:2. [PMID: 38166850 PMCID: PMC10763408 DOI: 10.1186/s12940-023-01041-3] [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: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Environmental lead (Pb) exposure have been suggested as a causative factor for amyotrophic lateral sclerosis (ALS). However, the role of Pb content of human body in ALS outcomes has not been quantified clearly. The purpose of this study was to apply Bayesian networks to forecast the risk of Pb exposure on the disease occurrence. METHODS We retrospectively collected medical records of ALS inpatients who underwent blood Pb testing, while matched controlled inpatients on age, gender, hospital ward and admission time according to the radio of 1:9. Tree Augmented Naïve Bayes (TAN), a semi-naïve Bayes classifier, was established to predict probability of ALS or controls with risk factors. RESULTS A total of 140 inpatients were included in this study. The whole blood Pb levels of ALS patients (57.00 μg/L) were more than twice as high as the controls (27.71 μg/L). Using the blood Pb concentrations to calculate probability of ALS, TAN produced the total coincidence rate of 90.00%. The specificity, sensitivity of Pb for ALS prediction was 0.79, or 0.74, respectively. CONCLUSION Therefore, these results provided quantitative evidence that Pb exposure may contribute to the development of ALS. Bayesian networks may be used to predict the ALS early onset with blood Pb levels.
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Affiliation(s)
- Wenxiu Yu
- Medical School of Chinese PLA, Beijing, 100853, China
- Neurological Department of the First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Fangfang Yu
- Department of Medical Innovation Research, PLA General Hospital, Beijing, 100853, China
| | - Mao Li
- Neurological Department of the First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Fei Yang
- Neurological Department of the First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Hongfen Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Neurological Department of the First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Han Song
- Department of Health Service, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Xusheng Huang
- Medical School of Chinese PLA, Beijing, 100853, China.
- Neurological Department of the First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China.
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de Carvalho M, Swash M. Diagnosis and differential diagnosis of MND/ALS: IFCN handbook chapter. Clin Neurophysiol Pract 2023; 9:27-38. [PMID: 38249779 PMCID: PMC10796809 DOI: 10.1016/j.cnp.2023.12.003] [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: 08/23/2023] [Revised: 11/01/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
•Accurate and rapid diagnosis of amyotrophic lateral sclerosis (ALS) is important to prevent erroneous interventions. •The recent Gold Coast criteria are easily applicable and have high sensitivity and specificity. •Future developments will help to distinguish ALS as a specific clinical-pathologic entity. Accurate and rapid diagnosis of amyotrophic lateral sclerosis (ALS) is essential in order to provide accurate information for patient and family, to avoid time-consuming investigations and to permit an appropriate management plan. ALS is variable regarding presentation, disease progression, genetic profile and patient reaction to the diagnosis. It is obviously important to exclude treatable conditions but, in most patients, for experienced neurologists the diagnosis is clear-cut, depending on the presence of progressive upper and lower motor neuron signs. Patients with signs of restricted lower motor neuron (LMN) or upper motor neuron (UMN) dysfunction may present diagnostic difficulty, but electromyography (EMG) is often a determinant diagnostic test since it may exclude other disorders. Transcranial magnetic stimulation may aid detection of UMN dysfunction, and brain and spinal cord MRI, ultrasound and blood neurofilament measurements, have begun to have clinical impact, although none are themselves diagnostic tests. Several sets of diagnostic criteria have been proposed in the past; all rely on clinical LMN and UMN signs in different anatomic territories, EMG changes, exclusion of other disorders, and disease progression, in particular evidence of spreading to other anatomic territories. Fasciculations are a characteristic clinical feature and increased importance is now attached to fasciculation potentials detected by EMG, when associated with classical signs of denervation and reinnervation. The Gold Coast diagnostic criteria rely on the presence of UMN and LMN signs in one (or more) anatomic territory, or LMN signs in two (or more) anatomic territories, recognizing the fundamental clinical requirements of disease progression and exclusion of other diseases. Recent studies confirm a high sensitivity without loss of specificity using these Gold Coast criteria. In considering the diagnosis of ALS a critical question for future understanding is whether ALS should be considered a syndrome or a specific clinico-pathologic entity; this can only be addressed in the light of more complete knowledge.
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Affiliation(s)
- Mamede de Carvalho
- Faculdade de Medicina- Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| | - Michael Swash
- Faculdade de Medicina- Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal
- Departments of Neurology and Neurosciences, Barts and the London School of Medicine, Queen Mary University of London and Royal London Hospital, UK
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Gwathmey KG, Corcia P, McDermott CJ, Genge A, Sennfält S, de Carvalho M, Ingre C. Diagnostic delay in amyotrophic lateral sclerosis. Eur J Neurol 2023; 30:2595-2601. [PMID: 37209406 DOI: 10.1111/ene.15874] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disease, and the time from symptom onset to diagnosis remains long. With the advent of disease-modifying treatments, the need to identify and diagnose ALS in a timely fashion has never been greater. METHODS We reviewed the literature to define the severity of ALS diagnostic delay, the various factors that contribute to this delay (including patient and physician factors), and the role that site of symptom onset plays in a patient's diagnostic journey. RESULTS Diagnostic delay is influenced by general practitioners' lack of recognition of ALS due to disease rarity and heterogenous presentations. As a result, patients are referred to non-neurologists, have unnecessary diagnostic testing, and may ultimately be misdiagnosed. Patient factors include their illness behavior-which impacts diagnostic delay-and their site of symptom onset. Limb-onset patients have the greatest diagnostic delay because they are frequently misdiagnosed with degenerative spine disease or peripheral neuropathy. CONCLUSION Prompt ALS diagnosis results in more effective clinical management, with earlier access to disease-modifying therapies, multidisciplinary care, and, if desired, clinical trial involvement. Due to lack of commercially available ALS biomarkers, alternative strategies to identify and triage patients who likely have ALS must be employed. Several diagnostic tools have been developed to encourage general practitioners to consider ALS and make an urgent referral to ALS specialists, bypassing unnecessary referrals to non-neurologists and unnecessary diagnostic workup.
