Disease progression rates in ambulatory Duchenne muscular dystrophy by steroid type, patient age and functional status.

Aim: To examine benefits of corticosteroids for Duchenne muscular dystrophy (DMD) by age and disease progression. Methods: Data from daily steroid users (placebo-treated) were pooled from four phase 2b/3 trials in DMD. Outcomes assessed overall and among subgroups included changes from baseline to 48 weeks in six-minute walk distance (6MWD), timed function tests and North Star Ambulatory Assessment total score. Results: Among 231 patients receiving deflazacort (n = 127) or prednisone (n = 104), observed differences in 6MWD favoring deflazacort over prednisone were significant for patients with relatively older age (≥8-years-old), greater disease progression (baseline timed stand from supine ≥5 s), or longer corticosteroid use (>3 years). Conclusion: Daily deflazacort had greater benefits than daily prednisone particularly among older/more progressed patients.

Functional and Clinical Outcomes Associated with Steroid Treatment among Non-ambulatory Patients with Duchenne Muscular Dystrophy1.

BACKGROUND: Evidence on the long-term efficacy of steroids in Duchenne muscular dystrophy (DMD) after loss of ambulation is limited. OBJECTIVE: Characterize and compare disease progression by steroid treatment (prednisone, deflazacort, or no steroids) among non-ambulatory boys with DMD. METHODS: Disease progression was measured by functional status (Performance of Upper Limb Module for DMD 1.2 [PUL] and Egen Klassifikation Scale Version 2 [EK] scale) and by cardiac and pulmonary function (left ventricular ejection fraction [LVEF], forced vital capacity [FVC] % -predicted, cough peak flow [CPF]). Longitudinal changes in outcomes, progression to key disease milestones, and dosing and body composition metrics were analyzed descriptively and in multivariate models. RESULTS: This longitudinal cohort study included 86 non-ambulatory patients with DMD (mean age 13.4 years; n = 40 [deflazacort], n = 29 [prednisone], n = 17 [no steroids]). Deflazacort use resulted in slower average declines in FVC % -predicted vs. no steroids (+3.73 percentage points/year, p < 0.05). Both steroids were associated with significantly slower average declines in LVEF, improvement in CPF, and slower declines in total PUL score and EK total score vs. no steroids; deflazacort was associated with slower declines in total PUL score vs. prednisone (all p < 0.05). Both steroids also preserved functional abilities considered especially important to quality of life, including the abilities to perform hand-to-mouth function and to turn in bed at night unaided (all p < 0.05 vs. no steroids). CONCLUSIONS: Steroid use after loss of ambulation in DMD was associated with delayed progression of important pulmonary, cardiac, and upper extremity functional deficits, suggesting some benefits of deflazacort over prednisone.

Condutas clínicas e barreiras no tratamento da polineuropatia amiloidótica familiar associada à transtirretina (PAF-TTR) no Brasil / Clinical practice and barriers in familial transthyretinrelated amyloidotic polyneuropathy (FAP) care in Brazil

Objetivo: Identificar as condutas terapêuticas e a variabilidade na prática clínica, assim como necessidades não atendidas e barreiras para a adequada assistência a pacientes com polineuropatia amiloidótica familiar relacionada à transtirretina (PAF-TTR), no Brasil. Métodos: Estudo transversal, por meio de questionário semiestruturado on-line enviado por e-mail. Foram incluídos médicos com experiência no manejo clínico-assistencial de pacientes com PAF-TTR no Brasil. O questionário foi composto por 30 questões envolvendo características gerais da população brasileira com PAF-TTR, características das escolhas terapêuticas e da falha, definições de progressão de doença e estadiamento, e métodos para mensuração do impacto na qualidade de vida. Resultados: Seis profissionais responderam ao inquérito. Quanto ao diagnóstico e à classificação da doença, houve consenso quanto ao uso de quadro clínico associado a testagem genética para o diagnóstico, e foram considerados adequados os critérios de Coutinho e do Ministério da Saúde, apesar de serem pouco úteis na avaliação da progressão da doença. Entre os especialistas, 83,3% entendem que a terapia atualmente disponível no Sistema Único de Saúde (SUS) atende às necessidades dos pacientes no estágio I da doença, entretanto todos os especialistas apontam necessidades assistenciais não atendidas, uma vez que esse medicamento não possui benefício definido para os estágios II e III da doença. A progressão da doença é definida como qualquer novo sintoma ou piora daqueles preexistentes, não sendo necessária modificação no estágio da doença para caracterizar tal evento. Conclusões: A condução deste estudo permitiu a identificação de aspectos importantes para auxiliar no entendimento da prática clínico-assistencial no país e das necessidades em saúde desses pacientes

Objective: To identify therapeutic approaches and variability in clinical practice, as well as unmet needs and barriers to adequate care for patients with familial transthyretin-related amyloidotic polyneuropathy (FAP) in Brazil. Methods: Cross-sectional study using an online semi-structured questionnaire sent by email. Physicians with experience in the clinical-care management of patients with FAP in Brazil were included. The questionnaire consisted of 30 questions involving general characteristics of the Brazilian population with FAP; characteristics of therapeutic choices and failure; definitions of disease progression and staging; and methods for measuring the impact on quality of life. Results: Six professionals responded to the survey. As for the diagnosis and classification of the disease, there was a consensus regarding the use of a clinical picture associated with genetic testing for the diagnosis and, as appropriate, the criteria proposed by Coutinho and the Ministry of Health, although not very useful in evaluating the progression of the disease. 83.3% of experts understand that the therapy currently available in the SUS meets the needs of patients in stage I of the disease, however, all experts point out unmet care needs, since this drug has no defined benefit for stages II and III of the disease. Disease progression is defined as any new symptom or worsening of pre-existing ones, and no change in the stage of the disease is necessary to characterize such an event. Conclusions: The conduction of this study allowed to identify important aspects to a better understanding of the clinical care practice in the country and unmet needs of these patients

Phenotypic and genotypic aspects of Townes-Brock syndrome: case report of patient in southern Brazil with a new SALL1 hotspot region nonsense mutation.

