Sanfilippo syndrome: consensus guidelines for clinical care

Sanfilippo syndrome is a group of rare, complex, and progressive neurodegenerative lysosomal storage disorders that is characterized by childhood dementia. The clinical management of patients with progressive neurological decline and multisystem involvement requires a multidisciplinary team with experience in the management of neurodegenerative disorders. Best practice guidelines for the clinical management of patients with these types of rare disorders are critical to ensure prompt diagnosis and initiation of appropriate care. However, there are no published standard global clinical care guidelines for patients with Sanfilippo syndrome. To address this, a literature review was conducted to evaluate the current evidence base and to identify evidence gaps. The findings were reviewed by an international steering committee composed of clinical experts with extensive experience in managing patients with Sanfilippo syndrome. The goal was to create a consensus set of basic clinical guidelines that will be accessible to and informed by clinicians globally, as well as providing a practical resource for families to share with their local care team who may not have experience with this rare disease. This review distills 178 guideline statements into an easily digestible document that provides evidence-based, expert-led recommendations for how to approach common management challenges and appropriate monitoring schedules in the care of patients with Sanfilippo syndrome.

Caregivers' assessment of meaningful and relevant clinical outcome assessments for Sanfilippo syndrome

OBJECTIVES

Sanfilippo syndrome is a rare multisystem disease with no approved treatments. This study explores caregiver perspectives on the most impactful symptoms and patient-relevant clinical outcomes assessments. The pediatric onset and progressive neurodegenerative nature of Sanfilippo limits use of self-report in clinical research. This study obtains Sanfilippo caregiver data to support the selection of fit-for-purpose and patient-relevant clinical outcome assessments (COAs).

METHODS

We conducted an asynchronous online focus group (n = 11) followed by individual interviews with caregivers (n = 19) of children with Sanfilippo syndrome. All participants reported on the impact of disease symptoms and level of unmet treatment need across Sanfilippo symptom domains. Focus group participants reviewed existing assessments relating to 8 symptom domains (15 total assessments) and provided feedback on meaningfulness and relevance. Focus group data were used to reduce the number of assessments included in subsequent interviews to 8 COAs across 7 symptom domains: communication, eating, sleep, mobility, pain, behavior and adapting. Interview respondents provided data on meaningfulness and relevance of assessments. Data were coded using an item-tracking matrix. Data summaries were analyzed by caregivers' responses regarding meaningfulness; relevance to Sanfilippo syndrome; and based on caregiver indication of missing or problematic subdomains and items.

RESULTS

Participants' children were 2-24 years in age and varied in disease progression. Caregivers reported communication and mobility as highly impactful domains with unmet treatment needs, followed closely by pain and sleep. Domains such as eating, adaptive skills, and behaviors were identified as impactful but with relatively less priority, by comparison. Participants endorsed the relevance of clinical outcome assessments associated with communication, eating, sleep, and pain, and identified them as highly favorable for use in a clinical trial. Participants specified some refinements in existing assessments to best reflect Sanfilippo symptoms and disease course.

DISCUSSION

The identification of impactful symptoms to treat and relevant and meaningful clinical outcome assessments supports patient-focused drug development. Our results inform targets for drug development and the selection of primary and secondary outcome assessments with high meaningfulness and face validity to Sanfilippo syndrome caregivers. Assessments identified as less optimal might be refined, replaced, or remain if the clinical trial necessitates.

Parent Experiences of Sanfilippo Syndrome Impact and Unmet Treatment Needs: A Qualitative Assessment

Introduction

Sanfilippo syndrome (MPS III) is a rare, degenerative condition characterized by symptoms impacting cognitive ability, mobility, behavior, and quality of life. Currently there are no approved therapies for this severe life-limiting disease. Integrating patient and caregiver experience data into drug development and regulatory decision-making has become a priority of the Food and Drug Administration and rare disease patient communities.

