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Yildirim M, Reich C, Salbach C, Pribe-Wolferts R, Milles BR, Täger T, Mueller-Hennessen M, Weiler M, Meder B, Frey N, Giannitsis E. Interpretation of elevated baseline concentrations and serial changes of high-sensitivity cardiac troponin T in confirmed muscular dystrophies. ESC Heart Fail 2024. [PMID: 38992971 DOI: 10.1002/ehf2.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/18/2024] [Accepted: 05/03/2024] [Indexed: 07/13/2024] Open
Abstract
AIMS Concentrations of high-sensitivity cardiac troponin T (hs-cTnT) are frequently elevated in stable patients with confirmed muscle dystrophies. However, sparse information is available on the interpretation of serial concentration changes. METHODS Hs-cTnT was collected in 35 stable outpatients with confirmed skeletal muscle dystrophies at 0 and 1 h and after 6-12 months during scheduled outpatient visits. We simulated the effectiveness of the European Society of Cardiology (ESC) 0/1 h algorithm and assessed biological variation at 6-12 months using two established methods: reference change value (RCV) and minimal important difference (MID). RESULTS Median baseline hs-cTnT concentrations were 34.4 ng/L [inter-quartile range (IQR): 17.5-46.2], and values > 99th percentile upper limit of normal were present in 34 of 35 patients. All patients were stable without cardiovascular adverse events during a follow-up of 6.6 months (IQR: 6-7). Median concentration change was 1.9 ng/L (IQR: 0.7-3.2) and 0.8 ng/L (IQR: 0-7.0) at 60 min and 6-9 months, respectively. Applying the criteria of the ESC 0/1 h algorithm for triage of suspected acute coronary syndrome (ACS) showed poor overall effectiveness of baseline hs-cTnT values. No patient would qualify for rule-out based on hs-cTnT less than the limit of detection, whereas five cases would qualify for rule-in based on hs-cTnT ≥ 52 ng/L. Biological variabilities at 6-12 months per MID and RCV were 1.2 ng/L [95% confidence interval (CI): 0.7-2.1] and 28.6% (95% CI: 27.9-29.6), respectively. A total of 8 (22.9%) and 25 (71.4%) cases exceeded the biological variation range, suggesting some additional myocardial damage. CONCLUSIONS The high prevalence of elevated hs-cTnT could negatively impact the effectiveness of rule-out and rule-in strategies based on a single hs-cTnT value. Knowledge of the physiological and biological variation of hs-cTnT after 6-12 months is helpful to detect the progression of cardiac involvement or to search for cardiac complications including but not limited to arrhythmias that may trigger acute or chronic myocardial damage.
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Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Christoph Reich
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- Institute for Cardiomyopathies & Center for Cardiogenetics, Department of Medicine III, Heidelberg University, Heidelberg, Germany
| | - Christian Salbach
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Regina Pribe-Wolferts
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Tobias Täger
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Markus Weiler
- Department of Neurology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Benjamin Meder
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Heidelberg, Germany
- Institute for Cardiomyopathies & Center for Cardiogenetics, Department of Medicine III, Heidelberg University, Heidelberg, Germany
- Stanford Genome Technology Center, Stanford University School of Medicine, Palo Alto, California, USA
| | - Norbert Frey
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
- German Centre for Cardiovascular Research (DZHK), Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
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McDonald C, Camino E, Escandon R, Finkel RS, Fischer R, Flanigan K, Furlong P, Juhasz R, Martin AS, Villa C, Sweeney HL. Draft Guidance for Industry Duchenne Muscular Dystrophy, Becker Muscular Dystrophy, and Related Dystrophinopathies - Developing Potential Treatments for the Entire Spectrum of Disease. J Neuromuscul Dis 2024; 11:499-523. [PMID: 38363616 DOI: 10.3233/jnd-230219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background Duchenne muscular dystrophy (DMD) and related dystrophinopathies are neuromuscular conditions with great unmet medical needs that require the development of effective medical treatments. Objective To aid sponsors in clinical development of drugs and therapeutic biological products for treating DMD across the disease spectrum by integrating advancements, patient registries, natural history studies, and more into a comprehensive guidance. Methods This guidance emerged from collaboration between the FDA, the Duchenne community, and industry stakeholders. It entailed a structured approach, involving multiple committees and boards. From its inception in 2014, the guidance underwent revisions incorporating insights from gene therapy studies, cardiac function research, and innovative clinical trial designs. Results The guidance provides a deeper understanding of DMD and its variants, focusing on patient engagement, diagnostic criteria, natural history, biomarkers, and clinical trials. It underscores patient-focused drug development, the significance of dystrophin as a biomarker, and the pivotal role of magnetic resonance imaging in assessing disease progression. Additionally, the guidance addresses cardiomyopathy's prominence in DMD and the burgeoning field of gene therapy. Conclusions The updated guidance offers a comprehensive understanding of DMD, emphasizing patient-centric approaches, innovative trial designs, and the importance of biomarkers. The focus on cardiomyopathy and gene therapy signifies the evolving realm of DMD research. It acts as a crucial roadmap for sponsors, potentially leading to improved treatments for DMD.
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Affiliation(s)
| | - Eric Camino
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Rafael Escandon
- DGBI Consulting, LLC, Bainbridge Island, Washington, DC, USA
| | | | - Ryan Fischer
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Kevin Flanigan
- Center for Experimental Neurotherapeutics, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Pat Furlong
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Rose Juhasz
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Ann S Martin
- Parent Project Muscular Dystrophy, Washington, DC, USA
| | - Chet Villa
- Trinity Health Michigan, Grand Rapids, MI, USA
| | - H Lee Sweeney
- Cincinnati Children's Hospital Medical Center within the UC Department of Pediatrics, Cincinnati, OH, USA
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3
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Birnkrant DJ, Black JB. Real world respiratory profiles and Duchenne muscular dystrophy. Pediatr Pulmonol 2023; 58:3374-3376. [PMID: 37737458 DOI: 10.1002/ppul.26692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 08/03/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Jane B Black
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Lechner A, Herzig JJ, Kientsch JG, Kohler M, Bloch KE, Ulrich S, Schwarz EI. Cardiomyopathy as cause of death in Duchenne muscular dystrophy: a longitudinal observational study. ERJ Open Res 2023; 9:00176-2023. [PMID: 37727676 PMCID: PMC10505954 DOI: 10.1183/23120541.00176-2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/06/2023] [Indexed: 09/21/2023] Open
Abstract
Background Cardiomyopathy has become an important life-limiting factor since survival in Duchenne muscular dystrophy (DMD) has greatly increased with long-term ventilation and cough assistance. The aim of this study was to investigate the association between impaired left ventricular ejection fraction (LVEF) and survival. Methods In a >20-year observational study in patients with DMD (age ≥16 years) with at least three echocardiograms, the association between LVEF and survival and time to cardiac or non-cardiac death was investigated using Kaplan-Meier survival analysis and Cox regression (for LVEF). Results In 67 DMD patients (430 echocardiograms), the decrease in LVEF over a mean±sd follow-up period of 9.1±5.1 years was -10.0±13.9% absolute, but LVEF progression varied widely. 84% were receiving an angiotensin-converting enzyme inhibitor and 54% a β-blocker at last follow-up with an LVEF of 37.5±12.4% at that time-point. Median (interquartile range) survival was 33 (25-40) years. 28 out of 67 (42%) of the cohort had died and LVEF was a significant negative predictor of survival (hazard ratio 0.95 (95% CI 0.91-0.99); p<0.007). Those who died of cardiac death (53% of known causes of death) had significantly lower LVEF at the time of death (LVEF -11.0% (95% CI -21.1- -0.9%); p=0.035) compared with non-cardiac death and tended to die at a younger age. Conclusions Cardiomyopathy with systolic heart failure is the leading cause of death and lower LVEF is an independent predictor of mortality at younger ages in patients with DMD. Patients with DMD appear to be undertreated with respect to heart failure drug therapy.
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Affiliation(s)
- Annabel Lechner
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Joël J. Herzig
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Jacqueline G. Kientsch
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
- Competence Centre Sleep and Health, University of Zurich (UZH), Zurich, Switzerland
| | - Konrad E. Bloch
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
- Competence Centre Sleep and Health, University of Zurich (UZH), Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
| | - Esther I. Schwarz
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich (USZ), Zurich, Switzerland
- Competence Centre Sleep and Health, University of Zurich (UZH), Zurich, Switzerland
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Shah MNA, Yokota T. Cardiac therapies for Duchenne muscular dystrophy. Ther Adv Neurol Disord 2023; 16:17562864231182934. [PMID: 37425427 PMCID: PMC10328182 DOI: 10.1177/17562864231182934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is a devastating disease that results in life-limiting complications such as loss of skeletal muscle function as well as respiratory and cardiac complications. Advanced therapeutics in pulmonary care have significantly reduced respiratory complication-related mortality, making cardiomyopathy the main determinant factor of survival. While there are multiple therapies such as the use of anti-inflammatory drugs, physical therapy, and ventilatory assistance targeted toward delaying the disease progression in DMD, a cure remains elusive. In the last decade, several therapeutic approaches have been developed to improve patient survival. These include small molecule-based therapy, micro-dystrophin gene delivery, CRISPR-mediated gene editing, nonsense readthrough, exon skipping, and cardiosphere-derived cell therapy. Associated with the specific benefits of each of these approaches are their individual risks and limitations. The variability in the genetic aberrations leading to DMD also limits the widespread use of these therapies. While numerous approaches have been explored to treat DMD pathophysiology, only a handful have successfully advanced through the preclinical stages. In this review, we summarize the currently approved as well as the most promising therapeutics undergoing clinical trials aimed toward treating DMD with a focus on its cardiac manifestations.
