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Castro D, Sejersen T, Bello L, Buccella F, Cairns A, Carranza-Del Río J, de Groot IJM, Elman L, Inzani I, Klein A, Mayer OH, Miller H, Onofri A, Araújo APDQC, Schara-Schmidt U, Vanden Wyngaert K, Ward LM, Wilmshurst JM, Quinlivan R. Transition of patients with Duchenne muscular dystrophy from paediatric to adult care: An international Delphi consensus study. Eur J Paediatr Neurol 2025; 54:130-139. [PMID: 39892019 DOI: 10.1016/j.ejpn.2025.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 11/22/2024] [Accepted: 01/08/2025] [Indexed: 02/03/2025]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a rare neuromuscular disorder characterized by a progressive decline in muscle function, leading to loss of ambulation, respiratory and cardiac failure, and ultimately death. Improvements in DMD management have increased patient life expectancy; therefore, there is a growing requirement for patients to transfer from paediatric to adult care services. There is also a need for clear recommendations to guide this process. AIM To establish international consensus guidelines regarding best practices for transitioning patients with DMD from paediatric to adult care and ensuring continuity of treatment. METHODS Consensus statements were developed using the Delphi process and scored using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The initiative was led by a steering committee (one non-voting chair and two voting members) who recruited 15 expert panellists to form the consensus group. Following an initial systematic literature search, the consensus group voted in three voting rounds. Round 1 (free-text responses to questions) and Round 2 (importance ranking of statements) were completed using an online survey. Round 3 (voting on final consensus statements) took place during a virtual consensus meeting. CONSENSUS STATEMENTS Consensus was reached on 48 statements covering the topics of transition planning, the transition process, post-transfer management, communicating with young people with DMD and supporting them with the transition to adult life. CONCLUSION These consensus statements provide guidelines for improving transition practices for young people with DMD and promoting continued care at a comparable standard in adulthood.
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Akhtar Y, Udupa JK, Tong Y, Wu C, Liu T, Tong L, Hosseini M, Al-Noury M, Chodvadiya M, McDonough JM, Mayer OH, Biko DM, Anari JB, Cahill P, Torigian DA. Auto-segmentation of hemi-diaphragms in free-breathing dynamic MRI of pediatric subjects with thoracic insufficiency syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.09.17.24313704. [PMID: 39371175 PMCID: PMC11451659 DOI: 10.1101/2024.09.17.24313704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2024]
Abstract
Purpose In respiratory disorders such as thoracic insufficiency syndrome (TIS), the quantitative study of the regional motion of the left hemi-diaphragm (LHD) and right hemi-diaphragm (RHD) can give detailed insights into the distribution and severity of the abnormalities in individual patients. Dynamic magnetic resonance imaging (dMRI) is a preferred imaging modality for capturing dynamic images of respiration since dMRI does not involve ionizing radiation and can be obtained under free-breathing conditions. Using 4D images constructed from dMRI of sagittal locations, diaphragm segmentation is an evident step for the said quantitative analysis of LHD and RHD in these 4D images. Methods In this paper, we segment the LHD and RHD in three steps: recognition of diaphragm, delineation of diaphragm, and separation of diaphragm along the mid-sagittal plane into LHD and RHD. The challenges involved in dMRI images are low resolution, motion blur, suboptimal contrast resolution, inconsistent meaning of gray-level intensities for the same object across multiple scans, and low signal-to-noise ratio. We have utilized deep learning (DL) concepts such as Path Aggregation Network and Dual Attention Network for the recognition step, Dense-Net and Residual-Net in an enhanced encoder-decoder architecture for the delineation step, and a combination of GoogleNet and Recurrent Neural Network for the identification of the mid-sagittal plane in the separation step. Due to the challenging images of TIS patients attributed to their highly distorted and variable anatomy of the thorax, in such images we localize the diaphragm using the auto-segmentations of the lungs and the thoraco-abdominal skin. Results We achieved an average±SD mean-Hausdorff distance of ∼3±3 mm for the delineation step and a positional error of ∼3±3 mm in recognizing the mid-sagittal plane in 100 3D test images of TIS patients with a different set of ∼430 3D images of TIS patients utilized for building the models for delineation, and separation. We showed that auto-segmentations of the diaphragm are indistinguishable from segmentations by experts, in images of near-normal subjects. In addition, the algorithmic identification of the mid-sagittal plane is indistinguishable from its identification by experts in images of near-normal subjects. Conclusions Motivated by applications in surgical planning for disorders such as TIS, we have shown an auto-segmentation set-up for the diaphragm in dMRI images of TIS pediatric subjects. The results are promising, showing that our system can handle the aforesaid challenges. We intend to use the auto-segmentations of the diaphragm to create the initial ground truth (GT) for newly acquired data and then refining them, to expedite the process of creating GT for diaphragm motion analysis, and to test the efficacy of our proposed method to optimize pre-treatment planning and post-operative assessment of patients with TIS and other disorders.
