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Groll AH, Ebrahimi-Fakhari D. Conference Report 33rd European Congress on Clinical Microbiology and Infectious Diseases (ECCMID): New developments in pediatric oncology infectious disease supportive care. Transpl Infect Dis 2023; 25:e14146. [PMID: 37695128 DOI: 10.1111/tid.14146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Abstract
Infections continue to be major causes of morbidity and mortality in immunocompromised children and adolescents with cancer or undergoing allogeneic hematopoietic cell transplantation. This report summarizes new clinical research data presented at the 33rd European Congress on Clinical Microbiology and Infectious Diseases on infections in this vulnerable population, with a focus on the epidemiology, diagnosis, and prevention of invasive fungal diseases and de-escalation strategies in neutropenic patients with fever of unknown origin.
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Affiliation(s)
- Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children´s Hospital Münster, Münster, Germany
| | - Daniel Ebrahimi-Fakhari
- Infectious Disease Research Program, Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, University Children´s Hospital Münster, Münster, Germany
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Hess S, Poryo M, Ruckes C, Papan C, Ehrlich A, Ebrahimi-Fakhari D, Bay JS, Wagenpfeil S, Simon A, Meyer S. Assessment of an umbilical venous catheter dwell-time of 8-14 days versus 1-7 days in very low birth weight infacts (UVC - You Will See): a pilot single-center, randomized controlled trial. Early Hum Dev 2023; 179:105752. [PMID: 36958105 DOI: 10.1016/j.earlhumdev.2023.105752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Umbilical venous catheters (UVCs) are used for central vascular access in preterm infants, but controversy exits with regard to the optimum dwell-time. PATIENTS AND METHODS Prospective, randomized controlled trial at a level III University neonatal intensive care unit (NICU), comparing a UVC dwell-time of 1-7 days (control group) to 8-14 days (intervention group) in very low birth weight (VLBW) infants. PRIMARY OUTCOME PARAMETER Number of infants requiring additional peripherally inserted central catheters (PICC) after removal of UVC. SECONDARY OUTCOME PARAMETERS Total number of central lines (CL = UVC and PICCs) until time point of full enteral feeds (130-160 mL/kg/d), total number of intravenous vascular catheters, number of CL-associated complications (infection, thrombosis/emboli, organ injury, secondary CL dislocation), number of X-rays for assessment of CL positioning, and days of therapy (DOT) (teicoplanin) for CL-associated blood stream infections (CLABSI). RESULTS Of 116 patients screened for eligibility, 63 patients were enrolled - control group: 31 infants, mean gestational age (GA) 280 weeks (standard deviation (SD) 2.6 weeks), mean birth weight (BW) 988.9 g (SD 322.0 g); intervention group: 32 infants, mean GA 285 weeks (SD 3.0 weeks), mean BW 1078.9 g (SD 324.6 g). In the control group, 28 infants required additional PICCs versus 16 in the intervention group (p < 0.001); total number of CLs: control group n = 58 versus intervention group n = 28; p < 0.001, and the total number of venous vascular devices was also significantly higher in the control group (109 versus 61; p = 0.04). No significant differences were seen with regard to CL-associated complications (p = 0.09). The number of X-rays for assessment of correct CL-position significantly lower in the intervention group (144 versus 96; p = 0.03). In the intervention group, length of hospital stay was significantly shorter (88.1 (SD: 35.3 days) versus 68.1 (SD: 32.6 days); p = 0.03) and GA significantly lower at discharge from the hospital (404: SD: 33 weeks) versus 385: SD: 25 weeks; p = 0.02. No differences existed with regard to neonatal morbidities and mortality at 36 weeks gestational age. CONCLUSIONS A longer UVC dwell-time of up to 14 days significantly decreased the number of painful invasive vascular procedures and radiation exposure, and shortened the length of the hospital stay. The findings of our pilot study should be confirmed in a larger, multi-center RCT with the primary focus on catheter-associated complications.
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Affiliation(s)
- Steffi Hess
- Saarland University Medical Center, Department of General Pediatrics and Neonatology, Homburg, Germany
| | - Martin Poryo
- Saarland University Medical Center, Department of Pediatric Cardiology, Homburg, Germany
| | - Christian Ruckes
- Interdisziplinäres Zentrum für Klinische Studien (IZKS), Iohannes Gutenberg-University, Mainz, Germany
| | - Cihan Papan
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany; Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Anne Ehrlich
- Interdisziplinäres Zentrum für Klinische Studien (IZKS), Iohannes Gutenberg-University, Mainz, Germany
| | | | - Johannes Saaradonna Bay
- Saarland University Medical Center, Department of General Pediatrics and Neonatology, Homburg, Germany
| | - Stefan Wagenpfeil
- Saarland University Medical Center, Institute for Medical Biometry, Epidemiology, and Medical Informatics (IMBEI), Homburg, Germany
| | - Arne Simon
- Saarland University Medical Center, Department of Pediatric Hematology and Oncology, Infectious Diseases, Homburg, Germany
| | - Sascha Meyer
- Saarland University Medical Center, Department of General Pediatrics and Neonatology, Homburg, Germany; Franz-Lust Klinik für Kinder- und Jgendmedizin, Karlsruhe, Germany.
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Meyer S, Langer J, Poryo M, Bay JG, Wagenpfeil S, Heinrich B, Nunold H, Strzelczyk A, Ebrahimi-Fakhari D. Epileptic Status in a PEDiatric cohort (ESPED) requiring intensive care treatment: A multicenter, national, two-year prospective surveillance study. Epilepsia Open 2023. [PMID: 36764666 DOI: 10.1002/epi4.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/25/2023] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE The aim of this study was to provide seizure etiology, semiology, underlying conditions, and out-of- and in-hospital diagnostics, treatment, and outcome data on children with out-of- or in-hospital-onset status epilepticus (SE) according to the International League Against Epilepsy definition that required admission to the pediatric intensive care unit (PICU) for ≥4 hours. METHODS This prospective national surveillance study on SE in childhood and adolescence was conducted over 2 years (07/2019-06/2021). RESULTS This study examined 481 SE episodes in 481 children with a median age of 43 months (1 month to 17 years 11 months), of which 46.2% were female and 50.7% had a previous seizure history. The most frequent acute SE cause was a prolonged, complicated febrile seizure (20.6%). The most common initial seizure types were generalized seizures (49.9%), focal seizures (18.0%), and unknown types (12.1%); 40.5% of patients suffered from refractory SE and 5.0% from super-refractory SE. The three most common medications administered by nonmedically trained individuals were diazepam, midazolam, and antipyretics. The three most frequent anti-seizure medications (ASMs) administered by the emergency physician were midazolam, diazepam, and propofol. The three most common ASMs used in the clinical setting were midazolam, levetiracetam, and phenobarbital. New ASMs administered included lacosamide, brivaracetam, perampanel, stiripentol, and eslicarbazepine. Status epilepticus terminated in 16.0% in the preclinical setting, 19.1% in the emergency department, and 58.0% in the PICU; the outcome was unknown for 6.9%. The median PICU stay length was 2 (1-121) days. The median modified Rankin scale was 1 (0-5) on admission and 2 (0-6) at discharge. New neurological deficits after SE were observed in 6.2%. The mortality rate was 3.5%. SIGNIFICANCE This study provides current real-world out-of- and in-hospital data on pediatric SE requiring PICU admission. New ASMs are more frequently used in this population. This knowledge may help generate a more standardized approach.