Methods

This study assesses parents’ perceptions of their child’s Sanfilippo syndrome disease-related symptoms using a research approach that is consistent with the Center for Drug Evaluation and Research (CDER) guidance. This study was initiated by the Cure Sanfilippo Foundation, and all steps in the research process were informed by a multidisciplinary advisory committee, with an objective of informing biopharmaceutical companies and regulatory agencies. We explored caregiver burden, symptoms with greatest impact, and meaningful but unmet treatment needs. Data were collected from 25 parents through three focus groups and a questionnaire. Transcripts were coded and analyzed using inductive thematic analysis, and descriptive analysis of quantitative data was conducted.

Results

Participating parents’ children ranged in age from 4 to 36 years. Participants endorsed high caregiving burden across all stages of the disease. Analysis revealed multiple domains of unmet need that impact child and family quality of life, including cognitive-behavioral challenges in communication, relationships, behavior, anxiety, and child safety; and physical health symptoms including sleep, pain, and mobility. Participants reported placing high value on incremental benefits targeting those symptoms, and on a treatment that would slow or stop symptom progression.

Conclusion

Even modest treatment benefits for Sanfilippo syndrome were shown to be highly valued. Despite high caregiver burden, most parents expressed a willingness to “try anything,” including treatments with potentially high risk profiles, to maintain their child’s current state.

Electronic supplementary material

The online version of this article (10.1007/s40120-020-00226-z) contains supplementary material, which is available to authorized users.

Evaluation of delayed timing of artificial insemination with sex-sorted sperm on pregnancy per artificial insemination in seasonal-calving, pasture-based lactating dairy cows

The objective was to use ovulation synchronization with timed artificial insemination (TAI) to evaluate the effect of timing of artificial insemination (AI) with frozen sex-sorted sperm on fertility performance in pasture-based compact calving herds. Ejaculates from 3 Holstein-Friesian bulls were split and processed to provide frozen sex-sorted sperm (SS) at 4 × 10⁶ sperm per straw, and frozen conventional sperm at 15 × 10⁶ sperm per straw (CONV). A modified Progesterone-Ovsynch protocol was used for estrous synchronization, with TAI occurring 16 h after the second GnRH injection for cows assigned to CONV, and either 16 h (SS-16) or 22 h (SS-22) for cows assigned to SS. Pregnancy diagnosis was conducted by transrectal ultrasound scanning of the uterus 35 to 40 d after TAI (n = 2,175 records available for analysis). Generalized linear mixed models were used to examine the effects of treatment on pregnancy per artificial insemination (P/AI). Fixed effects included treatment (n = 3), bull (n = 3), treatment by bull interaction, parity (n = 4), days-in-milk category (n = 3), and treatment by days-in-milk category, with herd (n = 24) included as a random effect. Pregnancy per AI was greater for CONV compared with both SS-16 and SS-22 (61.1%, 49.0%, and 51.3%, respectively), and the SS treatments did not differ from each other (relative P/AI for SS-16 and SS-22 vs. CONV were 80.2% and 84.0%, respectively). There were significant bull and treatment by bull interaction effects. Additional analysis was undertaken using a model that included herd as a fixed effect. This analysis identified marked herd-to-herd variation (within-herd relative P/AI for the combined SS treatments vs. CONV ranged from 48-121%). The tertile of herds with the best performance achieved a mean relative P/AI of 100% (range = 91-121%), indicating that P/AI equivalent to CONV is achievable with SS. Conversely, the tertile of herds with the poorest performance achieved a mean relative P/AI of 67% (range = 48-77%). We found that SS resulted in poorer overall P/AI compared with CONV sperm regardless of timing of AI. Marked variation existed between herds; however, one-third of herds achieved P/AI results equal to CONV. Identification of factors responsible for the large herd-to-herd variation in P/AI with SS, and development of strategies to reduce this variation, warrant further research.