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Affiliation(s)
- Md Nur Ahad Shah
- Department of Medical Genetics, University of Alberta, Edmonton, AB, Canada
| | - Toshifumi Yokota
- Department of Medical Genetics, University of Alberta, Edmonton, AB T6G 2H7, Canada
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Lupu M, Ioghen M, Perjoc RȘ, Scarlat AM, Vladâcenco OA, Roza E, Epure DAM, Teleanu RI, Severin EM. The Importance of Implementing a Transition Strategy for Patients with Muscular Dystrophy: From Child to Adult-Insights from a Tertiary Centre for Rare Neurological Diseases. CHILDREN (BASEL, SWITZERLAND) 2023; 10:959. [PMID: 37371191 DOI: 10.3390/children10060959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Progress in the field of muscular dystrophy (MD) using a multidisciplinary approach based on international standards of care has led to a significant increase in the life expectancy of patients. The challenge of transitioning from pediatric to adult healthcare has been acknowledged for over a decade, yet it continues to be a last-minute concern. Currently, there is no established consensus on how to evaluate the effectiveness of the transition process. Our study aimed to identify how well patients are prepared for the transition and to determine their needs. We conducted a descriptive, cross-sectional study on 15 patients aged 14 to 21 years. The patients completed a sociodemographic and a Transition Readiness Assessment Questionnaire (TRAQ). We also analyzed the comorbidities of these patients. Our study revealed that only 46.7% of the patients had engaged in a conversation with a medical professional, namely, a child neurologist, about transitioning. A total of 60% of the participants expressed having confidence in their self-care ability. However, the median TRAQ score of 3.6 shows that these patients overestimate themselves. We emphasize the necessity for a slow, personalized transition led by a multidisciplinary team to ensure the continuity of state-of-the-art care from pediatric to adult healthcare services and the achievement of the highest possible quality of life for these patients.
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Affiliation(s)
- Maria Lupu
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Mihaela Ioghen
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Radu-Ștefan Perjoc
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andra-Maria Scarlat
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Oana Aurelia Vladâcenco
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Eugenia Roza
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Diana Ana-Maria Epure
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Raluca Ioana Teleanu
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Paediatric Neurology, Dr Victor Gomoiu Children's Hospital, 022102 Bucharest, Romania
| | - Emilia Maria Severin
- Clinical Neurosciences Department, Peadiatric Neurology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Kennedy TL, Dugdale HF. Cardiac and Skeletal Muscle Pathology in the D2/mdx Mouse Model and Caveats Associated with the Quantification of Utrophin. Methods Mol Biol 2023; 2587:55-66. [PMID: 36401024 DOI: 10.1007/978-1-0716-2772-3_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) (the most common form of muscular dystrophy) is caused by a lack of dystrophin protein. Currently, although many therapeutic strategies are under investigation, there is no cure for DMD and unfortunately, patients succumb to respiratory and/or cardiac failure in their second or third decade of life. Preclinical work has focused on the mouse model C57BL/10ScSn-Dmdmdx/J (BL10/mdx), which does not exhibit a robust pathophenotype. More recently, the D2.B10-Dmdmdx/J (D2/mdx) mouse has been utilized, which presents a more severe pathology and therefore more closely mimics the human pathophenotype, particularly in the heart. Here, we outline important considerations when utilizing the D2/mdx model by highlighting the differences between these models in addition to describing histological and immunohistochemical methods utilized in Kennedy et al. (Mol Ther Methods Clin Dev 11:92-105, 2018) for both cardiac and skeletal muscle, which can quantify these differences. These considerations are particularly important when investigating treatment strategies that may be affected by regeneration; such is the case for upregulation of the dystrophin paralogue, utrophin.
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Affiliation(s)
- Tahnee L Kennedy
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Hannah F Dugdale
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, Guy's Campus, King's College London, London, UK.
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.
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8
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Weber C, Schallner J, Von Der Hagen M. Handgrip and finger flexion strength in children: A cross-sectional assessment of age-related normative data and application as a clinical functional marker in paediatric neuromuscular disorders. Brain Dev 2023; 45:26-38. [PMID: 36195477 DOI: 10.1016/j.braindev.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to evaluate handgrip and finger flexion strength (HGFS) as functional marker for disease progression in children with neuromuscular disorders (NMD) and present normative data in a paediatric healthy cohort. METHODS We applied the fixed hand and finger dynamometer HFD 200 to assess HGFS under standardised, isometric and biomechanical conditions. In our cross-sectional study HGFS was analysed in n = 233 paediatric healthy controls (HC) and a cohort of n = 33 children with NMD between five and 18 years. In seven children with spinal muscular atrophy (SMA), HGFS were assessed prior to and under treatment with nusinersen over a two months period. HGFS of children with NMD was correlated with respiratory parameters, anthropometric data, hand function and motor scores. RESULTS Patients with NMD exhibited a heterogenous HGFS pattern. HGFS was lower than in HC (p < 0.001). Children with SMA gained a significant increase in strength after two months of treatment (p < 0.05, r = 0.75-0.9). CONCLUSION HGFS is a sensitive functional marker in paediatric NMD to identify minimal changes in distal muscle strength. HGFS may evolve as a sensitive outcome measure to monitor upcoming therapeutic interventions in particular for non-ambulant patients with NMD.
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Affiliation(s)
- C Weber
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - J Schallner
- Abteilung für Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - M Von Der Hagen
- Abteilung für Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
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9
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Zambon AA, Trucco F, Laverty A, Riley M, Ridout D, Manzur AY, Abel F, Muntoni F. Respiratory Function and Sleep Disordered Breathing in Pediatric Duchenne Muscular Dystrophy. Neurology 2022; 99:e1216-e1226. [PMID: 35953292 DOI: 10.1212/wnl.0000000000200932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The decline of respiratory function in Duchenne muscular dystrophy (DMD) is associated with sleep disordered breathing (SDB) and alteration of nocturnal gas exchange, first manifesting as nocturnal hypoventilation (NH). However, the correlation between pulmonary function measured by spirometry (PFT) and the onset of SDB with or without NH is unclear. AIM To identify the prevalence and features of SDB and to investigate the relationship between lung function determined by forced vital capacity (FVC) and sleep abnormalities in a large paediatric DMD population. METHODS Retrospective, single-center cohort study. FVC% predicted (FVC%) was calculated using predicted equations from the Global Lung Function Initiative. NH was defined by transcutaneous (tc) CO2 >50 mmHg for >25% of total sleep time (TST); borderline NH by a mean tcCO2 between 45-50mmHg or tcCO2>50mmHg for ≤25% of TST; Clinically meaningful obstructive sleep apnea (OSA) by obstructive Apnea-Hypopnea Index >5. The sensitivity, specificity, positive and negative predictive value of FVC<50% to indicate presence of nocturnal hypoventilation were calculated. RESULTS 134 patients underwent 284 sleep studies and 1222 PFT. Mean (SD) age at first and last sleep study was 12.9 (2.7) and 14.3 (2.6) years. Borderline NH (n=31) was detected in both ambulant and early-non ambulant subjects, while 100% of NH cases (n=14) were non-ambulant. NH was detected in 4/14 patients despite an FVC>50%. Seventeen/26 patients with OSA presented with concomitant NH or borderline NH. FVC<50% was associated with NH indicating a sensitivity and specificity of 73% and 86%, respectively. Positive and negative predictive value were 32% and 97% respectively. PFT showed a non-linear, sudden FVC% decline in 18% of cases. CONCLUSIONS FVC% <50 was associated with NH in close to a third of patients. CO2 elevation can be associated with obstructive/pseudo-obstructive events and was also observed in early non-ambulant cases or in the presence of FVC>50%. These results are relevant for the clinical management of SDB.
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Affiliation(s)
- Alberto A Zambon
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital, London, UK.,Neuromuscular Repair Unit, Institute of Experimental Neurology (InSpe), Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federica Trucco
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital, London, UK.,Children's Sleep Medicine, Evelina Children Hospital - Paediatric Respiratory Department Royal Brompton Hospital, Guy's and St Thomas' Trust, London, UK
| | - Aidan Laverty
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital & UCL Institute of Child Health, London, UK
| | - Mollie Riley
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital & UCL Institute of Child Health, London, UK
| | - Deborah Ridout
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.,Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Adnan Y Manzur
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Francois Abel
- Children's Sleep Medicine, Evelina Children Hospital - Paediatric Respiratory Department Royal Brompton Hospital, Guy's and St Thomas' Trust, London, UK
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital, London, UK .,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
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10
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Birnkrant DJ, Bello L, Butterfield RJ, Carter JC, Cripe LH, Cripe TP, McKim DA, Nandi D, Pegoraro E. Cardiorespiratory management of Duchenne muscular dystrophy: emerging therapies, neuromuscular genetics, and new clinical challenges. THE LANCET RESPIRATORY MEDICINE 2022; 10:403-420. [DOI: 10.1016/s2213-2600(21)00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 01/06/2023]
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11
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Bourke JP, Watson G, Spinty S, Bryant A, Roper H, Chadwick T, Wood R, McColl E, Bushby K, Muntoni F, Guglieri M. Preventing Cardiomyopathy in DMD: A Randomized Placebo-Controlled Drug Trial. Neurol Clin Pract 2021; 11:e661-e668. [PMID: 34840880 DOI: 10.1212/cpj.0000000000001023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022]
Abstract
Objective To determine whether a combination of 2 heart medications would be tolerated and could prevent/delay the onset of cardiomyopathy in boys with Duchenne muscular dystrophy (DMD) compared with placebo. Methods This multicenter, parallel group, 1:1 patient randomized, placebo-controlled study of prophylactic perindopril and bisoprolol recruited boys with DMD aged 5-13 years, with normal ventricular function. Repeat assessments of left ventricular (LV) function, electrocardiogram, and adverse event reporting were performed 6 monthly. The primary outcome was change in ejection fraction between arms after 36 months. The study was approved by the National Research Ethics Service Committee East Midlands-Derby. Results Eighty-five boys were recruited (76% on steroid therapy) and randomized to combination heart drugs or matched placebo. Group change in left ventricular ejection fraction (LVEF%) at 36 months from baseline was -2.2% ± 6.0% and -2.9% ± 6.1% in active and placebo arms (adjusted mean difference: -2.1, 95% CI -5.2 to 1.1). There was no difference between treatment arms over repeated assessments (analysis of variance) up to 36 months (trial arms p = 0.53); arm-over-time (p = 0.44). Four participants on placebo but none on active therapy were withdrawn due to deteriorations in LV function. Secondary outcomes did not differ between arms either. Thirty-six serious adverse events occurred none due to cardiac events or trial medication. Conclusions Combination therapy was well tolerated. Consistent with the previous prophylactic perindopril heart study, there was no evidence of group benefit after 36-month treatment. Classification of Evidence This study provides Class I evidence that combination perindopril-bisoprolol therapy was well tolerated but did not change decline in LVEF significantly in boys with DMD.