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Tong Y, Udupa JK, McDonough JM, Wu C, Xie L, Rajapakse CS, Gogel S, Sarkar S, Mayer OH, Anari JB, Torigian DA, Cahill PJ. Characterizing Lung Parenchymal Aeration via Standardized Signal Intensity from Free-breathing 4D Dynamic MRI in Phantoms, Healthy Children, and Pediatric Patients with Thoracic Insufficiency Syndrome. Radiol Cardiothorac Imaging 2024; 6:e230262. [PMID: 39051878 PMCID: PMC11369656 DOI: 10.1148/ryct.230262] [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: 09/07/2023] [Revised: 05/02/2024] [Accepted: 05/31/2024] [Indexed: 07/27/2024]
Abstract
Purpose To investigate free-breathing thoracic bright-blood four-dimensional (4D) dynamic MRI (dMRI) to characterize aeration of parenchymal lung tissue in healthy children and patients with thoracic insufficiency syndrome (TIS). Materials and Methods All dMR images in patients with TIS were collected from July 2009 to June 2017. Standardized signal intensity (sSI) was investigated, first using a lung aeration phantom to establish feasibility and sensitivity and then in a retrospective research study of 40 healthy children (16 male, 24 female; mean age, 9.6 years ± 2.1 [SD]), 20 patients with TIS before and after surgery (11 male, nine female; mean age, 6.2 years ± 4.2), and another 10 healthy children who underwent repeated dMRI examinations (seven male, three female; mean age, 9 years ± 3.6). Individual lungs in 4D dMR images were segmented, and sSI was assessed for each lung at end expiration (EE), at end inspiration (EI), preoperatively, postoperatively, in comparison to normal lungs, and in repeated scans. Results Air content changes of approximately 6% were detectable in phantoms via sSI. sSI within phantoms significantly correlated with air occupation (Pearson correlation coefficient = -0.96 [P < .001]). For healthy children, right lung sSI was significantly lower than that of left lung sSI (at EE: 41 ± 6 vs 47 ± 6 and at EI: 39 ± 6 vs 43 ± 7, respectively; P < .001), lung sSI at EI was significantly lower than that at EE (P < .001), and left lung sSI at EE linearly decreased with age (r = -0.82). Lung sSI at EE and EI decreased after surgery for patients (although not statistically significantly, with P values of sSI before surgery vs sSI after surgery, left and right lung separately, in the range of 0.13-0.51). sSI varied within 1.6%-4.7% between repeated scans. Conclusion This study demonstrates the feasibility of detecting change in sSI in phantoms via bright-blood dMRI when air occupancy changes. The observed reduction in average lung sSI after surgery in pediatric patients with TIS may indicate postoperative improvement in parenchymal aeration. Keywords: MR Imaging, Thorax, Lung, Pediatrics, Thoracic Surgery, Lung Parenchymal Aeration, Free-breathing Dynamic MRI, MRI Intensity Standardization, Thoracic Insufficiency Syndrome Supplemental material is available for this article. © RSNA, 2024.
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Foley AR, Yun P, Leach ME, Neuhaus SB, Averion GV, Hu Y, Hayes LH, Donkervoort S, Jain MS, Waite M, Parks R, Bharucha-Goebel DX, Mayer OH, Zou Y, Fink M, DeCoster J, Mendoza C, Arévalo C, Hausmann R, Petraki D, Cheung K, Bönnemann CG. Phase 1 Open-Label Study of Omigapil in Patients With LAMA2- or COL6-Related Dystrophy. Neurol Genet 2024; 10:e200148. [PMID: 38915423 PMCID: PMC11139016 DOI: 10.1212/nxg.0000000000200148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/29/2024] [Indexed: 06/26/2024]
Abstract
Background and Objectives Omigapil is a small molecule which inhibits the GAPDH-Siah1-mediated apoptosis pathway. Apoptosis is a pathomechanism underlying the congenital muscular dystrophy subtypes LAMA2-related dystrophy (LAMA2-RD) and COL6-related dystrophy (COL6-RD). Studies of omigapil in the (dyw/dyw) LAMA2-RD mouse model demonstrated improved survival, and studies in the (dy2J/dy2J) LAMA2-RD mouse model and the (Col6a1-/-) COL6-RD mouse model demonstrated decreased apoptosis. Methods A phase 1 open-label, sequential group, ascending oral dose, cohort study of omigapil in patients with LAMA2-RD or COL6-RD ages 5-16 years was performed (1) to establish the pharmacokinetic (PK) profile of omigapil at a range of doses, (2) to evaluate the safety and tolerability of omigapil at a range of doses, and (3) to establish the feasibility of conducting disease-relevant clinical assessments. Patients were enrolled in cohorts of size 4, with each patient receiving 4 weeks of vehicle run-in and 12 weeks of study drug (at daily doses ranging from 0.02 to 0.08 mg/kg). PK data from each cohort were analyzed before each subsequent dosing cohort was enrolled. A novel, adaptive dose-finding method (stochastic approximation with virtual observation recursion) was used to allow for dose escalation/reduction between cohorts based on PK data. Results Twenty patients were enrolled at the NIH (LAMA2-RD: N = 10; COL6-RD: N = 10). Slightly greater than dose-proportional increases in systemic exposure to omigapil were seen at doses 0.02-0.08 mg/kg/d. The dose which achieved patient exposure within the pre-established target area under the plasma concentration-vs-time curve (AUC0-24h) range was 0.06 mg/kg/d. In general, omigapil was safe and well tolerated. No consistent changes were seen in the disease-relevant clinical assessments during the duration of the study. Discussion This study represents the thus far only clinical trial of a therapeutic small molecule for LAMA2-RD and COL6-RD, completed with an adaptive trial design to arrive at dose adjustments. The trial met its primary end point and established that the PK profile of omigapil is suitable for further development in pediatric patients with LAMA2-RD or COL6-RD, the most common forms of congenital muscular dystrophy. While within the short duration of the study disease-relevant clinical assessments did not demonstrate significant changes, this study establishes the feasibility of performing interventional clinical trials in these rare disease patient populations. Classification of Evidence This study provides Class IV evidence of omigapil in a dose-finding phase 1 study. Trial Registration Information Clinical Trials NCT01805024.
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Hao Y, Udupa JK, Tong Y, Wu C, McDonough JM, Gogel S, Mayer OH, Alnoury M, Cahill PJ, Anari JB, Torigian DA. Quantifying Normal Diaphragmatic Motion and Shape and their Developmental Changes via Dynamic MRI. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.12.24306850. [PMID: 38798322 PMCID: PMC11118591 DOI: 10.1101/2024.05.12.24306850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Background The diaphragm is a critical structure in respiratory function, yet in-vivo quantitative description of its motion available in the literature is limited. Research Question How to quantitatively describe regional hemi-diaphragmatic motion and curvature via free-breathing dynamic magnetic resonance imaging (dMRI)? Study Design and Methods In this prospective cohort study we gathered dMRI images of 177 normal children and segmented hemi-diaphragm domes in end-inspiration and end-expiration phases of the constructed 4D image. We selected 25 points uniformly located on each 3D hemi-diaphragm surface. Based on the motion and local shape of hemi-diaphragm at these points, we computed the velocities and sagittal and coronal curvatures in 13 regions on each hemi-diaphragm surface and analyzed the change in these properties with age and gender. Results Our cohort consisted of 94 Females, 6-20 years (12.09 + 3.73), and 83 Males, 6-20 years (11.88 + 3.57). We observed velocity range: ∼2mm/s to ∼13mm/s; Curvature range -Sagittal: ∼3m -1 to ∼27m -1 ; Coronal: ∼6m -1 to ∼20m -1 . There was no significant difference in velocity between genders, although the pattern of change in velocity with age was different for the two groups. Strong correlations in velocity were observed between homologous regions of right and left hemi-diaphragms. There was no significant difference in curvatures between genders or change in curvatures with age. Interpretation Regional motion/curvature of the 3D diaphragmatic surface can be estimated using free-breathing dynamic MRI. Our analysis sheds light on here-to-fore unknown matters such as how the pediatric 3D hemi-diaphragm motion/shape varies regionally, between right and left hemi-diaphragms, between genders, and with age.