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Affiliation(s)
- Sascha Meyer
- Department of General Pediatrics and Neonatology, and Neuropediatrics, Saarland University Medical Center, Homburg, Germany.,Franz-Lust Klinik für Kinder und Jugendliche, Karlsruhe, Germany
| | - Jaro Langer
- Department of General Pediatrics and Neonatology, and Neuropediatrics, Saarland University Medical Center, Homburg, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Johannes Goaliath Bay
- Department of General Pediatrics and Neonatology, and Neuropediatrics, Saarland University Medical Center, Homburg, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Beate Heinrich
- Erhebungseinheit für Seltene Pädiatrische Erkrankungen (ESPED), Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Holger Nunold
- Department of General Pediatrics and Neonatology, and Neuropediatrics, Saarland University Medical Center, Homburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany.,Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Ebrahimi-Fakhari
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
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- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
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4
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Ritter DM, Fessler BK, Ebrahimi-Fakhari D, Wei J, Franz DN, Krueger DA, Trout AT, Towbin AJ. Prevalence of thoracoabdominal imaging findings in tuberous sclerosis complex. Orphanet J Rare Dis 2022; 17:124. [PMID: 35292049 PMCID: PMC8922878 DOI: 10.1186/s13023-022-02277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) results in neurodevelopmental phenotypes, benign tumors, and cysts throughout the body. Recent studies show numerous rare findings in TSC. Guidelines suggest routine abdominal and chest imaging to monitor these thoracoabdominal findings, but imaging is not uniformly done across centers. Thus, the prevalence of many findings is unknown. To answer this, we categorized the clinical reads of 1398 thoracoabdominal scans from 649 patients of all ages in the Cincinnati Children’s Hospital TSC Repository Database. Results Typical TSC findings were present in many patients: kidney cysts (72%), kidney fat-containing angiomyolipomas (51%), kidney lipid-poor angiomyolipomas (27%), liver angiomyolipomas (19%), and lung nodules thought to represent multifocal micronodular pneumocyte hyperplasia (MMPH) (18%). While many features were more common in TSC2 patients, TSC1 patients had a higher prevalence of MMPH than TSC2 patients (24% versus 13%, p = 0.05). Many rare findings (e.g., lymphatic malformations and liver masses) are more common in TSC than in the general population. Additionally, most thoracoabdominal imaging findings increased with age except kidney cysts which decreased, with the 0–10 years age group having the highest percentage (69% 0–10 years, 49% 10–21 years, 48% 21 + years, p < 0.001). Finally, in our population, no patients had renal cell carcinoma found on abdominal imaging. Conclusions These results show that regular thoracoabdominal scans in TSC may show several findings that should not be ignored or, conversely, over-reacted to when found in patients with TSC. Female sex, TSC2 mutation, and age are risk factors for many thoracoabdominal findings. The data suggest novel interactions of genetic mutation with pulmonary nodules and age with renal cysts. Finally, in agreement with other works, these findings indicate that several rare thoracoabdominal imaging findings occur at higher rates in the TSC population than in the general population. This work supports obtaining detailed thoracoabdominal imaging in patients with TSC. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02277-x.
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Affiliation(s)
- David M Ritter
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Bailey K Fessler
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel Ebrahimi-Fakhari
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Jun Wei
- The First Hospital of Yichang, Yichang, China
| | - David N Franz
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Darcy A Krueger
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander J Towbin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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5
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Ebrahimi-Fakhari D, Stires G, Hahn E, Krueger D, Franz DN. Prenatal Sirolimus Treatment for Rhabdomyomas in Tuberous Sclerosis. Pediatr Neurol 2021; 125:26-31. [PMID: 34624607 DOI: 10.1016/j.pediatrneurol.2021.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/10/2021] [Accepted: 09/20/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND In tuberous sclerosis, most cardiac rhabdomyomas regress spontaneously. In some cases, the tumors can cause life-threatening hemodynamic compromise requiring subsequent surgical resection. The mechanistic target of rapamycin inhibitors everolimus and sirolimus have shown to be effective treatments for multiple conditions. There are four reports of off-label treatment with transplacental sirolimus for fetal rhabdomyomas due to tuberous sclerosis complex. The optimal dosing regimen is unknown. METHODS We reviewed the medical records of all patients treated prenatally with sirolimus for rhabdomyomas. All fetuses had a clinical and molecular diagnosis of tuberous sclerosis complex (2012 Consensus Diagnostic Criteria, including a positive genetic test). Clinical history, mechanistic target of rapamycin inhibitor dosing and levels, outcome, and adverse events were reviewed after initiation of sirolimus treatment. RESULTS Three fetuses were treated with maternal sirolimus. Dosing regimens and subsequent trough levels differed from 1 mg/day to 6 mg/day and <1.0 ng/mL to 12.2 ng/mL. Cardiac rhabdomyomas gradually shrank in all patients. Growth restriction was noted in one patient. No severe adverse events occurred during the treatment period. CONCLUSIONS Maternal sirolimus appears to be a safe treatment option in prenatally detected rhabdomyomas with possible need for intervention. Follow-up visits with fetal ultrasound, echocardiography, and laboratory work should be performed weekly during the treatment period. The optimal dosing and trough level timepoints remain unclear. Based on our results, we recommend a sirolimus starting dose of at least 2 mg/m2/day, preferably 3-3.5 mg/m2/day to achieve a target trough level of 10-12 ng/mL.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany.
| | - Gabrielle Stires
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eunice Hahn
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Darcy Krueger
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Neal Franz
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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6
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Mowrey K, Northrup H, Rougeau P, Hashmi SS, Krueger DA, Ebrahimi-Fakhari D, Towbin AJ, Trout AT, Capal JK, Franz DN, Rodriguez-Buritica D. Frequency, Progression, and Current Management: Report of 16 New Cases of Nonfunctional Pancreatic Neuroendocrine Tumors in Tuberous Sclerosis Complex and Comparison With Previous Reports. Front Neurol 2021; 12:627672. [PMID: 33897589 PMCID: PMC8062856 DOI: 10.3389/fneur.2021.627672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Tuberous sclerosis complex (TSC) is a genetic condition that causes benign tumors to grow in multiple organ systems. Nonfunctional pancreatic neuroendocrine tumors (PNETs) are a rare clinical feature of TSC with no specific guidelines outlined for clinical management at this time. Our purpose is to calculate the frequency of nonfunctional PNETs as well as characterize the presentation, current clinical management, and assess the impact of systemic mammalian target of rapamycin (mTOR) on nonfunctional PNETs in TSC. Methods: This retrospective chart review was performed by a query of the TS Alliance's Natural History Database and the Cincinnati Children's Hospital TSC Database for patients with nonfunctional PNET. Clinical data from these two groups was summarized for patients identified to have a nonfunctional PNET and compared to previously reported cases with TSC and nonfunctional PNETs. Results: Our calculated frequency of nonfunctional PNETs is 0.65%. We identified 16 individuals, nine males and seven females, with a median age of 18.0 years (interquartile range: −15.5 to 25.5). Just over half (56.3%, n = 9) of the patients provided results from genetic testing. Six had pathogenic variants in TSC2 whereas three had pathogenic variants in TSC1. The average age at PNET diagnosis was 15.0 years (range: 3–46 years). Almost all individuals were diagnosed with a PNET during routine TSC surveillance, 56.3% (n = 9) by MRI, 12.5% (n = 2) by CT, 25% (n = 4) by ultrasound, and 6.2% (n = 1) through a surgical procedure. Follow up after diagnosis involved 68.8% (n = 11) having serial imaging and nine of the sixteen individuals proceeding with surgical removal of the PNET. Eight individuals had a history of using systemic mTOR inhibitors. Tumor growth rate was slightly less in individuals taking an mTOR inhibitor (−0.8 mm/yr, IQR: −2.3 to 2.2) than those without (1.6 mm/yr; IQR: −0.99 to 5.01, p > 0.05). Conclusions: Nonfunctional PNETs occurred at younger ages in our TSC cohort and more commonly compared to ages and prevalence reported for the general population. PNETs in patients on systemic mTOR inhibitors had lower rates of growth. The outcome of this study provides preliminary evidence supporting the use of mTOR inhibitor therapy in conjunction with serial imaging as medical management for nonfunctional PNETs as an alternative option to invasive surgical removal.