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Affiliation(s)
- John P Bourke
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Gillian Watson
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Stefan Spinty
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Andrew Bryant
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Helen Roper
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Thomas Chadwick
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Ruth Wood
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Elaine McColl
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Kate Bushby
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Francesco Muntoni
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
| | - Michela Guglieri
- Department of Cardiology (JPB), Freeman Hospital, NUTH NHS Hospitals Foundation Trust; Clinical Trials Unit (MC, RW), Newcastle University, Newcastle upon Tyne; Department of Paediatric Neurology (SS), Alder Hey Children's NHS Foundation Trust, Liverpool; Population Health Sciences Institute (AB, TC, EM), Newcastle University, Newcastle upon Tyne; Department of Paediatrics (HR), Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust; John Walton Muscular Dystrophy Research Centre (KB, MG), Newcastle University and Newcastle upon Tyne, NHS Hospitals Foundation Trust, Newcastle upon Tyne; and NIHR Great Ormond Street Hospital Biomedical Research Centre (FM), Great Ormond Street Institute of Child Health, University College London, & Great Ormond Street Hospital Trust, UK
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12
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Wahlgren L, Kroksmark AK, Tulinius M, Sofou K. One in five patients with Duchenne muscular dystrophy dies from other causes than cardiac or respiratory failure. Eur J Epidemiol 2021; 37:147-156. [PMID: 34802091 PMCID: PMC8960570 DOI: 10.1007/s10654-021-00819-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/28/2021] [Indexed: 01/16/2023]
Abstract
Duchenne muscular dystrophy (DMD) is a severe neuromuscular disorder with increasing life expectancy from late teens to over 30 years of age. The aim of this nationwide study was to explore the prevalence, life expectancy and leading causes of death in patients with DMD in Sweden. Patients with DMD were identified through the National Quality Registry for Neuromuscular Diseases in Sweden, the Swedish Registry of Respiratory Failure, pathology laboratories, neurology and respiratory clinics, and the national network for neuromuscular diseases. Age and cause of death were retrieved from the Cause of Death Registry and cross-checked with medical records. 373 DMD patients born 1970–2019 were identified, of whom 129 patients deceased during the study period. Point prevalence of adult patients with DMD on December 31st 2019 was 3.2 per 100,000 adult males. Birth prevalence was 19.2 per 100,000 male births. Median survival was 29.9 years, the leading cause of death being cardiopulmonary in 79.9% of patients. Non-cardiopulmonary causes of death (20.1% of patients) mainly pertained to injury-related pulmonary embolism (1.3 per 1000 person-years), gastrointestinal complications (1.0 per 1000 person-years), stroke (0.6 per 1000 person-years) and unnatural deaths (1.6 per 1000 person-years). Death from non-cardiopulmonary causes occurred at younger ages (mean 21.0 years, SD 8.2; p = 0.004). Age at loss of independent ambulation did not have significant impact on overall survival (p = 0.26). We found that non-cardiopulmonary causes contribute to higher mortality among younger patients with DMD. We present novel epidemiological data on the increasing population of adult patients with DMD.
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Affiliation(s)
- Lisa Wahlgren
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Anna-Karin Kroksmark
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department for Health and Rehabilitation/Physiotherapy, University of Gothenburg, Gothenburg, Sweden
| | - Mar Tulinius
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kalliopi Sofou
- The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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13
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Murphy AP, Johnson A, Straub V, Heads-Baister A, Lord S, Bourke JP. Effects of cardiac medications on ventricular function in patients with Duchenne muscular dystrophy-related cardiomyopathy. Muscle Nerve 2021; 64:163-171. [PMID: 34050938 DOI: 10.1002/mus.27336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION/AIMS The DMD Care Considerations Working Group Guidelines 2010 recommended treating cardiac dystrophinopathy with angiotensin-converting enzyme-inhibitor (ACEi) and beta-blocker (BB) therapy to prevent the progressive decline in left ventricular function expected from earlier, natural history studies. The aim of this research was to audit change in measures of left ventricular function over 8 years to 4 years before and 4 years after deploying an ACEi/BB combination systematically at a dedicated "cardiology-muscle" clinic. METHODS This is an institutionally registered, retrospective, case-file-based audit of serial echocardiographic measures of left ventricular fractional shortening accumulated over the period 1995 to 2015. RESULTS Data from 104 genetically confirmed Duchenne muscular dystrophy (DMD) patients, aged 22.2 ± 5.3 years at data censure, were included. Mean age at first detection of left ventricular dysfunction was 15.1 ± 4.2 years, but older in those on maintenance steroid therapy (16.8 ± 4.2 vs 14.5 ± 4.1 years; P = .04). Group mean fractional shortening fell by 1.5%/year over the 4 years before therapy, but this decreased to 0.9%/year over the first 4 years after starting therapy. Analysis of limited left ventricular ejection fraction measures showed similar but nonsignificant changes. Neither age at detection of left ventricular dysfunction nor fractional shortening percent at time of therapy initiation affected the beneficial response. DISCUSSION The results support the international DMD recommendations of the time. This combination of cardiac medications helps stabilize heart function. For the best long-term effects, therapy needs to be initiated no later than on first detection left ventricular impairment.
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Affiliation(s)
- Alexander P Murphy
- The John Walton Muscular Dystrophy Research Centre, Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Anna Johnson
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Volker Straub
- The John Walton Muscular Dystrophy Research Centre, Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Alison Heads-Baister
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Lord
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John P Bourke
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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14
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Szabo SM, Salhany RM, Deighton A, Harwood M, Mah J, Gooch KL. The clinical course of Duchenne muscular dystrophy in the corticosteroid treatment era: a systematic literature review. Orphanet J Rare Dis 2021; 16:237. [PMID: 34022943 PMCID: PMC8141220 DOI: 10.1186/s13023-021-01862-w] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Duchenne muscular dystrophy (DMD) is a severe rare progressive inherited neuromuscular disorder, leading to loss of ambulation (LOA) and premature mortality. The standard of care for patients with DMD has been treatment with corticosteroids for the past decade; however a synthesis of contemporary data describing the clinical course of DMD is lacking. The objective was to summarize age at key clinical milestones (loss of ambulation, scoliosis, ventilation, cardiomyopathy, and mortality) in the corticosteroid-treatment-era. Methods A systematic review was conducted using MEDLINE and EMBASE. The percentage experiencing key clinical milestones, and the mean or median age at those milestones, was synthesized from studies from North American populations, published between 2007 and 2018. Results From 5637 abstracts, 29 studies were included. Estimates of the percentage experiencing key clinical milestones, and age at those milestones, showed heterogeneity. Up to 30% of patients lost ambulation by age 10 years, and up to 90% by 15 years of age. The mean age at scoliosis onset was approximately 14 years. Ventilatory support began from 15 to 18 years, and up to half of patients required ventilation by 20 years of age. Registry-based estimates suggest that 70% had evidence of cardiomyopathy by 15 years and almost all by 20 years of age. Finally, mortality rates up to 16% by age 20 years were reported; among those surviving to adulthood mortality was up to 60% by age 30 years. Conclusions Contemporary natural history studies from North America report that LOA on average occurs in the early teens, need for ventilation and cardiomyopathy in the late teens, and death in the third or fourth decade of life. Variability in rates may be due to differences in study design, treatment with corticosteroids or other disease-modifying agents, variations in clinical practices, and dystrophin mutations. Despite challenges in synthesizing estimates, these findings help characterize disease progression among contemporary North American DMD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01862-w.
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Affiliation(s)
- Shelagh M Szabo
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada.
| | - Renna M Salhany
- Sarepta Therapeutics, 215 First St, Cambridge, MA, 02142, USA
| | - Alison Deighton
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Meagan Harwood
- Broadstreet HEOR, 201 - 343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Jean Mah
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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15
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Starosta A, Konieczny P. Therapeutic aspects of cell signaling and communication in Duchenne muscular dystrophy. Cell Mol Life Sci 2021; 78:4867-4891. [PMID: 33825942 PMCID: PMC8233280 DOI: 10.1007/s00018-021-03821-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/26/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022]
Abstract
Duchenne muscular dystrophy (DMD) is a devastating chromosome X-linked disease that manifests predominantly in progressive skeletal muscle wasting and dysfunctions in the heart and diaphragm. Approximately 1/5000 boys and 1/50,000,000 girls suffer from DMD, and to date, the disease is incurable and leads to premature death. This phenotypic severity is due to mutations in the DMD gene, which result in the absence of functional dystrophin protein. Initially, dystrophin was thought to be a force transducer; however, it is now considered an essential component of the dystrophin-associated protein complex (DAPC), viewed as a multicomponent mechanical scaffold and a signal transduction hub. Modulating signal pathway activation or gene expression through epigenetic modifications has emerged at the forefront of therapeutic approaches as either an adjunct or stand-alone strategy. In this review, we propose a broader perspective by considering DMD to be a disease that affects myofibers and muscle stem (satellite) cells, as well as a disorder in which abrogated communication between different cell types occurs. We believe that by taking this systemic view, we can achieve safe and holistic treatments that can restore correct signal transmission and gene expression in diseased DMD tissues.