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Tong Y, Udupa JK, McDonough JM, Xie L, Wu C, Akhtar Y, Hosseini M, Alnoury M, Shaghaghi S, Gogel S, Biko DM, Mayer OH, Torigian DA, Cahill PJ, Anari JB. Do Rib-Based Anchors Impair Chest Wall Motion in Early Onset Scoliosis (EOS)? MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.01.24306556. [PMID: 38746195 PMCID: PMC11092725 DOI: 10.1101/2024.05.01.24306556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Purpose There is a concern in pediatric surgery practice that rib-based fixation may limit chest wall motion in early onset scoliosis (EOS). The purpose of this study is to address the above concern by assessing the contribution of chest wall excursion to respiration before and after surgery. Methods Quantitative dynamic magnetic resonance imaging (QdMRI) is performed on EOS patients (before and after surgery) and normal children in this retrospective study. QdMRI is purely an image-based approach and allows free breathing image acquisition. Tidal volume parameters for chest walls (CWtv) and hemi-diaphragms (Dtv) were analyzed on concave and convex sides of the spinal curve. EOS patients (1-14 years) and normal children (5-18 years) were enrolled, with an average interval of two years for dMRI acquisition before and after surgery. Results CWtv significantly increased after surgery in the global comparison including all EOS patients (p < 0.05). For main thoracic curve (MTC) EOS patients, CWtv significantly improved by 50.24% (concave side) and 35.17% (convex side) after age correction (p < 0.05) after surgery. The average ratio of Dtv to CWtv on the convex side in MTC EOS patients was not significantly different from that in normal children (p=0.78), although the concave side showed the difference to be significant. Conclusion Chest wall component tidal volumes in EOS patients measured via QdMRI did not decrease after rib-based surgery, suggesting that rib-based fixation does not impair chest wall motion in pediatric patients with EOS.
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Hosseini M, Udupa JK, Hao Y, Tong Y, Wu C, Akhtar Y, Al-Noury M, Shaghaghi S, McDonough JM, Biko DM, Gogel S, Mayer OH, Cahill PJ, Torigian DA, Anari JB. Assessment of 3D hemi-diaphragmatic motion via free-breathing dynamic MRI in pediatric thoracic insufficiency syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.02.24306551. [PMID: 38746409 PMCID: PMC11092715 DOI: 10.1101/2024.05.02.24306551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Purpose Thoracic insufficiency syndrome (TIS) affects ventilatory function due to spinal and thoracic deformities limiting lung space and diaphragmatic motion. Corrective orthopedic surgery can be used to help normalize skeletal anatomy, restoring lung space and diaphragmatic motion. This study employs free-breathing dynamic MRI (dMRI) and quantifies the 3D motion of each hemi-diaphragm surface in normal and TIS patients, and evaluates effects of surgical intervention. Materials and Methods In a retrospective study of 149 pediatric patients with TIS and 190 healthy children, we constructed 4D images from free-breathing dMRI and manually delineated the diaphragm at end-expiration (EE) and end-inspiration (EI) time points. We automatically selected 25 points uniformly on each hemi-diaphragm surface, calculated their relative velocities between EE and EI, and derived mean velocities in 13 homologous regions for each hemi-diaphragm to provide measures of regional 3D hemi-diaphragm motion. T-testing was used to compare velocity changes before and after surgery, and to velocities in healthy controls. Results The posterior-central region of the right hemi-diaphragm exhibited the highest average velocity post-operatively. Posterior regions showed greater velocity changes after surgery in both right and left hemi-diaphragms. Surgical reduction of thoracic Cobb angle displayed a stronger correlation with changes in diaphragm velocity than reduction in lumbar Cobb angle. Following surgery, the anterior regions of the left hemi-diaphragm tended to approach a more normal state. Conclusion Quantification of regional motion of the 3D diaphragm surface in normal subjects and TIS patients via free-breathing dMRI is feasible. Derived measurements can be assessed in comparison to normal subjects to study TIS and the effects of surgery.
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Tong Y, Udupa JK, McDonough JM, Xie L, Hao Y, Akhtar Y, Wu C, Rajapakse CS, Gogel S, Mayer OH, Anari JB, Torigian DA, Cahill PJ. Virtual Growing Child (VGC): A general normative comparative system via quantitative dynamic MRI for quantifying pediatric regional respiratory anomalies with application in thoracic insufficiency syndrome (TIS). BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.28.591554. [PMID: 38746219 PMCID: PMC11092456 DOI: 10.1101/2024.04.28.591554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background A normative database of regional respiratory structure and function in healthy children does not exist. Methods VGC provides a database with four categories of regional respiratory measurement parameters including morphological, architectural, dynamic, and developmental. The database has 3,820 3D segmentations (around 100,000 2D slices with segmentations). Age and gender group analysis and comparisons for healthy children were performed using those parameters via two-sided t-testing to compare mean measurements, for left and right sides at end-inspiration (EI) and end-expiration (EE), for different age and gender specific groups. We also apply VGC measurements for comparison with TIS patients via an extrapolation approach to estimate the association between measurement and age via a linear model and to predict measurements for TIS patients. Furthermore, we check the Mahalanobis distance between TIS patients and healthy children of corresponding age. Findings The difference between male and female groups (10-12 years) behave differently from that in other age groups which is consistent with physiology/natural growth behavior related to adolescence with higher right lung and right diaphragm tidal volumes for females(p<0.05). The comparison of TIS patients before and after surgery show that the right and left components are not symmetrical, and the left side diaphragm height and tidal volume has been significantly improved after surgery (p <0.05). The left lung volume at EE, and left diaphragm height at EI of TIS patients after surgery are closer to the normal children with a significant smaller Mahalanobis distance (MD) after surgery (p<0.05). Interpretation The VGC system can serve as a reference standard to quantify regional respiratory abnormalities on dMRI in young patients with various respiratory conditions and facilitate treatment planning and response assessment. Funding The grant R01HL150147 from the National Institutes of Health (PI Udupa).