Fertility of frozen sex-sorted sperm at 4 × 106 sperm per dose in lactating dairy cows in seasonal-calving pasture-based herds

The objective was to evaluate the reproductive performance of frozen sex-sorted sperm at 4 × 10⁶ sperm per dose (SexedULTRA 4M, Sexing Technologies, Navasota, TX) relative to frozen conventional sperm in seasonal-calving pasture-based dairy cows. Semen from Holstein-Friesian (n = 8) and Jersey (n = 2) bulls was used. Four of the Holstein bulls used were resident at or near a sex-sorting laboratory (Cogent, UK, or ST Benelux, the Netherlands). The remaining 6 bulls were located at studs in Ireland. For these 6 bulls, ejaculates were collected, diluted with transport medium, and couriered to Cogent in parcel shippers. Transit time from ejaculation to arrival at the sorting laboratory was 6 to 7 h. For all bulls, ejaculates were split and processed to provide frozen conventional sperm (CONV) at 15 × 10⁶ sperm per straw and frozen sex-sorted (SS) sperm at 4 × 10⁶ sperm per straw and used to inseminate lactating dairy cows after spontaneous estrus. Pregnancy diagnosis was performed by ultrasound scanning (n = 7,246 records available for analysis). Generalized linear mixed models were used to examine effects on pregnancy per AI (P/AI) at first artificial insemination, with sperm treatment (CONV vs. SS), bull (n = 10), and treatment × bull interaction as the fixed effects, and herd (n = 142) as a random effect. Overall, P/AI was greater for cows inseminated with CONV than for those inseminated with SS (59.9% vs. 45.5%; 76.0% relative to CONV). This study was not designed to compare resident bulls vs. shipped ejaculates, but the magnitude of the difference between P/AI achieved by CONV and SS was apparently less for resident bulls (60.3% vs. 50.2%) than for shipped ejaculates (58.6% vs. 40.7%). We discovered a treatment × bull interaction for shipped ejaculates (P/AI ranged from 45 to 86% relative to CONV) but not for the resident bulls (P/AI ranged from 81 to 87% relative to CONV). Relative P/AI of SS compared with CONV was greater in cows with high or average fertility potential (76.1% and 78.3%, respectively) than in cows with low fertility potential (58.1%). In 33.1% of the enrolled herds, the P/AI achieved with SS was 90% or more of the P/AI achieved with CONV; this was mainly explained by herds in which SS performed exceptionally well but CONV performed poorly. In conclusion, SS had lower overall P/AI compared with CONV; however, P/AI achieved with SS was dependent on the bull, fertility potential of the cow, and herd. Strategies to improve the P/AI with SS in seasonal-calving pasture-based lactating dairy cows require further research.

Pregabalin increases slow-wave sleep and may improve attention in patients with partial epilepsy and insomnia

Insomnia is a common phenomenon particularly in patients with epilepsy. This study was performed to look at the effects of pregabalin, an anticonvulsant known to increase sleep depth and decrease arousals, in patients with insomnia and well-controlled epilepsy.

METHODS

This was a double-blind, placebo-controlled, crossover study of subjects with insomnia and epilepsy. Each subject was treated with pregabalin 150 mg BID or placebo for two weeks, followed by a two-week washout period, then the other treatment for two weeks. Polysomnography and neuropsychological testing were performed at baseline and at the end of each treatment arm.

RESULTS

There was a significant increase in percentage of slow-wave sleep and a decrease in stage 1 sleep when subjects were taking pregabalin. Sleep efficiency increased during pregabalin treatment, although this was not statistically significant (84.5+/-4.6% for placebo versus 90.4+/-2.6% for pregabalin). There were a significant improvement in attention in the pregabalin group based on trial one of the Rey-Auditory Verbal Learning Test and a trend toward improvement in the psychomotor vigilance task; other neuropsychological measures were not significantly changed.

CONCLUSION

Concurrent treatment with pregabalin improves sleep depth in patients with insomnia and epilepsy and improves daytime attention.

Obstetric regional blocks for women with multiple sclerosis: a survey of UK experience

BACKGROUND

There has been a reluctance to use regional blocks for women with multiple sclerosis as effects on the course of the disease are unclear. We assessed the views of UK consultant obstetric anaesthetists regarding management of women with multiple sclerosis.

