an academic moment . . .
 

The thoracic diaphragm is formed of two muscles, whose innervations derive from the cervical spine areas 3 4 5 ('C3 4 5, keep the diaphragm alive'); the port (left) side lung shares some of its space with the heart and is therefore smaller than the starboard (right) side lung. The ALS regression need not be symmetrical and, as many patients know, one side may be affected before the other. Such is possible for the thoracic diaphragm, as was shown in one case during Dr. Onders's presentation in Greece last year. Since the starboard side lung is larger, one might be better off were any affects to occur at all, they would occur on the port lung side initially.

You've most likely dropped a bottle or can of soda at some point of time and discovered opening same soon after may result in foamy liquid bursting out of the container. I wonder if patting an ALS patient on the back might have a similar effect. If you have picked up a baby because it was crying and placed the baby over your shoulder, the baby soon stops crying possibly because of the carbon dioxide build-up. . . .

The usual practice in evaluating cases for inclusion in statistical calculations is to exclude cases where the patient did not provide all the data needed and with such practice in mind, the number of cases exceeding five years reached 45 percent. I thought I should add, there are 145 cases found so far where the patient had limb onset ALS; of these 61 exceeded five years, with more on the way: hence, the five year survival point for limb onset ALS patients using the pacer currently exceeds 40%, whereas 20% is indicated as the norm. Plausibly, well timed pacer utilization may double patient life expectancy. Possibly more important issue is the dEMG data from the pacer, . . . , Lechtzin observed a chart providing about five data points per patient regarding their respiratory health - the Onders's paper shows one method were thousands of data points could be obtained in one minute, possibly showing in real time the impact of the ALS disease processes on the diaphragm muscle . . . such may be better than a biomarker, so, so long as a patient has good health in their diaphragm they ought to be valuable subjects in clinical studies if they undergo the implant and avail the dEMG data to the researchers. Yet it remains the case clinical studies do not wish to accommodate the pacer . . . more thoughts on same later.

Although the fact remains I have no print copy of the DiPALS report, I continue to be developing or computing the analytical range of outcomes evidencing efficacy. Not an easy calculation but I think I almost have useful results and hope to post them this week.

French Study . . . Confirms: NeuRx DPS® Should Be Used With NIV In Later Stage . . .
 

French Study Of NeuRx® Diaphragm Pacing System (DPS) In Off-Label ALS Patients Confirms: NeuRx DPS® Should Be Used With NIV In Later Stage Of Disease

http://www.prnewswire.com/news-relea...#continue-jump

In reflecting upon media reports on medical research, I keep wondering whether those offering their opinions ought to include their academic background and areas of expertise: especially when they are not known for commenting on medical research. I suggest readers keep in mind each particular author's relevant qualifications; where an author does not disclose them and is unknown to the subject area, their opinion may have validity issues. We live in a country known for freedoms of speech and press . . . differences in the opinion of ordinary persons and experts exist in many areas, such as where issues are complex or remote and therefore poorly understood. Journalists want to make headlines . . . .

Diaphragmatic pacing in amyotrophic lateral sclerosis (review of French study)
 

Diaphragmatic pacing in amyotrophic lateral sclerosis
by Richard A. Lewis of Cedars Sinai, Los Angeles, California

http://www.thelancet.com/pdfs/journa...16)30259-9.pdf

Diaphragm pacing in patients with amyotrophic lateral sclerosis (re: DiPALS study)
 

Diaphragm pacing in patients with amyotrophic lateral sclerosis
by Robert G. Miller and Richard A. Lewis of Cedars Sinai, Los Angeles, California

http://www.thelancet.com/journals/la...012-6/fulltext

(comment on the DiPALS study report)

Early diaphragm pacing in patients with amyotrophic lateral sclerosis (RespiStimALS):
 

Early diaphragm pacing in patients with amyotrophic lateral sclerosis (RespiStimALS): a randomised controlled triple-blind trial

http://www.thelancet.com/pdfs/journa...16)30233-2.pdf

(RespiTrimALS report from France)

A quick note; I briefly accessed copy of the aforesaid reports but have not thoroughly read them. Apparently, ages for the french study matched ages for the DiPALS study; a web based randomization program is mentioned but not identified . . . median survival of treatment group was 51 months, comparing to 28 months in the DiPALS study? Since the treatment groups appear to be older and extensive literature regards age as worse adverse factor in prognosis.

In reflecting on the '. . . statistically significant . . .' expression used in both the DiPALS and the RespiStimALS study, I have doubts as to whether sufficient patients were involved in these studies for the determination to be valid due to the high variance of regression rates in patients. The report of the DiPALS study group implies the patients were of middle to fast regression rates - one third suffered from bulbar onset. The report of the RespiStimALS group implies the patients were of middle to slow regression rates, with less than the expected quantity of bulbar onset cases. The RespiStimALS also reports theirs was a multicenter study but is unclear on how many surgical teams were involved . . . only one, or one for each cite . . ? The RespiStimALS group also use a web based service to decide what group to enter each patient into.