BACKGROUND: Townes-Brocks syndrome (TBS) is a rare autosomal dominant condition characterized by renal, anal, limb, and auditory abnormalities. TBS diagnosis can be challenging in settings where genetic analysis is not readily available. TBS traits overlap with those of Goldenhar and VACTERL syndromes. CASE PRESENTATION: Here, we present the case of a 5-year-old Brazilian boy born with an anorectal abnormality, limb and external ears malformations, genitourinary anomalies, and a congenital heart defect. Genetic analysis revealed a SALL1 nonsense mutation. The case is discussed in the context of the current literature. CONCLUSIONS: Because of the variability in TBS clinical presentation, genetic analysis is key to the differential diagnosis of TBS relative to phenotypically similar syndromes.

Epilepsy and electroencephalographic features: comparative study of Down syndrome and non-syndromic mental retardation / Epilepsia e aspectos eletrencefalográficos: estudo comparativo entre síndrome de Down e deficiência mental não sindrômica

INTRODUCTION: Down syndrome (DS) is the most common chromosomal abnormality causing mental retardation and its association with epilepsy is highly variable in childhood. Although the first descriptions of the syndrome did not report seizures, their association with epilepsy is relatively common. METHODS: were evaluated 68 individuals with DS and 83 with non-syndromic mental retardation (N-SMR). All patients underwent digital EEG, lasting at least 30 minutes and electrodes positioned according to the International 10-20 System of Electrode Placement. Data were analyzed using descriptive statistics and proportions were compared with Student's t-test and test of Differences between Proportions with p<0.05 considered statistically significant. RESULTS: DS: 27.9% had epilepsy (first seizure with 2.2±3.7 years). Fifteen (22.1%) patients had epileptiform discharges, 5 (7.4%) hypsarrhythmia, 5 (7.4%) focal pattern, 3 (4.4%) generalized pattern and 2 (2.9%) multifocal pattern. N-SMR: 33.7% patients had epilepsy (first seizure with 1.2±4.5 years). Twenty-three (27.7%) patients had epileptiform discharges, 10 (12.0%) focal pattern, 5 (6.0%) generalized pattern and 8 (9.6%) multifocal pattern. CONCLUSION: The difference between the occurrence of epilepsy in DS and N-SMR was not statistically significant, as well as between normal EEG, EEGs with focal pattern, generalized pattern and multifocal pattern. In SD group 7.4% have shown hypsarrhythmia.The comparison with N-SMR was not possible because none of these has shown this EEG abnormality.

INTRODUÇÃO: síndrome de Down (SD) é a anormalidade cromossômica que mais comumente causa deficiência mental e sua associação com epilepsia é muito variável na infância. Embora as descrições iniciais da síndrome não relatassem crises, sua associação com epilepsia é relativamente comum. MÉTODOS: foram avaliados 68 indivíduos com SD e 83 com retardo mental não sindrômico (RMNS). Todos os pacientes foram submetidos à EEG digital, com duração mínima de 30 minutos e com eletrodos posicionados segundo o sistema internacional 10-20 de posicionamento de eletrodos. Dados foram analisados usando estatística descritiva e proporções foram comparadas com o teste t de Student e teste de Diferença entre Proporções com p<0,05 sendo considerado estatisticamente significativo. RESULTADOS: SD: 27,9% tinham epilepsia (primeira crise 2,2±3,7 anos). Quinze (22,1%) pacientes tinham descargas, 5 (7,4%) hipsarritmia, 5 (7,4%) padrão focal, 3 (4,4%) padrão generalizado, 2 (2,9%) padrão multifocal. N-SMR: 33,7% pacientes tinham epilepsia (primeira crise com 1,2±4,5 anos). Vinte e três (27,7%) pacientes tinham descargas, 10 (12,0%) padrão focal, 5 (6,0%) padrão generalizado e 8 (9,6%) padrão multifocal. CONCLUSÕES: a diferença entre a ocorrência de epilepsia no grupo SD e RMNS não foi estatisticamente significativa, assim como o EEG normal, com padrão focal, generalizado e multifocal. No grupo SD, 7,4% apresentaram hipsarritmia. A comparação com o grupo RMNS não foi possível por que ninguém neste grupo apresentou esta anormalidade no EEG.

Endoscopic transnasal approach for treatment of the medial orbital blowout fracture using nasal septum graft.

We present the experience of the Ear, Nose, and Throat Department of Santa Casa de Misericórdia de Curitiba and Hospital Universitário Cajuru PUC-PR in the transnasal endoscopic approach to medial orbital blowout fractures using nasal septum grafts. Seventeen patients have undergone endoscopic repair since June 2005, and septum grafts were used to maintain the orbital contents in position. All 17 patients were treated with this method. Two patients had diplopia on immediate postoperative evaluation. This symptom was corrected with orthoptic exercises in one patient, and the other had a little residual diplopia. Postoperative computed tomography scans showed anatomic reduction in 14 of 17 cases. There were no complications in these surgeries. The transnasal endoscopic approach is a reasonable method for the treatment of medial orbital blowout fractures. Use of septum graft is another surgical alternative for this technique.