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Affiliation(s)
- Alicja Starosta
- Faculty of Biology, Institute of Human Biology and Evolution, Adam Mickiewicz University, ul. Uniwersytetu Poznańskiego 6, 61-614, Poznań, Poland
| | - Patryk Konieczny
- Faculty of Biology, Institute of Human Biology and Evolution, Adam Mickiewicz University, ul. Uniwersytetu Poznańskiego 6, 61-614, Poznań, Poland.
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16
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Birnkrant DJ, Carter JC. Cardiopulmonary phenotypic variability and discordance in Duchenne muscular dystrophy: Implications for new therapies. Pediatr Pulmonol 2021; 56:738-746. [PMID: 33049122 DOI: 10.1002/ppul.25111] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 01/16/2023]
Abstract
Neuromuscular respiratory medicine has traditionally focused on assisted lung ventilation and mucus clearance. These therapies have prolonged survival for patients with Duchenne muscular dystrophy (DMD). However, the field is rapidly evolving in a new direction: it is being revolutionized by molecular and genetic therapies. A good correlation between a patient's dystrophin mutation and his cardiopulmonary phenotype would allow accurate prediction of patient prognosis and would facilitate the design of studies that assess new DMD therapies. Instead, patient prognosis and the design of valid therapeutic studies are complicated by cardiopulmonary phenotypic discordance and variability, by which a notable proportion of DMD patients have unexpectedly good or poor cardiopulmonary function. The likely cause of phenotypic variability and discordance is genetic modifiers. Once the modifiers that affect cardiopulmonary function are better understood, it should be possible to create a personalized genetic profile that accurately predicts the prognosis of each individual DMD patient. This would allow investigators to assess the effect of new therapies in the context of each patient's particular cardiopulmonary natural history. Amplification of beneficial cardiopulmonary genetic modifiers and blocking of detrimental modifiers is a promising strategy for creating new DMD therapies. When patients with chronic respiratory failure are treated with assisted ventilation, cardiac function determines their survival. Therefore, prioritizing new cardiac therapies is most likely to prolong patient survival. By focusing on these topics we aim to move neuromuscular respiratory medicine beyond assisted ventilation and coughing and into the age of translational medicine.
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Affiliation(s)
- David J Birnkrant
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - John C Carter
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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17
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Birnkrant DJ, Cripe LH. Introduction to the special issue on neuromuscular cardiopulmonary medicine in the age of emerging therapies. Pediatr Pulmonol 2021; 56:691-692. [PMID: 33232576 DOI: 10.1002/ppul.25163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 01/16/2023]
Affiliation(s)
- David J Birnkrant
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Linda H Cripe
- Division of Pediatric Cardiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
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18
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McKim DA, Cripe TP, Cripe LH. The effect of emerging molecular and genetic therapies on cardiopulmonary disease in Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:729-737. [PMID: 33142052 DOI: 10.1002/ppul.25079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 01/22/2023]
Abstract
Gene therapy is an attractive approach being intensively studied to prevent muscle deterioration in patients with Duchenne muscular dystrophy. While clinical trials are only in early stages, initial reports are promising for its effects on ambulation. Cardiopulmonary failure, however, is the most common cause of mortality in Duchenne muscular dystrophy (DMD) patients, and little is known regarding the prospects for gene therapy on alleviating DMD-associated cardiomyopathy and respiratory failure. Here we review current knowledge regarding effects of gene therapy on DMD cardiomyopathy and discuss respiratory endpoints that should be considered as outcome measures in future clinical trials.
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Affiliation(s)
- Douglas A McKim
- Division of Respiratory Medicine, CANVent Respiratory Rehabilitation Services, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy P Cripe
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Linda H Cripe
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio, USA
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19
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Cardiac Phenotype-Genotype Associations in DMD/BMD: A Meta-Analysis and Systematic Review. Pediatr Cardiol 2021; 42:189-198. [PMID: 33037470 DOI: 10.1007/s00246-020-02470-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/18/2020] [Indexed: 01/16/2023]
Abstract
Cardiac involvement of Duchenne and Becker muscular dystrophies (DMD/BMD) is the most common cause of fatal outcomes. It is still unclear whether some DMD/BMD gene mutations might be predictive of cardiac involvement. In this study, we provide a comprehensive overview on genotypes of cardiac disease in DMD/BMD. We systematically searched the PubMed/Medline, EMBASE and Cochrane electronic databases. Search results were filtered to include only human studies, English language and all dates up to August 2019. We summarized and extensively reviewed all studies that passed the selection criteria and performed a meta-analysis on key genotype parameters of cardiac disease in DMD/BMD. Of 3450 articles scanned, we included 18 studies from 9 regions in the meta-analysis. The pooled studies included 2661 DMD/BMD patients and 1324 DMD/BMD patients with cardiac disease. The most common mutation type was exon deletion, with a pooled frequency of 90% (P < 0.01). In DMD/BMD patients with cardiac dysfunction, a higher frequency of involvement of exons 45 and 46 was found in DMD/BMD patients with cardiac dysfunction. This might be predictive of cardiac involvement in patients with DMD/BMD.
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20
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Birnkrant DJ, Black JB. Year in review 2019: Neuromuscular diseases. Pediatr Pulmonol 2020; 55:2542-2546. [PMID: 32691988 DOI: 10.1002/ppul.24970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 12/16/2022]
Abstract
Neuromuscular cardiopulmonary medicine is entering a new and exciting phase, with studies that assess the respiratory effect of emerging genetic and molecular therapies. In this year's neuromuscular Year in Review, we focus on Duchenne muscular dystrophy (DMD), reviewing studies that evaluate the respiratory effect of eteplirsen, the cardiopulmonary effects of ataluren, and a study comparing the use of spironolactone with eplerenone for the treatment of DMD-related cardiomyopathy.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jane B Black
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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21
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Intronic Alternative Polyadenylation in the Middle of the DMD Gene Produces Half-Size N-Terminal Dystrophin with a Potential Implication of ECG Abnormalities of DMD Patients. Int J Mol Sci 2020; 21:ijms21103555. [PMID: 32443516 PMCID: PMC7278912 DOI: 10.3390/ijms21103555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 01/01/2023] Open
Abstract
The DMD gene is one of the largest human genes, being composed of 79 exons, and encodes dystrophin Dp427m which is deficient in Duchenne muscular dystrophy (DMD). In some DMD patient, however, small size dystrophin reacting with antibody to N-terminal but not to C-terminal has been identified. The mechanism to produce N-terminal small size dystrophin remains unknown. Intronic polyadenylation is a mechanism that produces a transcript with a new 3′ terminal exon and a C-terminal truncated protein. In this study, intronic alternative polyadenylation was disclosed to occur in the middle of the DMD gene and produce the half-size N-terminal dystrophin Dp427m, Dpm234. The 3′-rapid amplification of cDNA ends revealed 421 bp sequence in the downstream of DMD exon 41 in U-251 glioblastoma cells. The cloned sequence composing of the 5′ end sequence of intron 41 was decided as the terminal exon, since it encoded poly (A) signal followed by poly (A) stretch. Subsequently, a fragment from DMD exon M1 to intron 41 was obtained by PCR amplification. This product was named Dpm234 after its molecular weight. However, Dpm234 was not PCR amplified in human skeletal and cardiac muscles. Remarkably, Dpm234 was PCR amplified in iPS-derived cardiomyocytes. Accordingly, Western blotting of cardiomyocyte proteins showed a band of 234 kDa reacting with dystrophin antibody to N-terminal, but not C-terminal. Clinically, DMD patients with mutations in the Dpm234 coding region were found to have a significantly higher likelihood of two ECG abnormal findings. Intronic alternative splicing was first revealed in Dp427m to produce small size dystrophin.
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22
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Vita GL, Vita G. Is it the right time for an infant screening for Duchenne muscular dystrophy? Neurol Sci 2020; 41:1677-1683. [PMID: 32112218 PMCID: PMC7359158 DOI: 10.1007/s10072-020-04307-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/20/2020] [Indexed: 12/20/2022]
Abstract
Newborn screening (NBS) is an essential, preventive public health programme for early identification of disorders whose early treatment can lead to significant reduction in morbidity and mortality. NBS for Duchenne muscular dystrophy (DMD) has been a controversial matter for many years, because of false positives, the lack of effective drugs and the need of more data about screening efficacy. The still high diagnostic delay of DMD and the current availability of drugs such as steroid, ataluren, eteplirsen, golodirsen and forthcoming new drugs, improving the clinical conditions if early started, make appropriate to begin a concrete discussion between stakeholders to identify best practice for DMD screening. A two-step system CK/DNA screening programme is presented to be performed in male infants aged between 6 months and 42 months involving more than 30,000 male infants. Five to eight DMD subjects are believed to be diagnosed. The pilot project would give the opportunity to test in a small population the feasibility of an infant screening programme, which in the near future could be applicable to an entire country.