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McDonald CM, Mayer OH, Hor KN, Miller D, Goemans N, Henricson EK, Marden JR, Freimark J, Lane H, Zhang A, Frean M, Trifillis P, Koladicz K, Signorovitch J. Functional and Clinical Outcomes Associated with Steroid Treatment among Non-ambulatory Patients with Duchenne Muscular Dystrophy1. J Neuromuscul Dis 2023; 10:67-79. [PMID: 36565131 PMCID: PMC9881035 DOI: 10.3233/jnd-221575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Evidence on the long-term efficacy of steroids in Duchenne muscular dystrophy (DMD) after loss of ambulation is limited. OBJECTIVE Characterize and compare disease progression by steroid treatment (prednisone, deflazacort, or no steroids) among non-ambulatory boys with DMD. METHODS Disease progression was measured by functional status (Performance of Upper Limb Module for DMD 1.2 [PUL] and Egen Klassifikation Scale Version 2 [EK] scale) and by cardiac and pulmonary function (left ventricular ejection fraction [LVEF], forced vital capacity [FVC] % -predicted, cough peak flow [CPF]). Longitudinal changes in outcomes, progression to key disease milestones, and dosing and body composition metrics were analyzed descriptively and in multivariate models. RESULTS This longitudinal cohort study included 86 non-ambulatory patients with DMD (mean age 13.4 years; n = 40 [deflazacort], n = 29 [prednisone], n = 17 [no steroids]). Deflazacort use resulted in slower average declines in FVC % -predicted vs. no steroids (+3.73 percentage points/year, p < 0.05). Both steroids were associated with significantly slower average declines in LVEF, improvement in CPF, and slower declines in total PUL score and EK total score vs. no steroids; deflazacort was associated with slower declines in total PUL score vs. prednisone (all p < 0.05). Both steroids also preserved functional abilities considered especially important to quality of life, including the abilities to perform hand-to-mouth function and to turn in bed at night unaided (all p < 0.05 vs. no steroids). CONCLUSIONS Steroid use after loss of ambulation in DMD was associated with delayed progression of important pulmonary, cardiac, and upper extremity functional deficits, suggesting some benefits of deflazacort over prednisone.
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Tong Y, Udupa JK, McDonough JM, Wu C, Sun C, Xie L, Lott C, Clark A, Mayer OH, Anari JB, Torigian DA, Cahill PJ. Assessment of Regional Functional Effects of Surgical Treatment in Thoracic Insufficiency Syndrome via Dynamic Magnetic Resonance Imaging. J Bone Joint Surg Am 2023; 105:53-62. [PMID: 36598475 DOI: 10.2106/jbjs.22.00324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Quantitative regional assessment of thoracic function would enable clinicians to better understand the regional effects of therapy and the degree of deviation from normality in patients with thoracic insufficiency syndrome (TIS). The purpose of this study was to determine the regional functional effects of surgical treatment in TIS via quantitative dynamic magnetic resonance imaging (MRI) in comparison with healthy children. METHODS Volumetric parameters were derived via 129 dynamic MRI scans from 51 normal children (November 2017 to March 2019) and 39 patients with TIS (preoperatively and postoperatively, July 2009 to May 2018) for the left and right lungs, the left and right hemi-diaphragms, and the left and right hemi-chest walls during tidal breathing. Paired t testing was performed to compare the parameters from patients with TIS preoperatively and postoperatively. Mahalanobis distances between parameters of patients with TIS and age-matched normal children were assessed to evaluate the closeness of patient lung function to normality. Linear regression functions were utilized to estimate volume deviations of patients with TIS from normality, taking into account the growth of the subjects. RESULTS The mean Mahalanobis distances for the right hemi-diaphragm tidal volume (RDtv) were -1.32 ± 1.04 preoperatively and -0.05 ± 1.11 postoperatively (p = 0.001). Similarly, the mean Mahalanobis distances for the right lung tidal volume (RLtv) were -1.12 ± 1.04 preoperatively and -0.10 ± 1.26 postoperatively (p = 0.01). The mean Mahalanobis distances for the ratio of bilateral hemi-diaphragm tidal volume to bilateral lung tidal volume (BDtv/BLtv) were -1.68 ± 1.21 preoperatively and -0.04 ± 1.10 postoperatively (p = 0.003). Mahalanobis distances decreased after treatment, suggesting reduced deviations from normality. Regression results showed that all volumes and tidal volumes significantly increased after treatment (p < 0.001), and the tidal volume increases were significantly greater than those expected from normal growth for RDtv, RLtv, BDtv, and BLtv (p < 0.05). CONCLUSIONS Postoperative tidal volumes of bilateral lungs and bilateral hemi-diaphragms of patients with TIS came closer to those of normal children, indicating positive treatment effects from the surgical procedure. Quantitative dynamic MRI facilitates the assessment of regional effects of a surgical procedure to treat TIS. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Kelchtermans J, Mayer OH. Year in review 2021: Neuromuscular diseases. Pediatr Pulmonol 2023; 58:20-25. [PMID: 36134670 PMCID: PMC9771959 DOI: 10.1002/ppul.26159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 01/11/2023]
Abstract
In this years' review of neuromuscular respiratory medicine, there were a series of articles on home mechanical ventilation, real-world studies assessing the impact of nusinersen, and studies describing upper airway dysfunction. Beyond this, we highlight two excellent reviews regarding cardiac dysfunction in neuromuscular diseases.