Should trial sizes be in the neighborhood of 500?
 

Dr. Perrin mentioned at the recent ALS-TDI conference some approximately 500 patients ought to be involved in a trial in the case of ALS - in order for its results to be reliable. The comment was not a response to the pacer treatment, which was not brought up by anyone during the day.

. . . Fifty-one bytes times a few quadrillion 'lines' long . . . :

If each synapse contains about 100 vesicles . . . to simply label each vesicle would require a few fifty-thousand dollars times 100 or likely a few millions of dollars of hard drives . . .

thankfully, they are not very fast (synapses) . . . but present science wants to know what each vesicle is doing, thus storage sufficient to merely identify one is insufficient to represent what the vesicle is doing. . . ?

We are clearly over 70 patients who have exceeded the upper level life expectancy threshold, whereas 36 (20%) or so would be expected in a set of nearly 180 patients. More cases will develop as many of the patients could not reach the threshold yet but are clearly on their way. The lead research teams journal papers indicated the slope of the Forced Vital Capacity curve decreased by about fifty-percent, implying life expectancy might double under the treatment. This 'result' is very consistent with the inference - twenty-six patients already were over the maximum expectancy and at least forty-four have crossed over. Several others are close to doing so. This dataset clearly will appear efficacious upon completion.

Fast regression ALS patients may have caused anomalous ". . . statistically significant excess mortality . . ." in both DiPALS and RespiStimALS studies. In the set of case I have derived from internet disclosures by patients themselves or their care providers, the number of fast regression limb onset ALS patients is about the same as the number of ordinary bulbar onset ALS patients. Though they are limb onset patients, the fast regression types are often out-lived by the ordinary bulbar onset types. Thus the early 'fall-out' of patients includes the fast regression types as well as bulbar onset types and appears therefore larger than expected but such losses are not abnormal. In my study of about 176 cases there are about as many fast regression limb onset cases as there are ordinary onset bulbar cases in the 'early fallout.' An ordinary sample of ALS patients likely reflects five to ten percent fast regression limb onset cases. They are present in about the same number as ordinary bulbar onset patients but are significantly fewer than the overall number of bulbar onset patients, who sometimes manage to live more than ten years.

. . . partial
 

These lengthy remarks are partially complete . . . :

Improvement of the biological characterization of the β-phram muscles affected by the Amyotrophic Lateral Sclerosis syndrome became practical due to the deployment of the pacer as a prospective treatment. Although large, there are only two β-phram muscles, whereas there are some 700 other muscles in the body human. Located and forming the base of the thorax the β-phram muscles are difficult to reach because they are entirely interior to the body. There may be several million neuro-muscular synapses in the β-phragm muscles and as many as several billion involved synapses in the anterior horns and upper motor neuron regions of the motor cortex. Breathing is autonomous, but subject to the free will of the human, with their will modifiable by circumstances influencing emotion, activity or sleep, yet tending to remain involuntary. Thus, the pulmonary nervous system likely has extensive interfacing in the brain.

Internet media reported the DiPALS Writing Group challenges the FDA HUD/HDE approval on grounds of efficacy but because the approval does not include an efficacy claim - the approval's purpose is to further research into the question of whether the treatment has efficacy since the Onders's group found some evidence of efficacy developed in patients after they were implanted - DiPALS was concerned about the estimated number of candidates needed to fill the study. The approval contends the surgical process is reasonable to regard as safe, admits the resultant data inferentially evidences efficacy, and lends plausibility to the claim about 70% of the patients may benefit from the treatment. The evidence shows implantation must be timely, however. Too late, the β-phram muscles will not respond to stimulation, too early, the stimulators may not be optimally placed, diminishing their research and therapeutic value. Although not overty stated, the most substantial issue in the DiPALS Writing Group's report for challenging the FDA HUD/HDE approval is their difficulty in finding 108 admissible candidates within the 759 applicants. The FDA disclosure implies circa 531 candidates might be found among them but only fifty-one candidates remained in screening when the study's halt occurred - thirty-four more were needed. The applicants of the DiPALS study neared 90% chance of losing candidacy before undergoing implantation; losses nearer 30% would be expected based on the FDA estimate. The manufacturer's recent web site update implies circa 300 such candidates ought to exist in an applicant pool of 759 patients where one might infer fallout might reach about 60% of the applicants and therefore the study ought to achieve its needed 108 cases. But the study reached a point were 67% of the remaining candidates were needed - the reality of the situation and the manufacturer's estimates 'agreed:' the study could not reach the required number of cases. The FDA estimate was not even close throughout the entire DiPALS trial; so why was the yield so low the study itself was in jeopardy? This vital question remains unexplored.