METHODS

Following Obstetric Anaesthetists' Association approval a questionnaire was sent to UK consultant members. Opinions were sought on antenatal assessment, labour analgesia, anaesthesia for elective and emergency caesarean section, and modification in technique for those with multiple sclerosis. Enquiries were made of postnatal problems ascribed to regional blocks.

RESULTS

Of the 592 replies analysed, 91% of respondents had seen fewer than 10 cases of multiple sclerosis in the past 10 years. Antenatal assessment was recommended by many with postnatal relapse most commonly discussed (64%). Many highlighted the need for informed consent and minimising local anaesthetic dose. For labour analgesia 79% would perform a regional block; a further 20% would do so in certain circumstances. For elective caesarean section, epidural rather than spinal anaesthesia was preferred by 4%; 2% would not use a regional block, preferring general anaesthesia. For emergency caesarean section with time only for single-shot spinal, 3% would give a general anaesthetic. Deterioration of symptoms after delivery were reported by 20% with 3% attributing symptoms such as prolonged block, leg weakness, bladder dysfunction and postnatal relapse to regional blocks.

CONCLUSION

Most UK anaesthetists would perform regional blocks for labour and caesarean section in multiple sclerosis, although the experience of each anaesthetist is limited. Many emphasised the need for thorough pre-assessment and informed consent.

A patient decision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation: a randomized controlled trial

CONTEXT

Decision aids are tools designed to help patients participate in the clinical decision-making process.

OBJECTIVE

To determine whether use of an audiobooklet (AB) decision aid explaining the results of a clinical trial affected the decision-making process of study participants.

DESIGN

Randomized controlled trial conducted from May 1997 to April 1998.

SETTING

Fourteen centers that participated in the Stroke Prevention in Atrial Fibrillation (SPAF) III trial.

PARTICIPANTS

A total of 287 patients from the SPAF III aspirin cohort study, in which patients with atrial fibrillation and a relatively low risk of stroke received 325 mg/d of aspirin and were followed up for a mean of 2 years.

INTERVENTION

At the end of SPAF III, participants were randomized to be informed of the study results with usual care plus use of an AB (AB group) vs usual care alone (control group). The AB included pertinent information to help patients decide whether to continue taking aspirin or switch to warfarin.

MAIN OUTCOME MEASURES

Patients' ability to make choices regarding antithrombotic therapy, and 6-month adherence to these decisions. Their knowledge, expectations, decisional conflict (the amount of uncertainty about the course of action to take), and satisfaction with the decision-making process were also measured.

RESULTS

More patients in the AB group made a choice about antithrombotic therapy than in the control group (99% vs 94%; P = .02). Patients in the AB group were more knowledgeable and had more realistic expectations about the risk of stroke and hemorrhage (in the AB group, 53%-80% correctly estimated different risks; in the control group, 16%-28% gave correct estimates). Decisional conflict and satisfaction were similar for the 2 groups. After 6 months, a similar percentage of patients were still taking their initial choice of antithrombotic therapy (95% vs 93%; P = .44).

CONCLUSIONS

For patients with atrial fibrillation who had participated in a major clinical trial, the use of an AB decision aid improved their understanding of the benefits and risks associated with different treatment options and helped them make definitive choices about which therapy to take. Further studies are necessary to evaluate the acceptability and impact of decision aids in other clinical settings.

Internet technology: resources for perinatal nurses

The Internet and the World Wide Web (WWW) are being discussed in many forums. This huge body of information is becoming a widely used research tool. Within the last few years, the WWW has grown enormously. In 1993, there were approximately 130 WWW sites. By 1997, experts estimated there were over a million sites on the web, many of them useful for nurses and accessible from the nearest computer. For perinatal nurses in practice, research, or education the need for information is great. Nurses need current data for clinical decision making, policy writing, patient education, continuing education, and research. Understanding how to use the Internet, being aware of its advantages and disadvantages, and knowing how to critically examine what is available will assist perinatal nurses in making use of this newest form of information technology.

