Marital status is a prognostic factor in amyotrophic lateral sclerosis

BACKGROUND AND OBJECTIVES

Several variables have been linked to a shorter survival in patients with amyotrophic lateral sclerosis (ALS), for example, female sex, older age, site of disease onset, rapid disease progression, and a relatively short diagnostic delay. With regard to marital status, previous studies suggested that living with a partner might be associated to a longer survival and a higher likelihood to proceed to tracheostomy. Therefore, to further strengthen this hypothesis, we investigated the role of marital status as a prognostic variable in a cohort of ALS patients.

METHODS

We performed a retrospective analysis on 501 consecutive ALS patients for which a complete disease's natural history and clinical/demographic data were available. At diagnosis, 409 patients (81.6%) were married or lived with a stable partner, whereas 92 patients (18.4%) were single/widowed/divorced.

RESULTS

In our ALS cohort, being married was associated with a median longer survival (married, 35 months [24-50] vs unmarried, 27 months [18-42]; P<.004). Moreover, married and unmarried patients were significantly different in many clinical and demographic variables, including age at disease onset, gender, body mass index, and number of children. Cox regression analysis showed that age at onset, diagnostic delay, and marital status were independent predictors of survival. In unmarried patients, female sex was also significantly associated with shorter survival.

CONCLUSIONS

Marital status is a prognostic factor in ALS, and it significantly affects survival.

The eye-tracking computer device for communication in amyotrophic lateral sclerosis

OBJECTIVE

To explore the effectiveness of communication and the variables affecting the eye-tracking computer system (ETCS) utilization in patients with late-stage amyotrophic lateral sclerosis (ALS).

METHODS

We performed a telephone survey on 30 patients with advanced non-demented ALS that were provisioned an ECTS device. Median age at interview was 55 years (IQR = 48-62), with a relatively high education (13 years, IQR = 8-13). A one-off interview was made and answers were later provided with the help of the caregiver. The interview included items about demographic and clinical variables affecting the daily ETCS utilization.

RESULTS

The median time of ETCS device possession was 15 months (IQR = 9-20). The actual daily utilization was 300 min (IQR = 100-720), mainly for the communication with relatives/caregiver, internet surfing, e-mailing, and social networking. 23.3% of patients with ALS (n = 7) had a low daily ETCS utilization; most reported causes were eye-gaze tiredness and oculomotor dysfunction.

CONCLUSIONS

Eye-tracking computer system is a valuable device for AAC in patients with ALS, and it can be operated with a good performance. The development of oculomotor impairment may limit its functional use.

Genetic counselling in ALS: facts, uncertainties and clinical suggestions

The clinical approach to patients with amyotrophic lateral sclerosis (ALS) has been largely modified by the identification of novel genes, the detection of gene mutations in apparently sporadic patients, and the discovery of the strict genetic and clinical relation between ALS and frontotemporal dementia (FTD). As a consequence, clinicians are increasingly facing the dilemma on how to handle genetic counselling and testing both for ALS patients and their relatives. On the basis of existing literature on genetics of ALS and of other late-onset life-threatening disorders, we propose clinical suggestions to enable neurologists to provide optimal clinical and genetic counselling to patients and families. Genetic testing should be offered to ALS patients who have a first-degree or second-degree relative with ALS, FTD or both, and should be discussed with, but not offered to, all other ALS patients, with special emphasis on its major uncertainties. Presently, genetic testing should not be proposed to asymptomatic at-risk subjects, unless they request it or are enrolled in research programmes. Genetic counselling in ALS should take into account the uncertainties about the pathogenicity and penetrance of some genetic mutations; the possible presence of mutations of different genes in the same individual; the poor genotypic/phenotypic correlation in most ALS genes; and the phenotypic pleiotropy of some genes. Though psychological, social and ethical implications of genetic testing are still relatively unexplored in ALS, we recommend multidisciplinary counselling that addresses all relevant issues, including disclosure of tests results to family members and the risk for genetic discrimination.