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Affiliation(s)
- Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy. .,Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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Life expectancy at birth in Duchenne muscular dystrophy: a systematic review and meta-analysis. Eur J Epidemiol 2020; 35:643-653. [PMID: 32107739 PMCID: PMC7387367 DOI: 10.1007/s10654-020-00613-8] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/05/2020] [Indexed: 12/29/2022]
Abstract
Several studies indicate that prognosis for survival in Duchenne muscular dystrophy (DMD) has improved in recent decades. However, published evidence is inconclusive and some estimates may be obsolete due to improvements in standards of care, in particular the routine use of mechanical ventilatory support in advanced stages of the disease. In this systematic review and meta-analysis (PROSPERO identifier: CRD42019121800), we searched MEDLINE (through PubMed), CINAHL, Embase, PsycINFO, and Web of Science for studies published from inception up until December 31, 2018, reporting results of life expectancy in DMD. We pooled median survival estimates from individual studies using the median of medians, and weighted median of medians, methods. Risk of bias was established with the Newcastle–Ottawa Scale. Results were stratified by ventilatory support and risk of bias. We identified 15 publications involving 2662 patients from 12 countries from all inhabited continents except Africa. Median life expectancy without ventilatory support ranged between 14.4 and 27.0 years (pooled median: 19.0 years, 95% CI 18.0–20.9; weighted pooled median: 19.4 years, 18.2–20.1). Median life expectancy with ventilatory support, introduced in most settings in the 1990s, ranged between 21.0 and 39.6 years (pooled median: 29.9 years, 26.5–30.8; weighted pooled median: 31.8 years, 29.3–36.2). Risk of bias had little impact on pooled results. In conclusion, median life expectancy at birth in DMD seems to have improved considerably during the last decades. With current standards of care, many patients with DMD can now expect to live into their fourth decade of life.
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Motoki T, Shimizu-Motohashi Y, Saito I, Komaki H, Ishiyama A, Aibara K, Jogamoto T, Tezuka Y, Kawabe M, Makino A, Nagatani K, Tatara K, Kuwabara K, Kikuchi C, Fukuda M, Ishii E, Eguchi M. Renal dysfunction can occur in advanced-stage Duchenne muscular dystrophy. Muscle Nerve 2019; 61:192-197. [PMID: 31725904 DOI: 10.1002/mus.26757] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 11/10/2022]
Abstract
INTRODUCTION With improved treatments, patients with Duchenne muscular dystrophy (DMD) can survive far beyond adolescence. However, advanced-stage DMD patients are at risk of developing renal dysfunction. In this study, long-term renal function outcomes and associated risk factors in advanced stage DMD were analyzed. METHODS Fifty-one patients were classified into three different age groups (<20, 20-29, and ≥30 years of age), and cystatin C (CysC) levels were compared among groups. RESULTS Median serum CysC levels were 0.74 mg/L, 0.63 mg/L, and 0.76 mg/L in the age groups of <20, 20-29, and ≥30 years, respectively (P = .003). Five of the nine patients in the ≥30 years age group showed elevated serum CysC and decreased cardiac function compared with the other four in the group (P = .014). DISCUSSION Our results indicate an association between cardiac and renal dysfunction in patients with advanced-stage DMD.
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Affiliation(s)
- Takahiro Motoki
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Isao Saito
- Department of Public Health and Epidemiology, Faculty of Medicine, Oita University, Yufu, Oita, Japan
| | - Hirofumi Komaki
- Translational Medical Center, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Akihiko Ishiyama
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Kaori Aibara
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toshihiro Jogamoto
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yuko Tezuka
- Division of Pediatrics, Ehime Prefectural Niihama Hospital, Niihama, Ehime, Japan
| | - Mika Kawabe
- Ehime Rehabilitation Center for Children, Toon, Ehime, Japan
| | - Akira Makino
- Division of Pediatrics, Ehime Prefectural Niihama Hospital, Niihama, Ehime, Japan
| | - Koji Nagatani
- Division of Pediatrics, Uwajima City Hospital, Uwajima, Ehime, Japan
| | - Katsunori Tatara
- Division of Child Neurology, Shikoku Medical Center for Children and Adults, Zentsuji, Kagawa, Japan
| | - Kozue Kuwabara
- Division of Pediatrics, Ehime Prefectural Central Hospital, Matsuyama, Ehime, Japan
| | - Chiya Kikuchi
- Division of Pediatrics, National Hospital Organization Ehime Medical Center, Toon, Ehime, Japan
| | - Mitsumasa Fukuda
- Division of Pediatric Neurology, Tokyo Metropolitan Neurological Hospital, Fuchu, Tokyo, Japan
| | - Eiichi Ishii
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Mariko Eguchi
- Department of Pediatrics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Gower WA, Birnkrant DJ, Black JB, Noah TL. Pediatric Pulmonology Year in Review 2018: Rare lung disease, neuromuscular disease, and diagnostic testing. Pediatr Pulmonol 2019; 54:1655-1662. [PMID: 31402599 DOI: 10.1002/ppul.24461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/11/2019] [Indexed: 12/31/2022]
Abstract
Pediatric Pulmonology publishes original research, case reports, and review articles on topics related to a wide range of children's respiratory disorders. In this article, we highlight the past year's publications in the topic areas of rare lung diseases, respiratory complications of neuromuscular disorders, and diagnostic testing, as well as selected literature in these areas from other journals.
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Affiliation(s)
- William A Gower
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jane B Black
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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26
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Comparison of Pulmonary Function Decline in Steroid-Treated and Steroid-Naïve Patients with Duchenne Muscular Dystrophy. J Pediatr 2019; 210:194-200.e2. [PMID: 30955791 DOI: 10.1016/j.jpeds.2019.02.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/07/2019] [Accepted: 02/26/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe and compare the lung function decline in patients with Duchenne muscular dystrophy on glucocorticoid therapy in contrast with glucocorticoid-naïve patients, and to define the deciles of pulmonary decline in glucocorticoid-treated patients. STUDY DESIGN This retrospective study examined lung function of patients with Duchenne muscular dystrophy over 6 years of age followed between 2001 and 2015 at 2 centers-glucocorticoid-treated patients in Cincinnati, Ohio, and glucocorticoid-naïve patients in Paris, France. Forced vital capacity (FVC, FVC%), forced expiratory volume in 1 second, maximal inspiratory pressure, maximal expiratory pressure, and peak expiratory flow data were analyzed. Only FVC data were available for the French cohort. RESULTS There were 170 glucocorticoid-treated patients (92%), 5 patients (2.7%) with past glucocorticoid use, and 50 French glucocorticoid-naïve patients. The peak absolute FVC was higher and was achieved at earlier ages in glucocorticoid-treated compared with glucocorticoid-naïve patients (peak FVC, 2.4 ± 0.6 L vs 1.9 ± 0.7 L; P < .0001; ages 13.5 ± 3.0 years vs 14.3 ± 2.8 years; P = .03). The peak FVC% was also higher and was achieved at earlier ages in glucocorticoid-treated patients (peak FVC%, 105.1 ± 25.1% vs 56 ± 20.9%; P < .0001; ages 11.9 ± 2.9 years vs 13.6 ± 3.2 years; P = .002). Rates of decline for both groups varied with age. Maximal rates of decline were 5.0 ± 0.26% per year (12-20 years) for glucocorticoid-treated and 5.1 ± 0.39% per year for glucocorticoid-naïve patients (11-20 years; P = .2). Deciles of FVC% decline in glucocorticoid-treated patients show that patients experience accelerated decline at variable ages. CONCLUSIONS These data describe nonlinear rates of decline of pulmonary function in patients with Duchenne muscular dystrophy, with improved function in glucocorticoid-treated patients. FVC% deciles may be a useful tool for clinical and research use.
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Alfano LN, Charleston JS, Connolly AM, Cripe L, Donoghue C, Dracker R, Dworzak J, Eliopoulos H, Frank DE, Lewis S, Lucas K, Lynch J, Milici AJ, Flynt A, Naughton E, Rodino-Klapac LR, Sahenk Z, Schnell FJ, Young GD, Mendell JR, Lowes LP. Long-term treatment with eteplirsen in nonambulatory patients with Duchenne muscular dystrophy. Medicine (Baltimore) 2019; 98:e15858. [PMID: 31261494 PMCID: PMC6617421 DOI: 10.1097/md.0000000000015858] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
This analysis aims to describe the outcomes of two nonambulatory patients with Duchenne muscular dystrophy (DMD) who participated in two clinical studies. The two consecutive trials of eteplirsen (studies 201 and 202) were conducted in patients with DMD (N = 12) and confirmed genetic mutations amenable to exon 51 skipping.In study 201, 12 patients were randomized to receive once-weekly, double-blind intravenous infusions of eteplirsen 30 or 50 mg/kg or placebo for 24 weeks; patients then received open-label eteplirsen during weeks 25 through 28. All 12 patients continued onto open-label extension study 202 and received long-term treatment with eteplirsen. We compared cardiac, pulmonary, and upper limb function and dystrophin production in the nonambulatory twin patients versus the 10 ambulatory patients through 240 combined treatment weeks.Ten study patients remained ambulatory through both studies, while the identical twin patients both experienced early, rapid loss of ambulation. The twin patients had greater disease severity at baseline (6-minute walk test [6MWT], 330 and 256 m) versus the other patients (n = 10; 6MWT range, 341-418 m). They maintained cardiac and upper limb function through combined week 240, with outcomes similar to those of the patients who remained ambulatory. Dystrophin production was confirmed following eteplirsen treatment.Despite the loss of ambulation, other markers of disease progression remained relatively stable in the eteplirsen-treated twin patients and were similar to those of the ambulatory patients.
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Affiliation(s)
- Lindsay N. Alfano
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | | | - Anne M. Connolly
- Currently: Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Linda Cripe
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | | | - Robert Dracker
- Summerwood Pediatrics/Infusacare Medical Services, PC, Liverpool, NY
| | | | | | | | - Sarah Lewis
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | | | | | | | | | | | - Louise R. Rodino-Klapac
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
- Currently: Sarepta Therapeutics, Inc., Cambridge, MA, USA
| | - Zarife Sahenk
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | | | | | - Jerry R. Mendell
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | - Linda P. Lowes
- Pediatrics, Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
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Müller-Felber W, Wilichowski E. Aktuelle therapeutische Möglichkeiten bei Muskeldystrophien. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0675-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Muscular dystrophies represent a complex, varied, and important subset of neuromuscular disorders likely to require the care of a pulmonologist. The spectrum of conditions encapsulated by this subset ranges from severe and fatal congenital muscular dystrophies with onset in infancy to mild forms of limb and girdle weakness with onset in adulthood and minimal respiratory compromise. The list and classification of muscular dystrophies are undergoing near-constant revision, based largely on new insights from genetics and molecular medicine. The authors present an overview of the muscular dystrophies, including their basic features, common clinical phenotypes, and important facets of management.