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Servais L, Mayer OH, McDonald CM, Voit T, Mercuri E, Buyse GM. 074 Long-term effect of idebenone in reducing respiratory function decline in patients with Duchenne muscular dystrophy. Journal of Neurology, Neurosurgery and Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Two placebo-controlled trials of 52-week duration showed that idebenone consistently reduced respira- tory function decline rate in patients with DMD. Long-term data from the DELPHI-Extension (DELPHI-E) study and SYROS (DELOS patients who transitioned to idebenone under an Expanded Access Program) are now presented. The aim was to assess the consistency of the long-term effect of idebenone.11 DELPHI-E and 18 SYROS patients with abnormal (<80%) forced vital capacity (as percent predicted, FVC%p) were treated with idebenone for an average of 2.0 and 4.2 years respectively. Annualized FVC%p decline rates were compared to untreated patients from SYROS or matched external controls.Mean (SD) baseline age was 13.6 (2.3) and 13.3 (2.7) years in DELPHI (N=11) and DELOS (N=18), respec- tively, and FVC%p was 47.2% (19.7%) and 58.7% (17.6%). For the first 2-year period, the average annual decline rate was comparable in treated patients (4.5% and 5.4% in DELPHI-E and SYROS) and lower than in untreated SYROS patients and external controls (7.9% untreated and 8.1% in CINRG-DNHS). During years 3–6, the annual decline rate was consistently lower than for matched controls.Treatment with idebenone resulted in a sustained reduction in the rate of decline in respiratory function. laurent.servais@paediatrics.ox.ac.uk
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McDonald CM, Marbán E, Hendrix S, Hogan N, Ruckdeschel Smith R, Eagle M, Finkel RS, Tian C, Janas J, Harmelink MM, Varadhachary AS, Taylor MD, Hor KN, Mayer OH, Henricson EK, Furlong P, Ascheim DD, Rogy S, Williams P, Marbán L. Repeated intravenous cardiosphere-derived cell therapy in late-stage Duchenne muscular dystrophy (HOPE-2): a multicentre, randomised, double-blind, placebo-controlled, phase 2 trial. Lancet 2022; 399:1049-1058. [PMID: 35279258 DOI: 10.1016/s0140-6736(22)00012-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cardiosphere-derived cells (CDCs) ameliorate skeletal and cardiac muscle deterioration in experimental models of Duchenne muscular dystrophy. The HOPE-2 trial examined the safety and efficacy of sequential intravenous infusions of human allogeneic CDCs in late-stage Duchenne muscular dystrophy. METHODS In this multicentre, randomised, double-blind, placebo-controlled, phase 2 trial, patients with Duchenne muscular dystrophy, aged 10 years or older with moderate upper limb impairment, were enrolled at seven centres in the USA. Patients were randomly assigned (1:1) using stratified permuted blocks to receive CAP-1002 (1·5 × 108 CDCs) or placebo intravenously every 3 months for a total of four infusions. Clinicians, caregivers, patients, and clinical operations personnel were fully masked to treatment groups. The primary outcome was the change in mid-level elbow Performance of Upper Limb version 1.2 (PUL 1.2) score at 12 months, assessed in the intention-to-treat population. Safety was assessed in all individuals who received an investigational product. This trial is registered with ClinicalTrials.gov, NCT03406780. FINDINGS Between March 1, 2018, and March 31, 2020, 26 male patients with Duchenne muscular dystrophy were enrolled, of whom eight were randomly assigned to the CAP-1002 group and 12 to the placebo group (six were not randomised due to screening failure). In patients who had a post-treatment PUL 1.2 assessment (eight in the CAP-1002 group and 11 in the placebo group), the mean 12-month change from baseline in mid-level elbow PUL1.2 favoured CAP-1002 over placebo (percentile difference 36·2, 95% CI 12·7-59·7; difference of 2·6 points; p=0·014). Infusion-related hypersensitivity reactions without long-term sequelae were observed in three patients, with one patient discontinuing therapy due to a severe allergic reaction. No other major adverse reactions were noted, and no deaths occurred. INTERPRETATION CAP-1002 cell therapy appears to be safe and effective in reducing deterioration of upper limb function in patients with late-stage Duchenne muscular dystrophy. Various measures of cardiac function and structure were also improved in the CAP-1002 group compared with the placebo group. Longer-term extension studies are needed to confirm the therapeutic durability and safety of CAP-1002 beyond 12 months for the treatment of skeletal myopathy and cardiomyopathy in Duchenne muscular dystrophy. FUNDING Capricor Therapeutics.
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Magee L, Bram JT, Anari JB, Ramo B, Mayer OH, Matsumoto H, Brooks JT, Andras L, Lark R, Fitzgerald R, Truong W, Li Y, Karlin L, Schwend R, Weinstein S, Roye D, Snyder B, Flynn JM, Oetgen M, Smith J, Cahill PJ. Outcomes and Complications in Management of Congenital Myopathy Early-Onset Scoliosis. J Pediatr Orthop 2021; 41:531-536. [PMID: 34325442 DOI: 10.1097/bpo.0000000000001922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Congenital myopathies (CMs) are complex conditions often associated with early-onset scoliosis (EOS). The purpose of this study was to investigate radiographic outcomes in CM patients undergoing EOS instrumentation as well as complications. Secondarily, we sought to compare these patients to a population with higher prevalence, cerebral palsy (CP) EOS patients. METHODS This is a retrospective study of a prospectively collected multicenter registry. The registry was queried for EOS patients with growth-sparing instrumentation (vertical expandable prosthetic titanium ribs, magnetically controlled growing rods, traditional growing rod, or Shilla) and a CM or CP diagnosis with minimum 2 years follow-up. Outcomes included major curve magnitude, T1-S1 height, kyphosis, and complications. RESULTS Sixteen patients with CM were included. Six (37.5%) children with CM experienced 11 complications by 2 years. Mean major curve magnitude for CM patients was improved postoperatively and maintained at 2 years (P<0.01), with no significant increase in T1-S1 height or maximum kyphosis(P>0.05). Ninety-seven patients with CP EOS were included as a comparative cohort. Fewer CP patients required baseline respiratory support compared with CM patients (20.0% vs. 92.9%, P<0.01). Fifty-four (55.7%) CP patients experienced a total of 105 complications at 2 years. There was no evidence that the risk of complication or radiographic outcomes differs between cohorts at 2 years, though CP EOS patients experienced significant improvement in all measurements at 2 years. CONCLUSIONS EOS CM children face a high risk of complication after growing instrumentation, with similar curve correction and risk of complication to CP patients. LEVEL OF EVIDENCE Level III.