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Affiliation(s)
- Kate Mowrey
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Peyton Rougeau
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - S Shahrukh Hashmi
- Department of Pediatrics, Pediatric Research Center, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Darcy A Krueger
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Daniel Ebrahimi-Fakhari
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jamie K Capal
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David Neal Franz
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Division of Neurology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - David Rodriguez-Buritica
- Division of Medical Genetics, Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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7
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Ebrahimi-Fakhari D, Teinert J, Behne R, Wimmer M, D'Amore A, Eberhardt K, Brechmann B, Ziegler M, Jensen DM, Nagabhyrava P, Geisel G, Carmody E, Shamshad U, Dies KA, Yuskaitis CJ, Salussolia CL, Ebrahimi-Fakhari D, Pearson TS, Saffari A, Ziegler A, Kölker S, Volkmann J, Wiesener A, Bearden DR, Lakhani S, Segal D, Udwadia-Hegde A, Martinuzzi A, Hirst J, Perlman S, Takiyama Y, Xiromerisiou G, Vill K, Walker WO, Shukla A, Dubey Gupta R, Dahl N, Aksoy A, Verhelst H, Delgado MR, Kremlikova Pourova R, Sadek AA, Elkhateeb NM, Blumkin L, Brea-Fernández AJ, Dacruz-Álvarez D, Smol T, Ghoumid J, Miguel D, Heine C, Schlump JU, Langen H, Baets J, Bulk S, Darvish H, Bakhtiari S, Kruer MC, Lim-Melia E, Aydinli N, Alanay Y, El-Rashidy O, Nampoothiri S, Patel C, Beetz C, Bauer P, Yoon G, Guillot M, Miller SP, Bourinaris T, Houlden H, Robelin L, Anheim M, Alamri AS, Mahmoud AAH, Inaloo S, Habibzadeh P, Faghihi MA, Jansen AC, Brock S, Roubertie A, Darras BT, Agrawal PB, Santorelli FM, Gleeson J, Zaki MS, Sheikh SI, Bennett JT, Sahin M. Defining the clinical, molecular and imaging spectrum of adaptor protein complex 4-associated hereditary spastic paraplegia. Brain 2020; 143:2929-2944. [PMID: 32979048 PMCID: PMC7780481 DOI: 10.1093/brain/awz307] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/25/2019] [Accepted: 08/16/2019] [Indexed: 12/21/2022] Open
Abstract
Bi-allelic loss-of-function variants in genes that encode subunits of the adaptor protein complex 4 (AP-4) lead to prototypical yet poorly understood forms of childhood-onset and complex hereditary spastic paraplegia: SPG47 (AP4B1), SPG50 (AP4M1), SPG51 (AP4E1) and SPG52 (AP4S1). Here, we report a detailed cross-sectional analysis of clinical, imaging and molecular data of 156 patients from 101 families. Enrolled patients were of diverse ethnic backgrounds and covered a wide age range (1.0-49.3 years). While the mean age at symptom onset was 0.8 ± 0.6 years [standard deviation (SD), range 0.2-5.0], the mean age at diagnosis was 10.2 ± 8.5 years (SD, range 0.1-46.3). We define a set of core features: early-onset developmental delay with delayed motor milestones and significant speech delay (50% non-verbal); intellectual disability in the moderate to severe range; mild hypotonia in infancy followed by spastic diplegia (mean age: 8.4 ± 5.1 years, SD) and later tetraplegia (mean age: 16.1 ± 9.8 years, SD); postnatal microcephaly (83%); foot deformities (69%); and epilepsy (66%) that is intractable in a subset. At last follow-up, 36% ambulated with assistance (mean age: 8.9 ± 6.4 years, SD) and 54% were wheelchair-dependent (mean age: 13.4 ± 9.8 years, SD). Episodes of stereotypic laughing, possibly consistent with a pseudobulbar affect, were found in 56% of patients. Key features on neuroimaging include a thin corpus callosum (90%), ventriculomegaly (65%) often with colpocephaly, and periventricular white-matter signal abnormalities (68%). Iron deposition and polymicrogyria were found in a subset of patients. AP4B1-associated SPG47 and AP4M1-associated SPG50 accounted for the majority of cases. About two-thirds of patients were born to consanguineous parents, and 82% carried homozygous variants. Over 70 unique variants were present, the majority of which are frameshift or nonsense mutations. To track disease progression across the age spectrum, we defined the relationship between disease severity as measured by several rating scales and disease duration. We found that the presence of epilepsy, which manifested before the age of 3 years in the majority of patients, was associated with worse motor outcomes. Exploring genotype-phenotype correlations, we found that disease severity and major phenotypes were equally distributed among the four subtypes, establishing that SPG47, SPG50, SPG51 and SPG52 share a common phenotype, an 'AP-4 deficiency syndrome'. By delineating the core clinical, imaging, and molecular features of AP-4-associated hereditary spastic paraplegia across the age spectrum our results will facilitate early diagnosis, enable counselling and anticipatory guidance of affected families and help define endpoints for future interventional trials.
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Affiliation(s)
- Darius Ebrahimi-Fakhari
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julian Teinert
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Child Neurology and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Robert Behne
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Miriam Wimmer
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Angelica D'Amore
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Molecular Medicine, IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Kathrin Eberhardt
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Brechmann
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ziegler
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dana M Jensen
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Premsai Nagabhyrava
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Geisel
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin Carmody
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Uzma Shamshad
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kira A Dies
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Yuskaitis
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine L Salussolia
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Ebrahimi-Fakhari
- Pediatric Neurology, Saarland University Medical Center, Homburg/Saar, Germany
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Afshin Saffari
- Division of Child Neurology and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Ziegler
- Division of Child Neurology and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Kölker
- Division of Child Neurology and Metabolic Medicine, Centre for Paediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Antje Wiesener
- Institute of Human Genetics, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - David R Bearden
- Child Neurology, University of Rochester School of Medicine, Rochester, NY, USA
| | - Shenela Lakhani
- Center for Neurogenetics, Weill Cornell Medical College, New York, NY, USA
| | - Devorah Segal
- Center for Neurogenetics, Weill Cornell Medical College, New York, NY, USA
- Division of Child Neurology, Weill Cornell Medicine, New York City, NY, USA
| | - Anaita Udwadia-Hegde
- Department of Pediatric Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Andrea Martinuzzi
- Scientific Institute, IRCCS E. Medea, Unità Operativa Conegliano, Treviso, Italy
| | - Jennifer Hirst
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
| | - Seth Perlman
- Division of Neurology, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | | | | | - Katharina Vill
- Pediatric Neurology and Developmental Medicine, Dr. v. Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - William O Walker
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Anju Shukla
- Department of Medical Genetics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | | | - Niklas Dahl
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Ayse Aksoy
- Pediatric Neurology, Dr. Sami Ulus Hospital, Ankara, Turkey
| | - Helene Verhelst
- Pediatric Neurology, Ghent University Hospital, Ghent, Belgium
| | - Mauricio R Delgado
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Radka Kremlikova Pourova
- Department of Biology and Medical Genetics, Second Medical Faculty, Charles University and UH Motol, Prague, Czech Republic
| | - Abdelrahim A Sadek
- Pediatric Neurology, Faculty of Medicine, Sohag University, Sohag, Egypt
| | | | - Lubov Blumkin
- Movement Disorders Clinic, Pediatric Neurology Unit, Wolfson Medical Center, Holon, Sackler School of Medicine, Tel-Aviv University, Israel
| | | | - David Dacruz-Álvarez
- Neurología Pediátrica, Complexo Hospitalario Universitario, Santiago de Compostela, Spain
| | - Thomas Smol
- CHU Lille, Institut de Génétique Médicale, RADEME, Lille, France
| | - Jamal Ghoumid
- CHU Lille, Institut de Génétique Médicale, RADEME, Lille, France
| | - Diego Miguel
- Serviço de Genética Médica, Universidade Federal da Bahia, Salvador, Brazil
| | - Constanze Heine
- Institute of Human Genetics, University Hospital Leipzig, Leipzig, Germany
| | | | | | - Jonathan Baets