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30
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Yamamoto T, Awano H, Zhang Z, Sakuma M, Kitaaki S, Matsumoto M, Nagai M, Sato I, Imanishi T, Hayashi N, Matsuo M, Iijima K, Saegusa J. Cardiac Dysfunction in Duchenne Muscular Dystrophy Is Less Frequent in Patients With Mutations in the Dystrophin Dp116 Coding Region Than in Other Regions. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 11:e001782. [PMID: 29874176 PMCID: PMC6319568 DOI: 10.1161/circgen.117.001782] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/07/2017] [Indexed: 01/16/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Duchenne muscular dystrophy (DMD), the most common inherited muscular disease in childhood, is caused by dystrophin deficiency because of mutations in the DMD gene. Although DMD is characterized by fatal progressive muscle wasting, cardiomyopathy is the most important nonmuscle symptom threatening the life of patients with DMD. The relationship between cardiac involvement and dystrophin isoforms has not been analyzed. Methods and Results: The results of 1109 echocardiograms obtained from 181 Japanese DMD patients with confirmed mutations in the DMD gene were retrospectively analyzed. Patients showed an age-related decline in left ventricular ejection fraction. Patients were divided by patterns of dystrophin isoform deficiency into 5 groups. The cardiac dysfunction-free survival was significantly higher in the group with mutations in the Dp116 coding region than the others, whereas no significant differences in the other 3 groups. At age 25 years, the cardiac dysfunction-free rate was 0.6 in the Dp116 group, but only 0.1 in others. PCR amplification of Dp116 transcript in human cardiac muscle indicated promoter activation. Conclusions: Left ventricular ejection fraction in DMD declined stepwise with age. Cardiac dysfunction was less frequent in Dp116-deficient than other patients with DMD. Dp116 transcript was identified in human cardiac muscle for the first time. These results indicate that Dp116 is associated with cardiac involvement in DMD.
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Affiliation(s)
- Tetsushi Yamamoto
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Hiroyuki Awano
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Zhujun Zhang
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Mio Sakuma
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Shoko Kitaaki
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masaaki Matsumoto
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masashi Nagai
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Itsuko Sato
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Takamitsu Imanishi
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Nobuhide Hayashi
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Masafumi Matsuo
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.).
| | - Kazumoto Iijima
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
| | - Jun Saegusa
- From the Department of Clinical Laboratory, Kobe University Hospital, Kobe, Japan (T.Y., S.K., I.S., T.I., N.H., J.S.); Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan (H.A., M. Matsumoto, M.N., K.I.); Department of Pathology, Medical School of Nankai University, Tianjin, China (Z.Z.); Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, Kobe, Japan (Z.Z., M. Matsuo); and Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.E.-S.)
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31
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Lentle B, Koromani F, Brown JP, Oei L, Ward L, Goltzman D, Rivadeneira F, Leslie WD, Probyn L, Prior J, Hammond I, Cheung AM, Oei EH. The Radiology of Osteoporotic Vertebral Fractures Revisited. J Bone Miner Res 2019; 34:409-418. [PMID: 30645770 DOI: 10.1002/jbmr.3669] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/17/2018] [Accepted: 01/05/2019] [Indexed: 01/31/2023]
Abstract
Until recently there has been little evidence available to validate any method by which to make an accurate diagnosis of an osteoporotic vertebral fractures (OVFs) from plain radiographs. In part this reflects a lack of a completely satisfactory "gold standard," but primarily it relates to the absence of well-designed prospective studies in this context. Historically, OVFs were recognized by evidence of macroscopic structural failure in vertebrae using the criteria applied elsewhere in the skeleton. This comprised altered alignment, fragmentation, cortical disruptions, and breaks, among other changes. However, these morphological criteria were replaced by vertebral morphometry, referring to the use of quantitative or quasi-quantitative measurement tools for fracture diagnosis. Vertebral morphometry emerged as an understanding of and treatment for osteoporosis evolved, mainly in response to the need for expeditious assessments of large numbers of spine images for epidemiological and pharmaceutical purposes. Although most of the descriptions of such morphometric tools have stressed that they were not to be applied to clinical diagnosis with respect to individual patients, this constraint has been widely disregarded. Here we review the major attempts to develop a diagnostic strategy for OVF and describe their characteristics in adults and children. Recent evidence suggests that morphometric (quantitative; ie, based on measurement of dimensions and shape description) criteria are inferior to morphologic (qualitative; ie, based on structural integrity) vertebral damage assessment in identifying people with low bone density and at an increased risk of future fracture. Thus there is now an evidentiary basis for suggesting that morphological assessment is the preferred strategy for use in diagnosing OVF from radiographs. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Fjorda Koromani
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Jacques P Brown
- Department of Medicine, Division of Rheumatology, CHU de Québec Research Centre, Laval University, Québec City, QC, Canada
| | - Ling Oei
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Leanne Ward
- Division of Bone Health, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - David Goltzman
- Department of Medicine, McGill University and McGill University Health Centre, Montréal, QC, Canada
| | - Fernando Rivadeneira
- Department of Internal Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.,Department of Epidemiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Linda Probyn
- Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jerilynn Prior
- Division of Endocrinology, University of British Columbia, Vancouver, BC, Canada
| | - Ian Hammond
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - Angela M Cheung
- Department of Medicine and Joint Department of Medical Imaging, Centre of Excellence in Skeletal Health Assessment, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Edwin H Oei
- Department of Radiology and Nuclear Medicine, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
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32
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Jin JB, Carter JC, Sheehan DW, Birnkrant DJ. Cardiopulmonary phenotypic discordance is common in Duchenne muscular dystrophy. Pediatr Pulmonol 2019; 54:186-193. [PMID: 30549455 DOI: 10.1002/ppul.24205] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/29/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the prevalence of discordant cardiopulmonary function among patients with Duchenne muscular dystrophy (DMD) in our clinic. METHODS Retrospective chart review from 1999 to 2017. INCLUSION CRITERIA DMD patients age ≥ 18 years, alive, with discordant cardiopulmonary function. No patients received glucocorticoid therapy. Discordant cardiopulmonary function was defined as either: good heart function (EF ≥ 40%) and bad lung function (FVC < 1 L) (Group A); or, bad heart function (EF < 40%) and good lung function (FVC ≥ 1 L) (Group B). RESULTS Among 74 eligible patients, 25 patients (34%) had discordant cardiopulmonary function (21 patients in Group A and 4 patients in Group B). Three dystrophin mutations were shared by >2 patients (nine patients with deletion of exon 44; three patients with deletion of exon 51; three patients with duplication of exon 2). Among the 15 patients with a shared genotype, eight patients (53%) had discordant cardiopulmonary function (five patients in group A, three patients in group B). Twenty-six patients had a deletion involving or distal to exon 45. Ten of these patients (38%) had discordant cardiopulmonary function (eight patients in Group A, two patients in Group B). CONCLUSION In our cohort of DMD patients, discordant cardiopulmonary function was common (present in one-third of our patients), and the dystrophin genotype did not reliably predict a patient's cardiopulmonary phenotype. If confirmed by larger, multi-center studies, our findings have significant implications for predicting patient prognosis, evaluating DMD therapies, and designing new DMD therapies.
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Affiliation(s)
- Justin B Jin
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John C Carter
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Daniel W Sheehan
- Oishei Children's Hospital, University at Buffalo, Buffalo, New York
| | - David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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Kennedy TL, Guiraud S, Edwards B, Squire S, Moir L, Babbs A, Odom G, Golebiowski D, Schneider J, Chamberlain JS, Davies KE. Micro-utrophin Improves Cardiac and Skeletal Muscle Function of Severely Affected D2/ mdx Mice. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 11:92-105. [PMID: 30417024 PMCID: PMC6216100 DOI: 10.1016/j.omtm.2018.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/08/2018] [Indexed: 12/17/2022]
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked muscle-wasting disease caused by mutations in the dystrophin gene. DMD boys are wheelchair-bound around 12 years and generally survive into their twenties. There is currently no effective treatment except palliative care, although personalized treatments such as exon skipping, stop codon read-through, and viral-based gene therapies are making progress. Patients present with skeletal muscle pathology, but most also show cardiomyopathy by the age of 10. A systemic therapeutic approach is needed that treats the heart and skeletal muscle defects in all patients. The dystrophin-related protein utrophin has been shown to compensate for the lack of dystrophin in the mildly affected BL10/mdx mouse. The purpose of this investigation was to demonstrate that AAV9-mediated micro-utrophin transgene delivery can not only functionally replace dystrophin in the heart, but also attenuate the skeletal muscle phenotype in severely affected D2/mdx mice. The data presented here show that utrophin can indeed alleviate the pathology in skeletal and cardiac muscle in D2/mdx mice. These results endorse the view that utrophin modulation has the potential to increase the quality life of all DMD patients whatever their mutation.