Randomized trial of a portable, self-administered decision aid for postmenopausal women considering long-term preventive hormone therapy

Although practice guidelines suggest that postmenopausal women learn about the benefits and risks and consider their values when deciding about hormone therapy, the optimal decision-support method has not been established. In a randomized controlled trial, the authors compared the efficacy of a general educational pamphlet with that of a tailored decision aid. The pamphlet briefly summarized benefits, risks, and likely beneficiaries in general terms. The decision aid, delivered via booklet and audiotape, provided: detailed benefits and risks using functional terms and probabilities tailored to clinical risk; and steps for considering the issue in a woman's own situation, including a value-clarification exercise. Compared with the pamphlet group, the decision-aid group had statistically significant (p < 0.05) improvements in terms of realistic personal expectations of the benefits and risks, decisional conflict, and perceived acceptability of the intervention. Levels of general knowledge about the main benefits and risks were comparable for the two interventions. It is concluded that tailored decision aids prepare women for decision making better than do general pamphlets.

A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a woman's clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Women's values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Discharge teaching needs of parents in the NICU

Teaching parents how to care for their infant in the NICU can be a challenge. This study investigated card sort as a teaching aid. Proposed by many investigators to improve the effectiveness of nurses' teaching interventions, card sort is based on Q-technique, once used in research, now adapted as a teaching tool. Card sort involves parents in sorting out topics of information according to their own priorities. A pilot study was designed to test this method in the NICU. Ten parents and seven nurses participated in this trial. The parents were asked to sort a set of 17 colorful 5 x 7 inch cards into three piles (from least important to most important); each card was labeled with a discharge teaching topic. The nurses working with these parents also sorted the cards, and their responses were compared to those of the parents. Although parents' and nurses' discharge teaching priorities differed, both groups ranked CPR and signs and symptoms of illness as priorities. There are many advantages of the card sort method in relation to adult learning and social cognition theory. Parents are clearly the best source for determining their own teaching needs, and card sort is a useful tool that involves parents in discharge teaching through self-assessment of needs.

Reconstructive hand surgery for quadriplegic persons

Reconstructive hand surgery is one approach to restoring lost hand function in quadriplegic patients. This paper describes Craig Hospital's experience with the two-stage procedure for achieving active grasp and pinch for C7 spinal cord-injured patients. It describes the hand clinic, patient selection and education, the surgery itself, and postsurgical occupational therapy. It also includes follow-up results on all patients treated since the program's inception.

Assay of urinary oxalate: six methodologies compared

To assess how well results by different methods for urinary oxalate determinations agree with each other in a clinical setting, we compared six different assays: Hodgkinson and Williams (Clin Chim Acta 36:127-132, 1972), enzymatic, modified Hodgkinson and Williams, gas chromatography, ion chromatography, and "high-pressure" liquid chromatography. For the entire group of samples, the mean value by each method agreed relatively closely, although the enzymatic procedure produced a somewhat higher value. All six methods had large coefficients of variation within (8-58%) and between (15-88%) assays. In addition, analytical recovery by most assays was more than 100% of the added oxalate. Analytical recovery of 10 micrograms of oxalate added per milliliter of urine specimen ranged from 86 to 237%; for 20 micrograms/mL it was 83 to 320%. Thus for the six methods evaluated, no single method appeared to be superior to the others.

Assay of urinary oxalate: six methodologies compared

To assess how well results by different methods for urinary oxalate determinations agree with each other in a clinical setting, we compared six different assays: Hodgkinson and Williams (Clin Chim Acta 36:127-132, 1972), enzymatic, modified Hodgkinson and Williams, gas chromatography, ion chromatography, and "high-pressure" liquid chromatography. For the entire group of samples, the mean value by each method agreed relatively closely, although the enzymatic procedure produced a somewhat higher value. All six methods had large coefficients of variation within (8-58%) and between (15-88%) assays. In addition, analytical recovery by most assays was more than 100% of the added oxalate. Analytical recovery of 10 micrograms of oxalate added per milliliter of urine specimen ranged from 86 to 237%; for 20 micrograms/mL it was 83 to 320%. Thus for the six methods evaluated, no single method appeared to be superior to the others.