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Affiliation(s)
- Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Philippe Corcia
- CRMR SLA, CHU Tours, Tours, France
- UMR1253 iBrain UMR, Université de Tours, INSERM, Tours, France
| | - Chris J McDermott
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Angela Genge
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Stefan Sennfält
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mamede de Carvalho
- Institute of Physiology, Instituto de Medicina Molecular João Lobo Antunes, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Melka D, Demisse H, Assefa H, Zenebe Y, A Ayele B, Awraris M, Gelan Y, Kifelew S, Fedlu M, Tsehayneh F, Zebenigus M, Alemayehu S, Tesfaye H, Gulelat H, Guta T, Tafesse A, Bekele N, Saez M, Veldink JH, Al-Chalabi A, Povedano M, Al Khleifat A. Epidemiological and clinical profile of amyotrophic lateral sclerosis in Ethiopia: a 5-year multicenter retrospective study. Amyotroph Lateral Scler Frontotemporal Degener 2023:1-9. [PMID: 37496277 DOI: 10.1080/21678421.2023.2238016] [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: 05/09/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/28/2023]
Abstract
Background: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that results in progressive weakness of skeletal muscles including respiratory muscles. Epidemiological and clinical aspects of ALS are derived from a few world regions with very little representation of low- and middle-income countries. We therefore set out to determine the epidemiological and clinical phenotype of individuals with ALS in Ethiopia. Methods: Multicenter retrospective analysis was conducted using clinical records from ALS patients seen in Ethiopia at Tikur Anbessa Specialized Hospital and Yehuleshet specialty clinic between January 2016 and August 2021. The data collected included clinical characteristics, disease-related symptoms, a revised ALS functional rating scale, and medications. Results: Patients in Ethiopia had a younger age of onset with a mean age of disease onset of 51.9 years. 2.9% of patients had juvenile ALS, and the male-to-female ratio was almost 2:1. 4.9% had a positive family history of the disease. 68% of patients had spinal region involvement at onset, while 32% had bulbar region involvement at onset. Riluzole was used by 31% of ALS patients. 20.6% of patients had some respiratory symptoms, but none received a standard respiratory function assessment. 33.3% of patients were wheelchair-bound. Conclusion: In this retrospective study spanning 5 years, we examined the clinical phenotype of ALS in Ethiopian patients. Our findings suggest that most patients had clinically definite ALS with spinal region involvement. Further research, including genetic and epigenetic information, is necessary to understand the early onset of the disease in Ethiopia.
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Affiliation(s)
- Dereje Melka
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hanna Demisse
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hanna Assefa
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yared Zenebe
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Biniyam A Ayele
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Meron Awraris
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yohannese Gelan
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Selam Kifelew
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medina Fedlu
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fikiru Tsehayneh
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mehila Zebenigus
- Department of Neurology, Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | - Samson Alemayehu
- Department of Neurology, Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | | | | | - Tsega Guta
- Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | - Abenet Tafesse
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nebiyu Bekele
- Department of Internal Medicine Neurology Unit, College of Health Science, University of Gondar, Gondar, Ethiopia
| | - Marc Saez
- Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Girona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública/Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain
| | - Jan H Veldink
- Department of Neurology, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Ammar Al-Chalabi
- Department of Basic and Clinical, Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK, and
| | - Monica Povedano
- Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Ahmad Al Khleifat
- Department of Basic and Clinical, Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK, and
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Oliveira Santos M, Gromicho M, Pinto S, Pronto-Laborinho AC, de Carvalho M. Clinical characteristics in amyotrophic lateral sclerosis with Sub-Saharan Africa ancestry - A Portuguese hospital-based cohort study. Clin Neurol Neurosurg 2023; 227:107674. [PMID: 36933404 DOI: 10.1016/j.clineuro.2023.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/28/2023] [Accepted: 03/12/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Miguel Oliveira Santos
- Institute of Physiology, Instituto de Medicina Molecular-JLA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.
| | - Marta Gromicho
- Institute of Physiology, Instituto de Medicina Molecular-JLA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Susana Pinto
- Institute of Physiology, Instituto de Medicina Molecular-JLA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Catarina Pronto-Laborinho
- Institute of Physiology, Instituto de Medicina Molecular-JLA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mamede de Carvalho
- Institute of Physiology, Instituto de Medicina Molecular-JLA, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
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