- Neurogenetics Group and Neuromuscular Reference Center, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Saskia Bulk
- Medical Genetics, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Hossein Darvish
- Cancer Research Center and Department of Medical Genetics, Semnan University of Medical Sciences, Semnan, Iran
| | - Somayeh Bakhtiari
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michael C Kruer
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Elizabeth Lim-Melia
- Pediatric Medical Genetics, Maria Fareri Children's Hospital, Valhalla, NY, USA
| | - Nur Aydinli
- Pediatric Genetics, Department of Pediatrics, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yasemin Alanay
- Pediatric Neurology, Istanbul Medical Faculty, Istanbul, Turkey
| | | | | | - Chirag Patel
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | | | - Grace Yoon
- Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mireille Guillot
- Department of Paediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Canada
| | - Steven P Miller
- Department of Paediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Canada
| | - Thomas Bourinaris
- Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology, London, UK
| | - Laura Robelin
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mathieu Anheim
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Abdullah S Alamri
- Pediatric Neurology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Adel A H Mahmoud
- Pediatrics, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Soroor Inaloo
- Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parham Habibzadeh
- Persian BayanGene Research and Training Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Faghihi
- Persian BayanGene Research and Training Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Center for Therapeutic Innovation and Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, FL, USA
| | - Anna C Jansen
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Brussels, Belgium
| | - Stefanie Brock
- Pediatric Neurology Unit, Department of Pediatrics, UZ Brussel, Brussels, Belgium
| | | | - Basil T Darras
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pankaj B Agrawal
- Divisions of Newborn Medicine and Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Joseph Gleeson
- Rady Children's Institute for Genomic Medicine, Rady Children's Hospital, San Diego, CA, USA
| | - Maha S Zaki
- Clinical Genetics, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | | | - James T Bennett
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
INTRODUCTION Subependymal ependymal giant cell astrocytomas (SEGAs) occur almost exclusively in the setting of tuberous sclerosis (TSC). They are low-grade gliomas which typically produce clinical symptoms through either mass effect or hydrocephalus. As do other manifestations of tuberous sclerosis, these lesions result from mutations in either the TSC1 or the TSC2 gene. These mutations cause hyperactivation of the mechanistic target of rapamycin (mTOR). In view of their tendency to grow slowly, clinical symptoms usually only occur when the tumors reach a considerable size. Therapy can involve surgical resection, cerebrospinal fluid diversion, or medical therapy with an mTOR inhibitor. AREAS COVERED Herein, the authors discuss the diagnosis, symptoms, and practical management of SEGAs as well as providing their expert opinion. EXPERT OPINION mTOR inhibitors have largely replaced surgery as the primary modality for the management of SEGAs. Surgical treatment is largely limited to tumors that present with acute hydrocephalus and increased intracranial pressure. Patients with TSC should undergo periodic screening with CT or preferably MRI scans of the brain from childhood to approximately age 25 to identify SEGAs which require treatment. In addition to avoiding potential morbidity associated with surgical resection, mTOR inhibitors have the potential to improve the clinical status of tuberous sclerosis patients generally.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of General Pediatrics, University Children's Hospital Muenster , Muenster, Germany
| | - David Neal Franz
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
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9
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Ebrahimi-Fakhari D, Hussong J, Flotats-Bastardas M, Ebrahimi-Fakhari D, Zemlin M, von Gontard A, Meyer S. Tuberous Sclerosis Complex Associated Neuropsychiatric Disorders and Parental Stress: Findings from a National, Prospective TSC Surveillance Study. Neuropediatrics 2019; 50:294-299. [PMID: 31266065 DOI: 10.1055/s-0039-1693042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM To assess the role of the TAND (tuberous sclerosis complex [TSC] associated neuropsychiatric disorders) checklist as a screening tool for neuropsychiatric pathology, to evaluate behavioral and psychiatric symptoms and related parental stress in children with TSC, and to analyze associations between parental stress, TAND findings, and TSC pathology. METHOD This is a prospective cohort study including 22 individuals from a national TSC surveillance study in Germany using demographic and clinical data, the TAND checklist, the Child Behavior Checklist (CBCL), and the Parenting Stress Index (PSI). RESULTS Mean (standard deviation) age at follow-up was 4 years (3 years 9 months), and 13/22 of patients were male. Seventeen children had epilepsy (focal: 9; generalized: 4; infantile spasms: 4). Developmental delay was diagnosed in 12/22 patients. The most prevalent TAND items were anxiety and mood swings in 10/22 children. At least one TAND item was reported by 17/22 patients, internalizing symptoms by 10/22, and externalizing symptoms by 11/22. In contrast, only one patient had a clinically relevant score in the CBCL scales. Of 22 parents, 12 reported clinically relevant parental stress due to both child and parenting factors. Higher total parental stress was associated with a higher TAND externalizing score (r = 0.49; p = 0.028) and TAND total score (r = 0.51; p = 0.016), a higher CBCL total score (r = 0.59; p = 0.005), and the number of antiepileptic drugs (r = 0.50; p = 0.017). Developmental delay was correlated with child stress factors (r = 0.48; p = 0.023). INTERPRETATION The TAND checklist appears to be a promising screening tool for neuropsychiatric problems in very young children with TSC. Parental stress in children with TSC is modified by TSC-related pathology, both neuropsychiatric and neurological.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of Pediatric Neurology, Saarland University Medical Center, Saarland Tuberous Sclerosis Complex Center, Homburg, Germany
| | - Justine Hussong
- Department of Child and Adolescent Psychiatry, Saarland University Medical Center, Homburg, Germany
| | - Marina Flotats-Bastardas
- Department of Pediatric Neurology, Saarland University Medical Center, Saarland Tuberous Sclerosis Complex Center, Homburg, Germany
| | - Darius Ebrahimi-Fakhari
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael Zemlin
- Department of Pediatric Neurology, Saarland University Medical Center, Saarland Tuberous Sclerosis Complex Center, Homburg, Germany
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Medical Center, Homburg, Germany
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Saarland Tuberous Sclerosis Complex Center, Homburg, Germany
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10
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Flotats-Bastardas M, Ebrahimi-Fakhari D, Bernert G, Ziegler A, Schlachter K, Poryo M, Hahn A, Meyer S. [Non-ambulatory patients with Duchenne muscular dystrophy : Recommendations for monitoring disease progression and course of treatment]. Nervenarzt 2019; 90:817-823. [PMID: 31270551 DOI: 10.1007/s00115-019-0754-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) is a severe X‑linked recessive neuromuscular disorder. In children without corticosteroid therapy, progressive muscular weakness is associated with loss of ambulation on average by the age of 9.5 years. OBJECTIVE, MATERIAL AND METHODS On the basis of current guidelines, a group of experts in this field defined a number of clinical parameters and examinations that should be performed on a regular basis to assess changes over time in non-ambulant patients. RESULTS AND CONCLUSION To assess function of the upper extremities the Brooke upper extremity functional rating scale or the performance of upper limb test should be used. For assessment of pulmonary function measurement of forced vital capacity (FVC) is recommended. The extent of cardiac involvement can best be evaluated using cardiac magnetic resonance imaging (MRI), measurement of the ejection fraction (EF) and the left ventricular shortening fraction (LVSF) by echocardiography. The pediatric quality of life inventory should be used for assessment of quality of life. In addition, the body mass index (BMI), the number of infections and need for in-hospital treatment as well as early detection of orthopedic problems, most importantly the development of scoliosis should be monitored. After transition from pediatric to adult care DMD patients should be primarily cared for by adult neurologists and specialists in pulmonary and cardiac medicine.