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Johnson MA, Galagedera N, Ho S, Hilmara D, Campbell RM, Anari JB, Mayer OH, Cahill PJ. Correlation of Pulmonary Function to Novel Radiographic Parameters of Collapsing Parasol Deformity in Spinal Muscular Atrophy. Orthopedics 2021; 44:e287-e293. [PMID: 33373463 DOI: 10.3928/01477447-20201216-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Spinal muscular atrophy (SMA) is a neuromuscular disease with manifestations of scoliosis, pulmonary function decline, and, uniquely, collapse of the ribs. Methods to quantify rib deformity and its impact on pulmonary function are sparse. The authors propose new radiographic measurements to quantify the aspect of SMA known as collapsing parasol deformity and correlate these measurements with pulmonary function. Twenty-eight full-spine radiographs of pediatric SMA patients were measured twice by 3 independent investigators, with 2 weeks separating each measurement. Radiographic measurements, demographics, spirometry results, and assisted ventilation rating were obtained. Twenty-one patients with spirometry metrics were assessed to correlate pulmonary function and spinal measurements. The intrarater intraclass correlation coefficient (ICC) for the measurements ranged from 0.706 to 0.99, and the interrater ICC ranged from 0.64 to 0.97. Eighteen of 19 variables had ICC values greater than 0.75 for inter- and intrarater reliability. Twenty-one patients with forced expiratory volume in 1 second and forced vital capacity were assessed in terms of these measurements. Ratio of the concave hemithoracic width at T6/convex hemithoracic width at T6 (P=.004) and ratio of convex vertical rib displacement at the apical rib/concave vertical rib displacement (P=.021) were both significantly correlated with decreased pulmonary function. No significant correlation was found examining the average vertical rib displacement at the apical rib. High inter-and intrarater reliability can be obtained in a variety of spinal measurements of SMA patients. Various measurements are correlated to diminished pulmonary function, specifically variables showing asymmetric changes in the chest cavity. [Orthopedics. 2021;44(2):e287-e293.].
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Orbach MR, Servaes SE, Mayer OH, Cahill PJ, Balasubramanian S. Quantifying lung and diaphragm morphology using radiographs in normative pediatric subjects, and predicting CT-derived lung volume. Pediatr Pulmonol 2021; 56:2177-2185. [PMID: 33860632 DOI: 10.1002/ppul.25429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/03/2021] [Accepted: 04/11/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To quantify the effect of age on two-dimensional (2D) radiographic lung and diaphragm morphology and determine if 2D radiographic lung measurements can be used to estimate computer tomography (CT)-derived lung volume in normative pediatric subjects. MATERIALS AND METHODS Digitally reconstructed radiographs (DRRs) were created using retrospective chest CT scans from 77 pediatric male and female subjects aged birth to 19 years. 2D lung and diaphragm measurements were made on the DRRs using custom MATLAB code, and Spearman correlations and exponential regression equations were used to relate 2D measurements with age. In addition, 3D lung volumes were segmented using CT scans, and power regression equations were fitted to predict each lung's CT-derived volume from 2D lung measurements. The coefficient of determination (R2 ) and standard error of the estimate (SEE) were used to assess the precision of the predictive equations with p < .05 indicating statistical significance. RESULTS All 2D radiographic lung and diaphragm measurements showed statistically significant positive correlations with age (p < .01), including lung major axis (Spearman rho ≥ 0.90). Precise estimations of CT-derived lung volumes can be made using 2D lung measurements (R2 ≥ 0.95), including lung major axis (R2 ≥ 0.97). INTERPRETATIONS The reported pediatric age-specific reference data on 2D lung and diaphragm morphology and growth rates could be clinically used to identify lung and diaphragm pathologies during chest X-ray evaluations. The simple, precise, and clinically adaptable radiographic method for estimating CT-derived lung volumes may be used when pulmonary function tests are not readily available or difficult to perform.
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Neese JM, Yum S, Matesanz S, Raffini LJ, Whitworth HB, Loomes KM, Mayer OH, Alcamo AM. Intracranial hemorrhage secondary to vitamin K deficiency in X-linked myotubular myopathy. Neuromuscul Disord 2021; 31:651-655. [PMID: 34120822 DOI: 10.1016/j.nmd.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/05/2021] [Accepted: 04/29/2021] [Indexed: 11/16/2022]
Abstract
X-linked myotubular myopathy (XLMTM) is a rare congenital myopathy characterized by profound hypotonia and poor respiratory effort at birth. The condition is associated with multiple morbidities including chronic respiratory insufficiency, feeding tube dependence, and rarely, vitamin K deficiency leading to bleeding and coagulopathy. We report a case of a 6-month-old boy with X-linked myotubular myopathy who experienced a fatal intracranial hemorrhage due to vitamin K deficiency without prior clinical evidence of cholestasis or micronutrient deficiency. We propose clinically non-apparent cholestasis in combination with acute illness and poor weight gain led to his vitamin K deficiency and intracranial hemorrhage. However, the etiology and mechanism of his cholestasis remains unclear. We conclude that children with X-linked myotubular myopathy, especially with gene therapy on the horizon, may benefit from routine hepatic, coagulation, and nutritional screening to prevent potentially catastrophic bleeding.
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Miller K, Mayer OH. Pulmonary function testing in patients with neuromuscular disease. Pediatr Pulmonol 2021; 56:693-699. [PMID: 33290643 DOI: 10.1002/ppul.25182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Abstract
Progressive neuromuscular disease leads to muscle weakness or failure that produces loss of pulmonary function and clinical respiratory morbidity. Tracking pulmonary function in a practical and effective way is very important because it can help identify a stage of disease when a morbidity, such as inadequate airway clearance or respiratory failure, may be present. There are four general categories of pulmonary function outcome measures such as volume, flow, pressure, and gas exchange. These outcome measures have variable precision and accuracy in predicting clinical change, and practicality in performing them relative to age and condition. It is widely recommended to follow multiple measurements longitudinally and create an accurate and timely clinical picture. This manuscript will review the most commonly used and most practical measures for use in clinical practice and how they can help to assess morbidity, disease state, and help optimize patient management.