The best evidence I discovered before 2017 implies the treatment's leading edge of worth depends on the moment the surgical opportunity window opens and the trailing edge depends on when the β-phram muscles no longer respond to stimulation. Within the range, the treatment is thought to have value; outside the range, however, the treatment is thought to have little or no value. Even though qualified for the implant, a patient's β-phram muscles may be anywhere from completely unresponsive to 100% because their strength can only be finally determined during surgery at this time. The value of the treatment to a patient within the range decreases over time due to the neural regression observed in the syndrome. The rate each patient's regression develops may not be constant throughout the course of disease but most literature regards the rate as constant. The best administration of the treatment is believed to occur when implantation is made some time after the β-phram muscles become involved but before they become unresponsive to stimulation. I know of no journal paper presenting any surgeon's estimate of the percentage of involvement of each β-phram muscle measured during surgical implant, when the 'exterior' surface is 'fully' exposed for the surgical examination. The process of searching for the motor points of the β-phram muscles may require as many as one hundred stimulations to find the location and responsiveness of the neuromuscular junctions. A web video, apparently of Onders, presents medical imaging of one patient at a conference where the patient's starboard β-phram muscle was responsive but their port β-phram muscle apparently not. Onders indicated the patient was successfully implanted even though the patient's β-phram muscles were not bilaterally responsive. The motor point survey gives the greatest currently known insight into the health of the β-phram muscles but can only be done during surgery. There is no second chance, at a later time, to survey the motor points again, so the data from this study does not produce a sense of the regression's rate; the data shows the β-phram muscles' health at one 'freeze-frame' moment only. The doctors will know whether one of the muscles is in better shape than the other, as probably is the case because patients often report paralysis initiating on one side, but they will not know the rate the disease is causing the muscles to regress. In principle they could do the surgery again at a later time but practical issues may be prohibitive as ALS patients are thought to be poor candidates for surgery. An alternative does become possible however because, once implanted, each patient's β-phram muscles can undergo continuous electromyogram recordings. These recordings may be useful in finding the rate, if there is one. These recordings could show the disease processes 'live' and provide strong evidence on the question of the treatment's efficacy. With such live data, researchers may finally be able to interpolate the cause or, if there are multiple, the causes, of the ALS syndrome.

Irrespective of the work of others, the DiPALS Writing Group is obliged by the rules of science to base their report on the data they found in their study rather than data derived or observed in other studies. The DiPALS Writing Group did not corroberate or refute the observations of the lead research team on efficacy but their own data illuminated only ". . . low efficacy . . ." thereby raising the question of whether their trial's weighing of the treatment's benefit (median 28 months, n=37) cast doubt on the worth of the treatment in light of the risk factors associated with surgery. Of bulbar onset patients, in a large study, Forbes found the life expectancy median at 20 months (n=284?, 2004); in a small study, Turner found the median at 27 months (n=49, 2010). Riluzole was likely unavailable for the Forbes's patients but might have been for Turner's. The DiPALS median at 28 months (n<38, 2015) is only one month improvement over Turner or eight month improvement over Forbes but is much shorter than was expected for the study (the Onders study found +16 months AVERAGE of all the patients (rather than median) improvement in survival). Bulbar onset was not required of the DiPALS applicants, however. Yet one third of the DiPALS subjects who underwent implantation were bulbar onset. One can reasonably expect the AVERAGE to appear better than median in ALS but median was not in the original report - the median for the study (n=86, 2008) is likely higher than the Forbes, Turner and DiPALS medians though. I was going to challenge the DiPALS group on scientific grounds on some points but realized Lancet Neurology does not require its journal papers to be strictly based on science, so the points were moot - and made reading their paper more difficult.

*more soon*

Predictable?
 

Much is written regarding the unpredictability of the effect of ALS on any given individual: Prognosis. Some time ago, Prize4Life launched the prediction challenge and drew the attention of many teams of scholars in competition to develop algorithms to predict life expectancy and last year several teams were awarded prizes:

Completion announcement
Prize4Life, Sage Bionetworks and DREAM Announce Winners of ALS Stratification Challenge | Business Wire

Scores
Sage Synapse : Contribute to the Cure

The PRO-ACT database was deployed to provide data for the algorithms to evaluate:

PRO-ACT - HOME

While some impressive results developed, no one considers the regression caused by the ALS syndrome to be predictable.