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Affiliation(s)
- Marina Flotats-Bastardas
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland
| | - Daniel Ebrahimi-Fakhari
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland
| | - Günther Bernert
- Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef-Spital mit Gottfried von Preyer'schem Kinderspital, Wien, Österreich
| | - Andreas Ziegler
- Sektion für Neuropädiatrie und Stoffwechselmedizin, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Kurt Schlachter
- Klinik für Kinder- und Jugendheilkunde, Landeskrankenhaus Bregenz, Bregenz, Österreich
| | - Martin Poryo
- Klinik für Pädiatrische Kardiologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Andreas Hahn
- Abteilung Kinderneurologie, Sozialpädiatrie und Epileptologie, Universitätskinderklinik Gießen, Gießen, Deutschland
| | - Sascha Meyer
- Klinik für Allgemeine Pädiatrie und Neonatologie, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, Geb. 9, 66421, Homburg, Deutschland.
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11
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Ebrahimi-Fakhari D, Mann LL, Poryo M, Graf N, von Kries R, Heinrich B, Ebrahimi-Fakhari D, Flotats-Bastardas M, Gortner L, Zemlin M, Meyer S. Correction to: Incidence of tuberous sclerosis and age at first diagnosis: new data and emerging trends from a national, prospective surveillance study. Orphanet J Rare Dis 2019; 14:106. [PMID: 31084624 PMCID: PMC6513511 DOI: 10.1186/s13023-019-1090-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany.
| | - Lilian Lisa Mann
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Norbert Graf
- Department of Pediatric Oncology and Hematology, Saarland University Medical Center, Homburg, Germany
| | - Rüdiger von Kries
- Division of Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig Maximilian's University, Munich, Germany.,German Paediatric Surveillance Unit (ESPED), Coordination Center for Clinical Studies, Heinrich Heine University, Düsseldorf, Germany
| | - Beate Heinrich
- German Paediatric Surveillance Unit (ESPED), Coordination Center for Clinical Studies, Heinrich Heine University, Düsseldorf, Germany
| | - Darius Ebrahimi-Fakhari
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marina Flotats-Bastardas
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Ludwig Gortner
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Michael Zemlin
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
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12
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Aygün A, Poryo M, Wagenpfeil G, Wissing A, Ebrahimi-Fakhari D, Zemlin M, Gortner L, Meyer S. Birth weight, Apgar scores and gentamicin were associated with acute kidney injuries in VLBW neonates requiring treatment for patent ductus arteriosus. Acta Paediatr 2019; 108:645-653. [PMID: 30178614 DOI: 10.1111/apa.14563] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/19/2018] [Accepted: 08/31/2018] [Indexed: 11/27/2022]
Abstract
AIM We assessed the risk factors for transient acute kidney injury in very low birth weight (VLBW) infants treated for patent ductus arteriosus (PDA) using the serum creatinine-based criteria in Kidney Disease: Improving Global Outcomes. METHOD This retrospective study of infants requiring ibuprofen and, or, surgery for haemodynamic relevant PDAs was performed at the University Children's Hospital of Saarland, Homburg, Germany, from January 2009 to December 2015. RESULTS We studied 422 infants with a mean birth weight of 1059 ± 308.2 g. Acute kidney injuries developed in 150/295 infants (50.9%) with spontaneous PDA closure, in 46/82 (56.1%) who received intravenous ibuprofen treatment, in 18/24 (75.0%) who had surgery and in 15/21 infants (71.4%) who received both medical and surgical treatment. Acute kidney injuries were associated with birth weight and gestational age, Apgar scores at 10 minutes, the PDA size corrected for birth weight, a PDA with three affected circulatory territories, PDA surgery and gentamicin. Multiple logistic regression analysis showed particular associations between acute kidney injury and birth weight (p = 0.001), the 10-minute Apgar score (p = 0.02) and gentamicin (p = 0.043). CONCLUSION Birth weight, the 10-minute Apgar score and gentamicin were particularly associated with acute kidney injuries in our cohort.
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Affiliation(s)
- Aylin Aygün
- Medical School; University Hospital of Saarland; Homburg Germany
| | - Martin Poryo
- Department of Paediatric Cardiology; University Children's Hospital of Saarland; Homburg Germany
| | - Gudrun Wagenpfeil
- Institute of Medical Biometry, Epidemiology, and Medical Informatics; University Hospital of Saarland; Homburg Germany
| | - Antonia Wissing
- Medical School; University Hospital of Saarland; Homburg Germany
| | | | - Michael Zemlin
- Medical School; University Hospital of Saarland; Homburg Germany
- Department of General Paediatrics and Neonatology; University Children's Hospital of Saarland; Homburg Germany
| | - Ludwig Gortner
- Department of General Paediatrics and Neonatology; University Children's Hospital of Saarland; Homburg Germany
| | - Sascha Meyer
- Medical School; University Hospital of Saarland; Homburg Germany
- Department of General Paediatrics and Neonatology; University Children's Hospital of Saarland; Homburg Germany
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13
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Ebrahimi-Fakhari D, Dillmann U, Flotats-Bastardas M, Poryo M, Abdul-Khaliq H, Shamdeen MG, Mischo B, Zemlin M, Meyer S. Corrigendum: Off-Label Use of Ataluren in Four Non-ambulatory Patients With Duchenne Muscular Dystrophy: Effects on Cardiac and Pulmonary Function and Muscle Strength. Front Pediatr 2019; 7:284. [PMID: 31404150 PMCID: PMC6673654 DOI: 10.3389/fped.2019.00284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 11/13/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fped.2018.00316.].
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Affiliation(s)
| | - Ulrich Dillmann
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | | | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | | | - Bernhard Mischo
- Department of Pediatrics, Marienkrankenhaus St. Josef Kohlhof, Neunkirchen, Germany
| | - Michael Zemlin
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany
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14
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Poryo M, Wissing A, Zemlin M, Aygün A, Ebrahimi-Fakhari D, Geisel J, Schöpe J, Wagenpfeil S, Sauer H, Meyer S. Nucleated red blood cells and serum lactate values on days 2 and 5 are associated with mortality and morbidity in VLBW infants. Wien Med Wochenschr 2018; 169:87-92. [PMID: 30084094 DOI: 10.1007/s10354-018-0649-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/02/2018] [Indexed: 01/13/2023]
Abstract
AIM To correlate nucleated red blood cell counts and serum lactate concentrations on day 2 and 5 of life with morbidity and mortality in very low birth weight infants and to determine corresponding cutoff values. METHODS Retrospective analysis in a cohort of very low birth weight infants. RESULTS 250 very low birth weight infants were included in this study. Gestational age ranged from 23 to 35 weeks (mean 29.04) and birth weight was 320-1500 g (mean 1047.9). 55 (22%) patients developed intraventricular hemorrhage, 55 (22%) bronchopulmonary dysplasia, 12 (4.8%) periventricular leukomalacia, 93 (37.2%) retinopathy of prematurity, and 1 (0.4%) necrotizing enterocolitis. Mortality rate was 25/250 (10%). Nucleated red blood cells and serum lactate on day 2 of life were associated with mortality (p < 0.001). Serum lactate on day 5 of life demonstrated an association with retinopathy of prematurity (p = 0.017), bronchopulmonary dysplasia (p = 0.044), and intraventricular hemorrhage (p < 0.001). Cutoff values predicting mortality were >89.5 nucleated red blood cells/100 leucocytes (sensitivity 68.2%, specificity 89.0%) and serum lactate concentrations >8.5 mmol/l (sensitivity 69.6%, specificity 93.5%) on day 2 of life. CONCLUSION We conclude that both nucleated red blood cell count and serum lactate concentration are valuable biomarkers in predicting important outcome parameters in very low birth weight infants.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/Saar, Germany.