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Trucco F, Ridout D, Scoto M, Coratti G, Main ML, Muni Lofra R, Mayhew AG, Montes J, Pane M, Sansone V, Albamonte E, D'Amico A, Bertini E, Messina S, Bruno C, Parasuraman D, Childs AM, Gowda V, Willis T, Ong M, Marini-Bettolo C, De Vivo DC, Darras BT, Day J, Kichula EA, Mayer OH, Navas Nazario AA, Finkel RS, Mercuri E, Muntoni F. Respiratory Trajectories in Type 2 and 3 Spinal Muscular Atrophy in the iSMAC Cohort Study. Neurology 2020; 96:e587-e599. [PMID: 33067401 PMCID: PMC7905794 DOI: 10.1212/wnl.0000000000011051] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
Objective To describe the respiratory trajectories and their correlation with motor function in an international pediatric cohort of patients with type 2 and nonambulant type 3 spinal muscular atrophy (SMA). Methods This was an 8-year retrospective observational study of patients in the International SMA Consortium (iSMAc) natural history study. We retrieved anthropometrics, forced vital capacity (FVC) absolute, FVC percent predicted (FVC%P), and noninvasive ventilation (NIV) requirement. Hammersmith Functional Motor Scale (HFMS) and revised Performance of Upper Limb (RULM) scores were correlated with respiratory function. We excluded patients in interventional clinical trials and on nusinersen commercial therapy. Results There were 437 patients with SMA: 348 with type 2 and 89 with nonambulant type 3. Mean age at first visit was 6.9 (±4.4) and 11.1 (±4) years. In SMA type 2, FVC%P declined by 4.2%/y from 5 to 13 years, followed by a slower decline (1.0%/y). In type 3, FVC%P declined by 6.3%/y between 8 and 13 years, followed by a slower decline (0.9%/y). Thirty-nine percent with SMA type 2% and 9% with type 3 required NIV at a median age 5.0 (1.8–16.6) and 15.1 (13.8–16.3) years. Eighty-four percent with SMA type 2% and 80% with type 3 had scoliosis; 54% and 46% required surgery, which did not significantly affect respiratory decline. FVC%P positively correlated with HFMS and RULM scores in both subtypes. Conclusions In SMA type 2 and nonambulant type 3, lung function declines differently, with a common leveling after age 13 years. Lung and motor function correlated in both subtypes. Our data further define the milder SMA phenotypes and provide information to benchmark the long-term efficacy of new treatments for SMA.
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Sawnani H, Mayer OH, Modi AC, Pascoe JE, McConnell K, McDonough JM, Rutkowski AM, Hossain MM, Szczesniak R, Tadesse DG, Schuler CL, Amin R. Randomized trial of lung hyperinflation therapy in children with congenital muscular dystrophy. Pediatr Pulmonol 2020; 55:2471-2478. [PMID: 32658385 PMCID: PMC9047443 DOI: 10.1002/ppul.24954] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/07/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Respiratory compromise in congenital muscular dystrophy (CMD) occurs, in part, from chest wall contractures. Passive stretch with hyperinsufflation therapy could reduce related costo-vertebral joint contractures. We sought to examine the impact of hyperinsufflation use on lung function and quality of life in children with CMD. STUDY DESIGN We conducted a randomized controlled trial on hyperinsufflation therapy in children with CMD at two centers. An individualized hyperinsufflation regimen of 15 minutes twice daily using a cough assist device over a 12 months period was prescribed. We measured lung function, quality of life, and adherence. To demonstrate reproducibility, pulmonary function was measured twice on the same day. A mixed-effects regression model adjusting for confounders was used to assess the effects of hyperinsufflation. RESULTS We enrolled 34 participants in the study; 31 completed the trial (n = 17 treatment group and n = 14 controls). Participants in the treatment group demonstrated a relative gain in lung volume measured at 4 and 8 months, but not at 12 months. The control group required increases in the maximum insufflation pressures to achieve maximum lung volumes while the treatment group did not. Adherence was best early in the study, peaking at the first visit and decreasing at subsequent visits. Caregiver-reported quality of life was higher in the treatment group. CONCLUSION Hyperinsufflation therapy is effective in increasing and sustaining lung volume over time. Adherence, however, was inconsistent and difficult to maintain. Further research should determine if improved adherence leads to sustained benefits of hyperinsufflation.
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Udupa JK, Tong Y, Capraro A, McDonough JM, Mayer OH, Ho S, Wileyto P, Torigian DA, Campbell RM. Understanding Respiratory Restrictions as a Function of the Scoliotic Spinal Curve in Thoracic Insufficiency Syndrome: A 4D Dynamic MR Imaging Study. J Pediatr Orthop 2020; 40:183-189. [PMID: 32132448 PMCID: PMC6426694 DOI: 10.1097/bpo.0000000000001258] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over the past 100 years, many procedures have been developed for correcting restrictive thoracic deformities which cause thoracic insufficiency syndrome. However, none of them have been assessed by a robust metric incorporating thoracic dynamics. In this paper, we investigate the relationship between radiographic spinal curve and lung volumes derived from thoracic dynamic magnetic resonance imaging (dMRI). Our central hypothesis is that different anteroposterior major spinal curve types induce different restrictions on the left and right lungs and their dynamics. METHODS Retrospectively, we included 25 consecutive patients with thoracic insufficiency syndrome (14 neuromuscular, 7 congenital, 4 other) who underwent vertical expandable prosthetic titanium rib surgery and received preimplantation and postimplantation thoracic dMRI for clinical care. We measured thoracic and lumbar major curves by the Cobb measurement method from anteroposterior radiographs and classified the curves as per Scoliosis Research Society (SRS)-defined curve types. From 4D dMRI images, we derived static volumes and tidal volumes of left and right lung, along with left and right chest wall and left and right diaphragm tidal volumes (excursions), and analyzed their association with curve type and major curve angles. RESULTS Thoracic and lumbar major curve angles ranged from 0 to 136 and 0 to 116 degrees, respectively. A dramatic postoperative increase in chest wall and diaphragmatic excursion was seen qualitatively. All components of volume increased postoperatively by up to 533%, with a mean of 70%. As the major curve, main thoracic curve (MTC) was associated with higher tidal volumes (effect size range: 0.7 to 1.0) than thoracolumbar curve (TLC) in preoperative and postoperative situation. Neither MTC nor TLC showed any meaningful correlation between volumes and major curve angles preoperatively or postoperatively. Moderate correlations (0.65) were observed for specific conditions like volumes at end-inspiration or end-expiration. CONCLUSIONS The relationships between component tidal volumes and the spinal curve type are complex and are beyond intuitive reasoning and guessing. TLC has a much greater influence on restricting chest wall and diaphragm tidal volumes than MTC. Major curve angles are not indicative of passive resting volumes or tidal volumes. LEVEL OF EVIDENCE Level II-diagnostic.