Causes and place of death in Italian patients with amyotrophic lateral sclerosis

OBJECTIVES

To determine the causes and place of death in a cohort of Italian patients with amyotrophic lateral sclerosis (ALS). A better understanding of the likely causes of death in ALS might improve the palliative care at the end-of-life, whereas knowing the place of death will help to verify the need for highly specialized care services, e.g. hospice and nursing home.

PATIENTS AND METHODS

Between 2000 and 2008, 182 ALS patients (onset: spinal, 127; bulbar, 55; M/F: 1.6) were followed in a single ALS Tertiary Centre in Palermo, Sicily, Italy until death. Medical data for each individual patient were recorded in a large database throughout the disease course. Information concerning causes and place of death were obtained by consultation with relatives or the family physician.

RESULTS

Respiratory failure (terminal respiratory insufficiency, pneumonia) was the most frequent cause of death (81.3%), which included six cases (3.3%) who requested a terminal sedation. Sudden death and death during sleep accounted for by 6.0% and 6.6% of all deaths, respectively. Heart-related causes of death were relatively infrequent in our cohort, accounting for by 7.1% of all deaths (i.e. sudden death: 6.0% and myocardial infarct: 1.1%). Patients (85.2%) died at home.

CONCLUSIONS

The leading cause of death in ALS remains the respiratory failure, followed by the sudden death and death during sleep. Most patients in our cohort died at home, a choice that might be only partially driven by cultural factors. These findings might have a great impact on the development of the advanced and end-of-life palliative care and in the planning of specialized care services, as hospice and nursing home.

MMPI-2 profiles in traumatic and non-traumatic spinal cord injured patients

This study investigated the relationship of type of onset of disability to the MMPI-2 profiles of 73 spinal cord patients receiving comprehensive inpatient rehabilitation. Participants were divided into three onset groups: non-traumatic, passive-traumatic, and active-traumatic (active and passive participation in the injury). A 2 x 3 factorial MANOVA (gender and onset) with age as a covariate was performed on the MMPI-2 profiles. A main effect for gender (scales D and MAC-R) was found. The medical and functional impairments common to the onset subtypes suggest a somato-psychic direction in psychological adjustment.

Evaluation of lopamidol and diatrizoate in excretory urography: a double-blind clinical study

Image opacification, patients' tolerance, and clinical and laboratory findings were evaluated in patients having excretory urography at three centers. In a double-blind, parallel study, iopamidol was compared with diatrizoate (50-ml dose), and in an open-label trial, the administration of a 100-ml dose of iopamidol was evaluated. In the double-blind study, a total of 84 patients received 50 ml of either iopamidol or diatrizoate. In the open-label study, another 42 patients received a 100-ml dose of iopamidol. Image opacification scores after the administration of the 50-ml doses showed better opacification with iopamidol than with diatrizoate in the renal calices (p less than .05) and in the composite kidney (p less than .05). Opacification scores were higher for 100-ml doses of iopamidol than for 50-ml doses in all anatomic regions as well as in the composite kidney (p = .0001). Patients' tolerance to iopamidol was significantly better than their tolerance to diatrizoate (p less than .025). Investigators observed adverse drug reactions in a total of 10 patients. In the double-blind study, one of 43 patients had transient bradycardia after the administration of iopamidol. In the same study, four of 41 patients who received diatrizoate had five minor adverse drug reactions. With 100-ml doses of iopamidol, five of 42 patients had adverse reactions. No adverse side effects required therapy in either study. There were no significant changes in vital signs or laboratory values after drug administration. The results of this study show that iopamidol is a suitable agent for excretory urography at doses of 50 and 100 ml. Patients report fewer unpleasant side effects with iopamidol than with diatrizoate. Overall image quality was better with iopamidol than with diatrizoate. Overall evaluation of drug performance was better with iopamidol than with diatrizoate.

Pneumatosis intestinalis as a complication of jejunoileal bypass

Four patients with pneumatosis intestinalis involving the unbypassed functioning bowel after jejunoileal bypass for obesity are reported. Previous publications of pneumatosis intestinalis after jejunoileal bypass discussed involvement only of the bypassed defunctionalized bowel. Symptomatology can range from mild to severe. The treatment of pneumatosis intestinalis is conservative. The specific etiology of the pneumatosis in this group of patients is not known.