| | - Antonia Wissing
- Medical School, University of Saarland, Homburg/Saar, Germany
| | - Michael Zemlin
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Aylin Aygün
- Medical School, University of Saarland, Homburg/Saar, Germany
| | | | - Jürgen Geisel
- Department of Clinical chemistry and Laboratory medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jakob Schöpe
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Harald Sauer
- Department of Pediatric Cardiology, Saarland University Hospital, Kirrberger Straße, 66421, Homburg/Saar, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany.,Department of Pediatric Neurology, Saarland University Medical Center, Homburg/Saar, Germany
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15
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Ebrahimi-Fakhari D, Mann LL, Poryo M, Graf N, von Kries R, Heinrich B, Ebrahimi-Fakhari D, Flotats-Bastardas M, Gortner L, Zemlin M, Meyer S. Incidence of tuberous sclerosis and age at first diagnosis: new data and emerging trends from a national, prospective surveillance study. Orphanet J Rare Dis 2018; 13:117. [PMID: 30016967 PMCID: PMC6050673 DOI: 10.1186/s13023-018-0870-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/06/2018] [Indexed: 01/01/2023] Open
Abstract
Background Tuberous Sclerosis Complex (TSC) is a rare multisystem disorder. In 2012 diagnostic criteria for TSC were revised. However, data on the incidence of TSC are limited. Methods Prospective, national surveillance study in Germany over a 2-year-period (03/2015–02/2017) using current revised criteria for TSC. Patients up to the age of 18 years with a new diagnosis of definite or possible TSC (clinical and/or genetic) were included. The aims of this study were 1) to generate up-to-date data on the incidence of definite or possible TSC, 2) to assess age at first diagnosis, and 3) to compare these data with previous epidemiologic data. Results In total, 86 patients met inclusion criteria (definite or possible TSC) with a median age at diagnosis of 6 months (range: 5 months before birth – 197 months of age). Among patients identified with features of TSC, 73.3% met criteria for definite diagnosis (median age: 7 months) and 26.7% met criteria for a possible diagnosis (median age: 3 months). 55.8% of patients were male. When excluding prenatally diagnosed patients, median age at diagnosis was 11 months with a range of 0 to 197 months. The 3 most common clinical features at diagnosis of TSC were central nervous system involvement in 73.3% patients (of these 95.2% experienced seizures), cutaneous involvement in 58.1% patients (with the most common lesion being hypomelanotic macules in 92%) and cardiac rhabdomyoma in half of the patients. Cardiac rhabdomyoma were detected by prenatal ultrasonography in 22.1% of patients. The presence of cardiac rhabdomyoma was associated with cardiac arrhythmias in 25.6% (about 13% of all diagnosed patients) in our cohort. The overall prevalence of seizure disorders was 69.8%. The annual incidence rate of TSC is estimated at a minimum of 1:17.785 live births. However correcting for underreporting, the estimated incidence rate of definite or possible TSC is approximately 1:6.760–1:13.520 live births in Germany. Conclusions This is the first study that assessed prospectively the incidence rate of TSC in children and adolescents using the updated diagnostic criteria of 2012. This prospective surveillance study demonstrates a low age at first diagnosis (median: 6 months), likely due to antenatal detection of cardiac rhabdomyoma. Early diagnosis bears the potential for implementing effective therapies at an earlier stage. Electronic supplementary material The online version of this article (10.1186/s13023-018-0870-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany.
| | - Lilian Lisa Mann
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Norbert Graf
- Department of Pediatric Oncology and Hematology, Saarland University Medical Center, Homburg, Germany
| | - Rüdiger von Kries
- Division of Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig Maximilian's University, Munich, Germany.,German Paediatric Surveillance Unit (ESPED), Coordination Center for Clinical Studies, Heinrich Heine University, Düsseldorf, Germany
| | - Beate Heinrich
- German Paediatric Surveillance Unit (ESPED), Coordination Center for Clinical Studies, Heinrich Heine University, Düsseldorf, Germany
| | - Darius Ebrahimi-Fakhari
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marina Flotats-Bastardas
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Ludwig Gortner
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Michael Zemlin
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Building 9, Kirrberger Strasse, 66421, Homburg, Saarland, Germany
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Flotats-Bastardas M, Ebrahimi-Fakhari D, Gortner L, Poryo M, Zemlin M, Macaya-Ruiz A, Meyer S. Diagnosis and Treatment of Tuberous Sclerosis Manifestations in Children: A Multicenter Study. Neuropediatrics 2018; 49:193-199. [PMID: 29558773 DOI: 10.1055/s-0038-1637738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disease with a significant morbidity and mortality. We conducted a retrospective analysis of two cohorts (Vall d'Hebron University Hospital [HVH], Barcelona, Spain, 1982-2015, and at Saarland University Medical Center [UKS], Homburg, Germany, 1998-2015) to assess prevalence and treatment of TSC associated manifestations and to evaluate if the follow-up was in line with published recommendations. This was considered if more than 15% of patients did not receive adequate examination with regard to potential organ involvement. A definite diagnosis was made in 52 patients (96%), and a possible diagnosis was made in 2 patients (4%). Thirty-four (63%) patients were from HVH and 20 (37%) from UKS. Median age at first presentation was 6 months (interquartile range: 0-38 months), and median time of follow-up was 6 years (interquartile range: 2-13 years). Clinical symptoms that led to a diagnosis of TSC were cardiac rhabdomyoma (22/54), epilepsy (20/54), and cutaneous manifestations (4/54). Assessment of neuropsychiatric, renal, and ocular manifestations was inadequate in both hospitals, whereas cutaneous manifestation was inadequate at UKS only. Our data demonstrate insufficient examinations in a substantial number of TSC patients with regard to neuropsychiatric, renal, ocular, and cutaneous manifestations. The recently published guidelines may prove valuable in establishing a more comprehensive approach.