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Servais L, Straathof CSM, Schara U, Klein A, Leinonen M, Hasham S, Meier T, De Waele L, Gordish-Dressman H, McDonald CM, Mayer OH, Voit T, Mercuri E, Buyse GM. Long-term data with idebenone on respiratory function outcomes in patients with Duchenne muscular dystrophy. Neuromuscul Disord 2019; 30:5-16. [PMID: 31813614 DOI: 10.1016/j.nmd.2019.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/25/2022]
Abstract
Decline in respiratory function in patients with DMD starts during early teenage years and leads to early morbidity and mortality. Published evidence of efficacy for idebenone on respiratory function outcomes is currently limited to 12 months of follow-up time. Here we report data collected as retrospective cohort study (SYROS) from 18 DMD patients not using glucocorticoids who were treated with idebenone (900 mg/day) under Expanded Access Programs (EAPs). The objective was to assess the long-term respiratory function evolution for periods On-Idebenone compared to periods Off-Idebenone in the same patients. The mean idebenone exposure in the EAPs was 4.2 (range 2.4-6.1) years. The primary endpoint was the annual change in forced vital capacity percent of predicted (FVC%p) compared between Off-Idebenone and On-Idebenone periods. The annual rate of decline in FVC%p was reduced by approximately 50% from -7.4% (95% CI: -9.1, -5.8) for the Off-Idebenone periods to -3.8% (95% CI: -4.8, -2.8) for the On-Idebenone periods (N = 11). Similarly, annual change in peak expiratory flow percent of predicted (PEF%p) was -5.9% (95% CI: -8.0, -3.9) for the Off-Idebenone periods (N = 9) and reduced to -1.9% (95% CI: -3.2, -0.7) for the On-Idebenone periods during the EAPs. The reduced rates of decline in FVC%p and PEF%p were maintained for several years with possible beneficial effects on the rate of bronchopulmonary adverse events, time to 10% decline in FVC%p and risk of hospitalization due to respiratory cause. These long-term data provide Class IV evidence to further support the disease modifying treatment effect of idebenone previously observed in randomized, controlled trials.
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Cahill PJ, Campbell RE, Lakomkin N, Flynn JM, Nance ML, Mayer OH, Taylor JA, Baldwin KD, Campbell RM. Comprehensive Wound Risk Stratification of Rib-Based Distraction Instrumentation Procedures. Spine Deform 2019; 7:971-978. [PMID: 31732010 DOI: 10.1016/j.jspd.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 03/11/2019] [Accepted: 04/28/2019] [Indexed: 11/19/2022]
Abstract
STUDY DESIGN Single-center retrospective analysis of a prospectively collected registry. OBJECTIVES Identify factors predictive of rib-based distraction (RBD) instrumentation wound complication. Create a risk stratification model for RBD instrumentation wound complication. SUMMARY OF BACKGROUND DATA RBD instrumentation procedures have a high rate of wound complications, often requiring unplanned operative treatment. Currently, there is a relative lack of understanding of RBD complication risk factors compared with the comprehensive understanding of complication risk factors for other spine surgeries. METHODS Between January 2011 and September 2015, patients treated with RBD instrumentation at a single institution were analyzed for risk factors associated with surgical wound complications that resulted in unplanned operative treatment. Univariate logistic regression determined predictors of wound complication and multivariate regression determined independent predictive factors; α = 0.10. RESULTS A total of 122 patients aged 0-18 years underwent 140 implant surgeries in which 22 resulted in complications: 18 (82%) infectious and 4 (18%) noninfectious. Mean age at surgery was 5.2 years. Univariate analysis showed a correlation between wound complication rates and the following: male gender (p = .097), diapered patient with lower back incision (p = .004), bilateral procedure (p = .008), more than three incisions (p = .011), left iliac incision (p = .097), right iliac incision (p = .009), patient age ≤4 years (p = .10), and operative time >150 minutes (p = .079). Multivariate analysis identified the following independent predictors: age ≤ 4 years (p = .002), male gender (p = .04), number of skin incisions (p = .001), left iliac incision (p = .018), and nutritionally challenged (p = .044). The multivariate model predicted wound complications with an area under the receiver operating characteristic curve of 0.88. CONCLUSIONS Knowledge of risk factors for RBD instrumentation wound complications can be used to construct patient risk models. This can identify patients at higher risk for complications and influence clinical decision making. LEVEL OF EVIDENCE Level II.
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Tong Y, Udupa JK, McDonough JM, Wileyto EP, Capraro A, Wu C, Ho S, Galagedera N, Talwar D, Mayer OH, Torigian DA, Campbell RM. Quantitative Dynamic Thoracic MRI: Application to Thoracic Insufficiency Syndrome in Pediatric Patients. Radiology 2019; 292:206-213. [PMID: 31112090 PMCID: PMC6614911 DOI: 10.1148/radiol.2019181731] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/07/2019] [Accepted: 03/28/2019] [Indexed: 11/11/2022]
Abstract
Background Available methods to quantify regional dynamic thoracic function in thoracic insufficiency syndrome (TIS) are limited. Purpose To evaluate the use of quantitative dynamic MRI to depict changes in regional dynamic thoracic function before and after surgical correction of TIS. Materials and Methods Images from free-breathing dynamic MRI in pediatric patients with TIS (July 2009-August 2015) were retrospectively evaluated before and after surgical correction by using vertical expandable prosthetic titanium rib (VEPTR). Eleven volumetric parameters were derived from lung, chest wall, and diaphragm segmentations, and parameter changes before versus after operation were correlated with changes in clinical parameters. Paired analysis from Student t test on MRI parameters and clinical parameters was performed to detect if changes (from preoperative to postoperative condition) were statistically significant. Results Left and right lung volumes at end inspiration and end expiration increased substantially after operation in pediatric patients with thoracic insufficiency syndrome, especially right lung volume with 22.9% and 26.3% volume increase at end expiration (P = .001) and end inspiration (P = .002), respectively. The average lung tidal volumes increased after operation for TIS; there was a 43.8% and 55.3% increase for left lung tidal volume and right lung tidal volume (P < .001 for both), respectively. However, clinical parameters did not show significant changes from pre- to posttreatment states. Thoracic and lumbar Cobb angle were poor predictors of MRI tidal volumes (chest wall, diaphragm, and left and right separately), but assisted ventilation rating and forced vital capacity showed moderate correlations with tidal volumes (chest wall, diaphragm, and left and right separately). Conclusion Vertical expandable prosthetic titanium rib operation was associated with postoperative increases in all components of tidal volume (left and right chest wall and diaphragm, and left and right lung tidal volumes) measured at MRI. Clinical parameters did not demonstrate improvements in postoperative tidal volumes. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Paltiel in this issue.
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Mayer OH. Turning the tide in spinal muscular atrophy: A different respiratory course. Pediatr Pulmonol 2019; 54:935-936. [PMID: 30884211 DOI: 10.1002/ppul.24315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/11/2022]
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