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Affiliation(s)
- Tahnee L Kennedy
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Simon Guiraud
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Ben Edwards
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Sarah Squire
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Lee Moir
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Arran Babbs
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
| | - Guy Odom
- Wellstone Muscular Dystrophy Research Centre, Department of Neurology, University of Washington, Seattle, WA, USA
| | | | | | - Jeffrey S Chamberlain
- Wellstone Muscular Dystrophy Research Centre, Department of Neurology, University of Washington, Seattle, WA, USA
| | - Kay E Davies
- Oxford Neuromuscular Centre at the University of Oxford, Department of Physiology, Anatomy and Genetics, Oxford OX1 3PT, UK
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Sheehan DW, Birnkrant DJ, Benditt JO, Eagle M, Finder JD, Kissel J, Kravitz RM, Sawnani H, Shell R, Sussman MD, Wolfe LF. Respiratory Management of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S62-S71. [PMID: 30275250 DOI: 10.1542/peds.2018-0333h] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
In 2010, Care Considerations for Duchenne Muscular Dystrophy, sponsored by the Centers for Disease Control and Prevention, was published in Lancet Neurology, and in 2018, these guidelines were updated. Since the publication of the first set of guidelines, survival of individuals with Duchenne muscular dystrophy has increased. With contemporary medical management, survival often extends into the fourth decade of life and beyond. Effective transition of respiratory care from pediatric to adult medicine is vital to optimize patient safety, prognosis, and quality of life. With genetic and other emerging drug therapies in development, standardization of care is necessary to accurately assess treatment effects in clinical trials. This revision of respiratory recommendations preserves a fundamental strength of the original guidelines: namely, reliance on a limited number of respiratory tests to guide patient assessment and management. A progressive therapeutic strategy is presented that includes lung volume recruitment, assisted coughing, and assisted ventilation (initially nocturnally, with the subsequent addition of daytime ventilation for progressive respiratory failure). This revision also stresses the need for serial monitoring of respiratory muscle strength to characterize an individual's respiratory phenotype of severity as well as provide baseline assessments for clinical trials. Clinical controversies and emerging areas are included.
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Affiliation(s)
- Daniel W Sheehan
- Department of Pediatrics, Oishei Children's Hospital and The University at Buffalo, Buffalo, New York;
| | - David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Joshua O Benditt
- Department of Medicine, University of Washington, Seattle, Washington
| | - Michelle Eagle
- University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Jonathan D Finder
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Kissel
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Hemant Sawnani
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard Shell
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | | | - Lisa F Wolfe
- Department of Medicine, Northwestern University, Evanston, Illinois
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Leigh F, Ferlini A, Biggar D, Bushby K, Finkel R, Morgenroth LP, Wagner KR. Neurology Care, Diagnostics, and Emerging Therapies of the Patient With Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S5-S16. [PMID: 30275245 DOI: 10.1542/peds.2018-0333c] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
Duchenne muscular dystrophy is the most common form of childhood muscular dystrophy. A mutation in the DMD gene disrupts dystrophin (protein) production, causing damage to muscle integrity, weakness, loss of ambulation, and cardiopulmonary compromise by the second decade of life. Life expectancy has improved from mid-teenage years to mid-20s with the use of glucocorticoids and beyond the third decade with ventilator support and multidisciplinary care. However, Duchenne muscular dystrophy is associated with comorbidities and is a fatal disease. Glucocorticoids prolong ambulation, but their side effects are significant. Emerging investigational therapies have surfaced over the past decade and have rapidly been tested in clinical trials. Gene-specific strategies include nonsense readthrough, exon skipping, gene editing, utrophin modulation, and gene replacement. Other mechanisms include muscle regeneration, antioxidants, and antifibrosis and anti-inflammatory pathways. With potential therapies emerging, early diagnosis is needed to initiate treatment early enough to minimize morbidity and mortality. Newborn screening can be used to significantly improve early diagnosis, especially for gene-specific therapeutics.
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Affiliation(s)
- Fawn Leigh
- Massachusetts General Hospital and Harvard Medical School, Harvard University, Cambridge, Massachusetts; .,Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - Doug Biggar
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Katharine Bushby
- John Walton Centre for Muscular Dystrophy Research, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Kathryn R Wagner
- Kennedy Krieger Institute, Baltimore, Maryland; and.,School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Messina S, Vita GL. Clinical management of Duchenne muscular dystrophy: the state of the art. Neurol Sci 2018; 39:1837-1845. [PMID: 30218397 DOI: 10.1007/s10072-018-3555-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/04/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is a devastating, progressive neuromuscular disorder for which there is no cure. As the dystrophin gene is located on the X chromosome, DMD occurs predominately in males. DMD is caused by a lack of functional dystrophin protein resulting from mutations in the 2.2-Mb DMD gene, whichdisrupts the reading frame. Care considerations for DMD advocate a coordinated, multidisciplinary approach to the management of DMD in order to optimize management of the primary manifestations of DMD as well as any secondary complications that may arise. METHODS This review provides an overview of the multidisciplinary clinical management of DMD with regard to the respiratory, cardiology, orthopedic, and nutritional needs of patients with DMD. Recent advances in novel disease-modifying treatments for DMD are also discussed with specific reference to exon skipping and suppression of premature stop codons as promising genetic therapies. RESULTS The combination of multidisciplinary clinical management alongside novel gene therapiesoffers physicians a powerful armamentarium for the treatment of DMD.
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Affiliation(s)
- Sonia Messina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy. .,Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy. .,Unit of Neurology and Neuromuscular Diseases, AOU Policlinico "G. Martino", Building E, 2° Floor, Via Consolare Valeria 1, 98125, Messina, Italy.
| | - Gian Luca Vita
- Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy
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Murphy S, Zweyer M, Mundegar RR, Swandulla D, Ohlendieck K. Proteomic identification of elevated saliva kallikrein levels in the mdx-4cv mouse model of Duchenne muscular dystrophy. Biochem Biophys Rep 2018; 18:100541. [PMID: 31193643 PMCID: PMC6537026 DOI: 10.1016/j.bbrep.2018.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/30/2018] [Accepted: 05/23/2018] [Indexed: 12/21/2022] Open
Abstract
Dystrophinopathies are multi-system disorders that affect the skeletal musculature, the cardio-respiratory system and the central nervous system. The systematic screening of suitable biofluids for released or altered proteins promises new insights into the highly complex pathophysiology of X-linked muscular dystrophy. However, standard detection approaches using antibody-based assays often fail to reproducibly detect low-abundance protein isoforms in dilute biological fluids. In contrast, mass spectrometric screening approaches enable the proteome-wide identification of minor protein changes in biofluids. This report describes the findings from the comparative proteomic analysis of whole saliva samples from wild type versus the established mdx-4cv mouse model of highly progressive muscular dystrophy, focusing on the kallikrein protein family. Kallikrein-1 (Klk1) and 13 Klk1-related peptidases were identified in saliva and serum from normal mice. Comparative proteomics revealed elevated saliva levels of the Klk1-related peptidases Klk1-b1, Klk1-b5 and Klk-b22, as well as an increased Klk-1 concentration, which agrees with higher Klk-1 levels in serum from mdx-4cv mice. This indicates altered cellular signaling, extracellular matrix remodeling and an altered immune response in the mdx-4cv mouse, and establishes liquid biopsy procedures as suitable bioanalytical tools for the systematic survey of complex pathobiochemical changes in animal models of muscular dystrophy.
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Affiliation(s)
- Sandra Murphy
- Department of Biology, Maynooth University, National University of Ireland, Maynooth, Co. Kildare, Ireland
| | - Margit Zweyer
- Institute of Physiology II, University of Bonn, D53115 Bonn, Germany
| | - Rustam R Mundegar
- Institute of Physiology II, University of Bonn, D53115 Bonn, Germany
| | - Dieter Swandulla
- Institute of Physiology II, University of Bonn, D53115 Bonn, Germany
| | - Kay Ohlendieck
- Department of Biology, Maynooth University, National University of Ireland, Maynooth, Co. Kildare, Ireland
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Andrews JG, Wahl RA. Duchenne and Becker muscular dystrophy in adolescents: current perspectives. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2018; 9:53-63. [PMID: 29588625 PMCID: PMC5858539 DOI: 10.2147/ahmt.s125739] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are life-limiting and progressive neuromuscular conditions with significant comorbidities, many of which manifest during adolescence. BMD is a milder presentation of the condition and much less prevalent than DMD, making it less represented in the literature, or more severely affected individuals with BMD may be subsumed into the DMD population using clinical cutoffs. Numerous consensus documents have been published on the clinical management of DMD, the most recent of which was released in 2010. The advent of these clinical management consensus papers, particularly respiratory care, has significantly increased the life span for these individuals, and the adolescent years are now a point of transition into adult lives, rather than a period of end of life. This review outlines the literature on DMD and BMD during adolescence, focusing on clinical presentation during adolescence, impact of living with a chronic illness on adolescents, and the effect that adolescents have on their chronic illness. In addition, we describe the role that palliative-care specialists could have in improving outcomes for these individuals. The increasing proportion of individuals with DMD and BMD living into adulthood underscores the need for more research into interventions and intracacies of adolescence that can improve the social aspects of their lives.
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Affiliation(s)
| | - Richard A Wahl
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
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39
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Wang M, Birnkrant DJ, Super DM, Jacobs IB, Bahler RC. Progressive left ventricular dysfunction and long-term outcomes in patients with Duchenne muscular dystrophy receiving cardiopulmonary therapies. Open Heart 2018. [PMID: 29531771 PMCID: PMC5845428 DOI: 10.1136/openhrt-2018-000783] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Objective To describe the natural history of cardiomyopathy in patients with Duchenne muscular dystrophy (DMD) who are receiving contemporary therapies. Methods This is a single-institution retrospective cohort study of 57 patients aged >15 years with DMD. Serial digital echocardiograms were performed over a median follow-up of 8 years. Left ventricular dysfunction (LVD) was defined as shortening fraction (SF) <29% plus focal wall motion abnormalities. Therapies included ACE inhibitors, beta-blockers and assisted ventilation. Results The SF declined progressively in 53/57 patients (93%). LVD occurred in 40 of 57 patients (70%), with variable age at onset (median 18 years, IQR 14–21.5 years). Rate of SF decline (–1.51%±1.16%/year) was variable and unrelated to genotype. However, survival was shorter for patients with LVD onset at age <18 years vs onset at ≥18 years (death at 21.1±2.5 years vs 33.1±4.4 years; P<0.001). Death occurred in 27/57 (47%) patients at a median age of 26.3 years (IQR 20.6–31.5). Death was preceded by LVD in 22/27 patients (81%), 15 (68%) of whom developed class 4 heart failure (CHF). Time from CHF to death was brief (median 8.0 months). Conclusion Despite contemporary therapies, SF declined progressively in almost all patients. Age at onset of LVD and age at death were variable and unrelated to genotype; however, survival was shortened for patients with LVD onset at age <18 years. Death was usually preceded by LVD. CHF was a sentinel event, with death occurring shortly thereafter.