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Affiliation(s)
- Marina Flotats-Bastardas
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany.,Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Ludwig Gortner
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany.,Department of Pediatrics and Neonatology, Medical University Vienna, Vienna, Austria
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Michael Zemlin
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Alfons Macaya-Ruiz
- Department of Pediatric Neurology, Vall d'Hebron University Hospital, Barcelona, Spain.,Pediatric Neurology Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany
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Ebrahimi-Fakhari D, Zemlin M, Sauer H, Poryo M, Graf N, Meyer S. [25 Years of ESPED as a Surveillance Tool for Rare Diseases in Children in Germany: A Critical Analysis]. Klin Padiatr 2018; 230:215-224. [PMID: 29614515 DOI: 10.1055/a-0586-4365] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The German Paediatric Surveillance Unit (ESPED) was founded in 1992 to generate incidence data and detailed clinical descriptions of rare, childhood-onset diseases. METHODS Retrospective analysis of the ESPED epidemiological data collection from 1992-2017, and analysis of all published national and international publications originating from ESPED surveys. Center of Disease Control and Prevention (CDC) criteria for evaluating surveillance systems (simplicity, flexibility, timeliness, usefulness, data quality, representativeness, stability and acceptability) were adopted and applied to available ESPED data. RESULTS Between 1992 and 2017 ESPED completed 96 prospective studies on rare diseases in children. The 3 most frequent clinical entities were: Infectious/communicable disease (n=30), neurological diseases (n = 14) and hematologic diseases (n=10). Studies resulted in 337 publications in national and international journals. The median impact factor of the 192 journal publications with (impact factor) was 2,587 (range 0,032-28,409). The highest impact factors were seen in the fields of endocrinology/metabolism (n=130; median IF=3,534), infectious diseases (n=83; median IF=3,131) and hematology (n=37; median IF=2,497). Our analysis indicates that ESPED surveys meet CDC quality standards. CONCLUSION ESPED surveys are an important contributor in the field of clinical epidemiology in children with rare diseases. The high quality of ESPED surveys is reflected by high-impact publications in both national and international journals.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Michael Zemlin
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Harald Sauer
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Norbert Graf
- Department of Pediatric Haematology and Oncology, Saarland University Medical Center, Homburg, Germany
| | - Sascha Meyer
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
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Ebrahimi-Fakhari D, Dillmann U, Flotats-Bastardas M, Poryo M, Abdul-Khaliq H, Shamdeen MG, Mischo B, Zemlin M, Meyer S. Off-Label Use of Ataluren in Four Non-ambulatory Patients With Nonsense Mutation Duchenne Muscular Dystrophy: Effects on Cardiac and Pulmonary Function and Muscle Strength. Front Pediatr 2018; 6:316. [PMID: 30406066 PMCID: PMC6206203 DOI: 10.3389/fped.2018.00316] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/05/2018] [Indexed: 11/13/2022] Open
Abstract
About 15% of Duchenne muscular dystrophy (DMD) cases are caused by point mutations leading to premature stop codons and disrupted synthesis of the dystrophin protein. Stop codon read-through therapy is available with the drug Ataluren (Translarna® by PTC Therapeutics). Following positive results in ambulatory nmDMD (non-sense mutation Duchenne muscular dystrophy) patients, Ataluren received conditional approval in ambulant nmDMD patients by the EMA in 2014. However, there are limited data on non-ambulatory nmDMD patients treated with Ataluren. Here, we report our experience in four non-ambulatory nmDMD patients. Routine investigations included cardiac function, pulmonary function tests and muscle strength. We compared changes in left ventricular fractional shorting, forced volume vital capacity and BMI from two defined time periods (18-26-month period prior to and after Ataluren start). Mean age at loss of ambulation was 10.1 ± 0.5 years, mean age when initiating Ataluren treatment 14.1 ± 1.4 years. Serial echocardiography, pulmonary lung function tests, and assessment of muscle strength indicated mild attenuation of disease progression after initiation of Ataluren treatment. A possible side effect of Ataluren was a reduction in BMI. There were no adverse clinical effects or relevant abnormalities in routine laboratory values. We conclude that Ataluren appears to mildly ameliorate the clinical course in our patients with a good safety profile. However, larger clinical trials are required to assess the role of Ataluren and its long-term impact on disease progression in non-ambulant nmDMD patients.
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Affiliation(s)
| | - Ulrich Dillmann
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | | | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Hashim Abdul-Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | | | - Bernhard Mischo
- Department of Pediatrics, Marienkrankenhaus St. Josef Kohlhof, Neunkirchen, Germany
| | - Michael Zemlin
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany
| | - Sascha Meyer
- Department of Pediatric Neurology, Saarland University Medical Center, Homburg, Germany
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19
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Poryo M, Boeckh JC, Gortner L, Zemlin M, Duppré P, Ebrahimi-Fakhari D, Wagenpfeil S, Heckmann M, Mildenberger E, Hilgendorff A, Flemmer AW, Frey G, Meyer S. Ante-, peri- and postnatal factors associated with intraventricular hemorrhage in very premature infants. Early Hum Dev 2018; 116:1-8. [PMID: 29091782 DOI: 10.1016/j.earlhumdev.2017.08.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/21/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is one of the most serious complications in preterm infants and is associated with neurological sequelae and mortality. Over the past few decades, the rate of IVH has decreased due to improved neonatal intensive care. However, up to 15-25% of very and extremely premature infants (<32 and <28weeks of pregnancy (WOP) respectively) still suffer from IVH. STUDY PURPOSE The aim of this study was to perform an updated, multicenter analysis to identify ante-, peri, and postnatal factors other than gestational age/birth weight associated with IVH of any grade in a large cohort of very and extremely premature infants. METHODS We performed a retrospective analysis in a prospectively conducted multicenter cohort study between 01/01/1998-31/12/2012 at 5 level 3 perinatal centers. All relevant ante-, peri- and neonatal data were collected and univariate as well as multivariate logistic regression analysis was performed. RESULTS 765 inborn infants with a gestational age<32 WOP were enrolled into this study (369 (48.2%) female; 396 (51.8%) male). Birth weight ranged from 315g to 2200g (mean 1149.7g, SD 371.9g); 279 (36.5%) were born ≤27+6 WOP and 486 (63.5%)≥28+0 WOP. IVH was seen in 177 (23.1%) patients. Multivariate analysis revealed that in addition to higher gestational age (OR 0.7, CI [0.6-0.8]), antenatal steroid treatment (OR 0.3, CI [0.2-0.6]) and caesarian section without uterine contraction (OR 0.6, CI [0.4-0.9]) were associated with a lower rate of IVH while RDS (OR 5.6, CI [1.3-24.2]), pneumothorax (OR 2.8, CI [1.4-5.5]) and use of catecholamines (OR 2.7, CI [1.7-4.5]) were associated with an increased risk of IVH. After exclusion of gestational age and birth weight from multivariate analysis, early onset sepsis (OR 1.6, CI [1.01-2.7]) and patent ductus arteriosus (OR 1.9, CI [1.1-3.1]) were associated with a higher rate of IVH. In addition, univariate analysis revealed that Apgar scores at 5min (p<0.001), BDP/ROP/NEC (p<0.001), mechanical ventilation (p<0.001) and inhalative nitric oxide (p<0.001) were significantly associated with IVH. CONCLUSIONS Our comprehensive analysis demonstrated that the occurrence of IVH in very premature infants is significantly associated with ante-, peri- and postnatal factors being either related to the degree of immaturity or indicating a critical clinical course after birth. The analysis reiterates the necessity for a very close cooperation between obstetricians and neonatologists to reduce the incidence of IVH in this susceptible cohort.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Judith Caroline Boeckh
- Department of Internal Medicine, Katharinenhospital Klinikum Stuttgart, Stuttgart, Germany
| | - Ludwig Gortner
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Michael Zemlin
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Perrine Duppré
- University of Saarland, Medical School, Homburg/Saar, Germany
| | | | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Campus Homburg/Saar, Germany
| | - Matthias Heckmann
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, Germany
| | - Eva Mildenberger
- Department of Neonatology, University Medical Center, Johannes Gutenberg University Mainz, Germany
| | - Anne Hilgendorff
- Department of Neonatology, University Medical Center, Ludwig-Maximilian-University Munich, Germany
| | - Andreas W Flemmer
- Department of Neonatology, University Medical Center, Ludwig-Maximilian-University Munich, Germany
| | - Georg Frey
- Department of Pediatric Cardiology and Neonatology, Darmstaedter Kinderkliniken Prinzessin Margaret, Darmstadt, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg/Saar, Germany; Department of Pediatric Neurology, Saarland University Medical Center, Homburg/Saar, Germany
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20