*continued*

While the percentage of patients expected to exceed five years is about 20%, I discovered no written reports on the percentage of bulbar onset patients expected to exceed three years but presume their threshold is 20% too. Although fast regression cases of ALS are well known, no reference to their expected percentage of the whole is evident in any of the papers I read. The data I collected suggests the expected number of fast regression cases may be estimated as five to ten percent. Due to their shorter life expectancy, fast regression ALS patients are significantly less likely to make the radar of research studies. The DiPALS study had a disproportionate number of bulbar onset patients in the treatment group; did they also have a disproportionate number of fast regression patients? Further, many patients opted out of the DiPALS study before implantation could achieve meaningful success; the number of bulbar onset patients may have reached one-third of the those successfully implanted. Onders reported about 30% of the pacing patients eventually opted to turn off the pacer in order to be allowed to die.

Since none of the DiPALS treatment group patients survived more than five years, did the slow regressors opt out after selection? In the various disclosures from the web there are many implanted patients who survived more than seven years from implant - the question remains open whether there are ALS patients who qualify for the implant but for whom the treatment would not benefit - possibly because several diseases may cause ALS and one of the diseases could be made worse by the treatment. To the best of my knowledge and belief, the case remains there are no biomarkers to form a basis for a diagnosis . . . the cause or causes of ALS remain unknown. One ought not ignore the question of whether a patient might have lived longer if they did not undergo the implant? The DiPALS group does not specify particular patients or illuminate whether their vulnerability, if any, could be detected earlier. At present, no clear answer appears to exist . . . there are very few papers addressing expectations of patients over five years post-symptom onset; indeed, are there any?

*more soon*

great news, Deborah Ross Hawks has alerted us to their continued existence and advised their 'absence' is the product of losing their ability to use their arms to control the computer . . . hopefully alternatives will be found; one can use their feet with certain foot controls. There are also eye gaze systems many patients use.

Deborah and Devorah Schochet are the most recent pacing ALS patients to reach beyond the maximum upper bound for ALS survival.

I continue to be working on this report. I have encountered quite a few unexpected disruptions, most recently a big snowstorm . . . we have several snowstorms forecast, about one every other day for about a week to ten days!

. . . aaaarghhhhh . . . :
 

And now I have to retype my report as draft edition deleted mysteriously and early versions apparently not available except for ones several weeks old!:eek:

was unexpectedly away for a few weeks with no opportunity to computer . . . hopefully, I will have the back log current by next Monday.

I feel I am nearing completion; longer than I thought . . . 16 pages plus? Y?

I had no idea it would take this long, ten pages practically done, only small edits remain; ten more pages nearly readable, maybe tomorrow more likely early next week. Sorry!

Prognostic factors in ALS: A critical review

Prognostic factors in ALS: A critical review

is the source for the ALS Datasets data in post dated 01-04-2017 04:27 PM

at last I feel like I can see the light at the end of the tunnel. If I don't have the report competed in a couple of days I can at least present the first ten to twenty pages.

'new' publication . . . "Health Technology Assessment, No. 20.45."
 

I have briefed only:

Chapter 5
Qualitative substudy

(its great, at least because it contains comments one might expect to find in 'social media,' though none were found there during their trial).

of:

Qualitative substudy - DiPALS: Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis – a randomised controlled trial - NCBI Bookshelf

Apparently published by DiPALS or some of their members . . . :

and apparently a public document (full scale book)

Publication date is June, 2016, several months ago.

PrototypeReportA
 

After reviewing this evening, the first half of the report needed very few edits, the second half, while readable needs quite a bit of work. Some thirty pages, not counting references . . . so I avail as prototype and welcome any comment or suggestions. It will likely become 20% to 30% longer.

PrototypeReportA

improved but incomplete report . . . :
 

new interim report . . . development continues but not yet adequate . . . :

Pacer vJul 5, 2017

three research reports from western Turkey clinical trials, re: pacer
 

Results Of Diaphragm Pacing Application in Amyotrophic Lateral Sclerosis Patients. First Turkish Experience (July 2013)
(PDF) Results Of Diaphragm Pacing Application in Amyotrophic Lateral Sclerosis Patients. First Turkish Experience

Importance of diaphragm thickness in amyotrophic lateral sclerosis patients with diaphragm pacing system implantation (January 2016)
Importance of diaphragm thickness in amyotrophic lateral sclerosis patients with diaphragm pacing system implantation | SpringerLink

Preoperative parameters and their prognostic value in amyotrophic lateral sclerosis patients undergoing implantation of a diaphragm pacing stimulation system. (January 2017)
Preoperative parameters and their prognostic value in amyotrophic lateral sclerosis patients undergoing implantation of a diaphragm pacing stimulat... - PubMed - NCBI

the first reports one ALS patient weaned from trach after pacer implantation, the second and third address the diaphragm thickness issue, otherwise only reported by Onders at this moment.