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Ebrahimi-Fakhari D, Poryo M, Graf N, Zemlin M, Flotats-Bastardas M, Heine G, Ragoschke-Schumm A, Meyer S. Optimized care in Patients with Rare Diseases: TSC at the Center for Rare Diseases (ZSEUKS) at Saarland University Medical Center, Germany. Klin Padiatr 2017; 229:311-315. [PMID: 29132163 DOI: 10.1055/s-0043-120069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Providing comprehensive medical care for patients with rare diseases is both challenging and rewarding. We will give a short summary of the most relevant medical issues pertinent to this subject, and will illustrate some of these issues by sharing our experience in the care of patients with TSC disease.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Norbert Graf
- Department of Pediatric Haematology and Oncology, Saarland University Medical Center, Homburg, Germany
| | - Michael Zemlin
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Marina Flotats-Bastardas
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Gunnar Heine
- Department of Nephrology, Saarland University Medical Center, Homburg, Germany
| | | | - Sascha Meyer
- Department of General Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
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Ebrahimi-Fakhari D, Meyer S, Vogt T, Pföhler C, Müller CSL. Dermatologische Manifestationen der tuberösen Sklerose (TSC). J Dtsch Dermatol Ges 2017; 15:695-701. [DOI: 10.1111/ddg.13264_g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Klinik für Allgemeine Pädiatrie und Neonatologie, Tuberöse Sklerose Zentrum Saarland; Universitätsklinikum des Saarlands; Homburg/Saar
| | - Sascha Meyer
- Klinik für Allgemeine Pädiatrie und Neonatologie, Tuberöse Sklerose Zentrum Saarland; Universitätsklinikum des Saarlands; Homburg/Saar
| | - Thomas Vogt
- Klinik für Allgemeine Pädiatrie und Neonatologie, Tuberöse Sklerose Zentrum Saarland; Universitätsklinikum des Saarlands; Homburg/Saar
| | - Claudia Pföhler
- Klinik für Dermatologie, Allergologie und Venerologie; Universitätsklinikum des Saarlands; Homburg/Saar
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22
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Ebrahimi-Fakhari D, Meyer S, Vogt T, Pföhler C, Müller CSL. Dermatological manifestations of tuberous sclerosis complex (TSC). J Dtsch Dermatol Ges 2017; 15:695-700. [PMID: 28598544 DOI: 10.1111/ddg.13264] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/21/2017] [Indexed: 11/30/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disorder with prominent skin involvement that frequently occurs in early childhood. Dermatologic manifestations include facial angiofibromas, hypomelanotic macules, fibrous cephalic plaques, shagreen patches, and ungual fibromas. The International TSC Consensus Conference in 2012 provided guidelines for standardized baseline evaluation and follow-up. Detailed clinical dermatological evaluation at the time of diagnosis and annual skin examination is recommended for both pediatric and adult populations. The onset of dermatological manifestations is clearly age-related. However, dermatologists also have to assess for clinical manifestations beyond their own specialty. With advances in genetics and the advent of mTORC1 inhibitors, new specific therapeutic options have become available for TSC patients with skin manifestations. Early intervention is commonly recommended for symptomatic, rapidly evolving, disfiguring, or debilitating lesions. The consensus guidelines recommend "treatment as appropriate for the lesion and clinical context" and suggest the use of surgical excision, laser therapy, or topical mTORC1 inhibitors. Topical mTORC1 inhibitors present a useful option for TSC-associated skin lesions, particularly in medically complex patients. They may prevent or reduce the risks of subsequent surgeries and permanent scarring.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Claudia Pföhler
- Department of Dermatology, Allergology, and Venereology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Cornelia Sigrid Lissi Müller
- Department of Dermatology, Allergology, and Venereology, Saarland University Medical Center, Homburg/Saar, Germany
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Ebrahimi-Fakhari D, Müller CSL, Meyer S, Flotats-Bastardas M, Vogt T, Pföhler C. Topical Rapamycin for Facial Angiofibromas in a Child with Tuberous Sclerosis Complex (TSC): A Case Report and Long-Term Follow-up. Dermatol Ther (Heidelb) 2017; 7:175-179. [PMID: 28181194 PMCID: PMC5336437 DOI: 10.1007/s13555-017-0174-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Indexed: 10/28/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a genetic multisystem disorder with prominent skin involvement including facial angiofibromas that often appear in early childhood. Here we report the case of a 12-year-old girl with widespread disfiguring facial angiofibromas that were successfully treated with topical rapamycin, a mTOR inhibitor. A sustained remission of skin lesions was documented in detail over a 3-year follow-up. This case highlights the fact that topical rapamycin is a useful option in treating TSC-associated skin lesions. Especially in medically complex patients topical treatment may lessen the need for surgical interventions, reducing the risks of surgery, its adverse effects and permanent scarring. However, there is no standard dose or formulation at present. Topical rapamycin appears safe, but long-term maintenance therapy is necessary to prevent facial lesions from regrowth.
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Affiliation(s)
- Daniel Ebrahimi-Fakhari
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Cornelia Sigrid Lissi Müller
- Department of Dermatology, Allergology, and Venereology, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Marina Flotats-Bastardas
- Department of Pediatrics and Neonatology, Saarland Tuberous Sclerosis Center, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Dermatology, Allergology, and Venereology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Claudia Pföhler
- Department of Dermatology, Allergology, and Venereology, Saarland University Medical Center, Homburg/Saar, Germany
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Mann L, Ebrahimi-Fakhari D, Heinrich B, Flotats-Bastardas M, Gortner L, von Gontard A, Niemcyzk J, Poryo M, Meyer S. [ESPED-Survey: TSC-disease in children and adolescents: preliminary results from a German epidemiological survey]. Wien Med Wochenschr 2016; 167:271-275. [PMID: 27812765 DOI: 10.1007/s10354-016-0522-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/03/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) disease is a rare genetic, multi-organ disorder characterized by the occurrence of multiple hamartoma. METHODS In cooperation with ESPED, Germany, a prospective, epidemiological study was performed to assess the incidence of newly diagnosed TSC disease in patients ≤18 years in Germany. Moreover, the following parameters were assessed: 1. Age distribution at initial diagnosis; 2. Percentage of patients with in utero diagnosis of TSC; 3. Detailed description of pathological clinical findings; 4. Results from genetic testing. RESULTS In this one-year interim analysis, 84 electronic questionnaires were received, 17 of which did not contain complete sets of data and were not included in data analysis. Twenty-three of 67 questionnaires did not report TSC patients and 3 reports contained redundant data sets and were excluded. In total, 41 reports were included into data analysis (female: 23; male: 18); median age at first diagnosis was 6 months (range: 0-151 months). The three most common symptoms were: central nervous affection: 31/41 patients ((75.6 %); 29/31 with seizures); rhabdomyoma: in 20/41 (48.8 %); cutaneous affection: hypomelanotic maculae ("white spots"): 20/41 (48.8 %). The three following organ manifestations were seen most often in a comprehensive diagnostic work-up: rhabdomyoma: 23/41 ((56.1 %); cortical dysplasia: 22/41 (53.7 %); "white spots"): 20/41 (48.8 %). In 11/41 patients, cardiac rhabdomyoma were detected by ultrasonography prenatally. In 6 patients, a TSC-2 mutation was found while in 4 patients a TSC-1 mutation was noted; in 1 patient, genetic testing was negative. CONCLUSIONS Based on our preliminary findings, the annual incidence rate for TSC disease is estimated at approximately 1:12,300 live births, but this is a very rough approximation.
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Affiliation(s)
- Lilian Mann
- Medizinische Fakultät, Universität des Saarlandes Campus Homburg, 66421, Homburg, Deutschland
| | - Daniel Ebrahimi-Fakhari
- Medizinische Fakultät, Universität des Saarlandes Campus Homburg, 66421, Homburg, Deutschland
| | | | - Marina Flotats-Bastardas
- Klinik für Allgemeine Pädiatrie und Neonatologie, TSC-Zentrum Saarland, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - Ludwig Gortner
- Klinik für Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - Alexander von Gontard
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - Justine Niemcyzk
- Klinik für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - Martin Poryo
- Klinik für Pädiatrische Kardiologie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland
| | - Sascha Meyer
- Klinik für Allgemeine Pädiatrie und Neonatologie, TSC-Zentrum Saarland, Sektion Neuropädiatrie, Universitätsklinikum des Saarlandes, 66421, Homburg, Deutschland.
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Ebrahimi-Fakhari D, Kang KS, Kotzaeridou U, Kohlhase J, Klein C, Assmann BE. Child Neurology: PRRT2-associated movement disorders and differential diagnoses. Neurology 2014; 83:1680-3. [DOI: 10.1212/wnl.0000000000000936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ebrahimi-Fakhari D, Schönland SO, Hegenbart U, Lohse P, Beimler J, Wahlster L, Ho AD, Lorenz HM, Blank N. Familial Mediterranean fever in Germany: clinical presentation and amyloidosis risk. Scand J Rheumatol 2012; 42:52-8. [DOI: 10.3109/03009742.2012.714796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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