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Affiliation(s)
- Mary Wang
- Case Western Reserve School of Medicine, Houston, Texas, USA
| | - David J Birnkrant
- Case Western Reserve School of Medicine at MetroHealth Medical Center, Tucson, Arizona
| | - Dennis M Super
- Case Western Reserve School of Medicine at MetroHealth Medical Center, Tucson, Arizona
| | - Irwin B Jacobs
- Case Western Reserve School of Medicine at MetroHealth Medical Center, Tucson, Arizona
| | - Robert C Bahler
- Case Western Reserve School of Medicine at MetroHealth Medical Center, Tucson, Arizona
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Cirino RHD, Scola RH, Ducci RDP, Wermelinger ACC, Kay CSK, Lorenzoni PJ, Werneck LC, Carmes ER, Da Cunha CLP. Predictors of early left ventricular systolic dysfunction in duchenne muscular dystrophy patients. Muscle Nerve 2018; 58:84-89. [PMID: 29443387 DOI: 10.1002/mus.26102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Early detection of left ventricular systolic dysfunction (LVSD) is important for therapeutic strategies for Duchenne muscular dystrophy (DMD) patients. We analyzed myocardial strain using echocardiography for early detection of LVSD and determined the predictors of early LVSD. METHODS This investigation was a cross-sectional study of 40 DMD patients with normal left ventricular ejection fraction. Global longitudinal strain (GLS) was used to analyze subtle disturbances in longitudinal contraction of the myocardium. Patients were determined to have early LVSD (GLS > -18) or normal left ventricular systolic function (GLS ≤ -18). RESULTS Patients who had early LVSD were older and had a higher frequency of corticosteroid therapy and of mutations in exons 45, 46, 47, 48, 49, 50, and 52. DISCUSSION Myocardial strain measurements are useful for the early diagnosis of LVSD in DMD patients. Older age, use of corticosteroids, and mutations within the "hot-spot" region of the DMD gene are associated with early LVSD. Muscle Nerve, 2018.
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Affiliation(s)
- Raphael Henrique Déa Cirino
- Cardiology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Rua General Carneiro, 181-12 º andar Curitiba, 80060-900, Paraná, Brazil
| | - Rosana Herminia Scola
- Neuromuscular Service, Neurology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Renata Dal-Prá Ducci
- Neuromuscular Service, Neurology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Ana Cristina Camarozano Wermelinger
- Cardiology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Rua General Carneiro, 181-12 º andar Curitiba, 80060-900, Paraná, Brazil
| | - Claudia Suemi Kamoi Kay
- Neuromuscular Service, Neurology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Paulo José Lorenzoni
- Neuromuscular Service, Neurology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Lineu Cesar Werneck
- Neuromuscular Service, Neurology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Eliane Ribeiro Carmes
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Claudio Leinig Pereira Da Cunha
- Cardiology Division, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Rua General Carneiro, 181-12 º andar Curitiba, 80060-900, Paraná, Brazil
- Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Paraná, Brazil
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Birnkrant DJ, Bushby K, Bann CM, Alman BA, Apkon SD, Blackwell A, Case LE, Cripe L, Hadjiyannakis S, Olson AK, Sheehan DW, Bolen J, Weber DR, Ward LM. Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management. Lancet Neurol 2018; 17:347-361. [PMID: 29395990 DOI: 10.1016/s1474-4422(18)30025-5] [Citation(s) in RCA: 569] [Impact Index Per Article: 94.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
A coordinated, multidisciplinary approach to care is essential for optimum management of the primary manifestations and secondary complications of Duchenne muscular dystrophy (DMD). Contemporary care has been shaped by the availability of more sensitive diagnostic techniques and the earlier use of therapeutic interventions, which have the potential to improve patients' duration and quality of life. In part 2 of this update of the DMD care considerations, we present the latest recommendations for respiratory, cardiac, bone health and osteoporosis, and orthopaedic and surgical management for boys and men with DMD. Additionally, we provide guidance on cardiac management for female carriers of a disease-causing mutation. The new care considerations acknowledge the effects of long-term glucocorticoid use on the natural history of DMD, and the need for care guidance across the lifespan as patients live longer. The management of DMD looks set to change substantially as new genetic and molecular therapies become available.
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Affiliation(s)
- David J Birnkrant
- Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Katharine Bushby
- John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Carla M Bann
- RTI International, Research Triangle Park, NC, USA
| | - Benjamin A Alman
- Department of Orthopaedic Surgery, Duke University School of Medicine and Health System, Durham, NC, USA
| | - Susan D Apkon
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Laura E Case
- Doctor of Physical Therapy Division, Department of Orthopaedics, Duke University School of Medicine, Durham, NC, USA
| | - Linda Cripe
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Stasia Hadjiyannakis
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
| | - Aaron K Olson
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Daniel W Sheehan
- John R Oishei Children's Hospital, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Julie Bolen
- Rare Disorders and Health Outcomes Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David R Weber
- Division of Endocrinology and Diabetes, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Leanne M Ward
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, and University of Ottawa, Ottawa, ON, Canada
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Birnkrant DJ, Black JB, Tapia IE, Nicolai T, Gower WA, Noah TL. Pediatric Pulmonology year in review 2016: Part 1. Pediatr Pulmonol 2017; 52:1226-1233. [PMID: 28440921 DOI: 10.1002/ppul.23720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 04/04/2017] [Indexed: 11/07/2022]
Abstract
Pediatric Pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. As we have done annually in recent years, we here summarize the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. This review (Part 1) covers selected articles on sleep, diagnostic testing/endoscopy, respiratory complications of neuromuscular disorders, and rare lung diseases.
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Affiliation(s)
- David J Birnkrant
- Metro Health Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jane B Black
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ignacio E Tapia
- Sleep Center, Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - William A Gower
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Johnstone VPA, Viola HM, Hool LC. Dystrophic Cardiomyopathy-Potential Role of Calcium in Pathogenesis, Treatment and Novel Therapies. Genes (Basel) 2017; 8:genes8040108. [PMID: 28338606 PMCID: PMC5406855 DOI: 10.3390/genes8040108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/16/2017] [Accepted: 03/21/2017] [Indexed: 01/06/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is caused by defects in the DMD gene and results in progressive wasting of skeletal and cardiac muscle due to an absence of functional dystrophin. Cardiomyopathy is prominent in DMD patients, and contributes significantly to mortality. This is particularly true following respiratory interventions that reduce death rate and increase ambulation and consequently cardiac load. Cardiomyopathy shows an increasing prevalence with age and disease progression, and over 95% of patients exhibit dilated cardiomyopathy by the time they reach adulthood. Development of the myopathy is complex, and elevations in intracellular calcium, functional muscle ischemia, and mitochondrial dysfunction characterise the pathophysiology. Current therapies are limited to treating symptoms of the disease and there is therefore an urgent need to treat the underlying genetic defect. Several novel therapies are outlined here, and the unprecedented success of phosphorodiamidate morpholino oligomers (PMOs) in preclinical and clinical studies is overviewed.
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Affiliation(s)
- Victoria P A Johnstone
- School of Human Sciences, The University of Western Australia, Crawley, WA 6009, Australia.
| | - Helena M Viola
- School of Human Sciences, The University of Western Australia, Crawley, WA 6009, Australia.
| | - Livia C Hool
- School of Human Sciences, The University of Western Australia, Crawley, WA 6009, Australia.
- Victor Chang Cardiac Research Institute, Sydney, NSW 2010, Australia.
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Van Ruiten H, Bushby K, Guglieri M. State-Of-The-Art Advances in Duchenne Muscular Dystrophy. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10311993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a severe and fatal muscle condition affecting young children. Without interventions, affected boys lose the ability to walk independently by the age of 10 and develop progressive cardiac and respiratory failure. The last 20 years have seen a change in the natural history of DMD following improvements in clinical care and proactive interventions to manage complications of the disease. An international collaboration of DMD experts has created care imperatives for best practice in DMD; these are now available in 30 different languages and are disseminated worldwide. An update of these care recommendations is currently under review.
More recently, the field has seen encouraging scientific progress in regard to new therapeutic approaches of which a large number are currently being evaluated in clinical trials. With time, improvements in clinical care and access to new treatments and innovations are changing the natural course of DMD, from a relentless progressive illness with death in teenage years to a more chronic illness with a good quality of life and increased life expectancy. This is a particularly encouraging time for DMD, and experiences built in the muscular dystrophy field are likely to be of benefit to the development of new approaches and therapies in other rare diseases.
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Affiliation(s)
- Henriette Van Ruiten
- The John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Katherine Bushby
- The John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Michela Guglieri
- The John Walton Muscular Dystrophy Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, UK
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Saito T, Kawai M, Kimura E, Ogata K, Takahashi T, Kobayashi M, Takada H, Kuru S, Mikata T, Matsumura T, Yonemoto N, Fujimura H, Sakoda S. Study of Duchenne muscular dystrophy long-term survivors aged 40 years and older living in specialized institutions in Japan. Neuromuscul Disord 2016; 27:107-114. [PMID: 28003112 DOI: 10.1016/j.nmd.2016.11.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/29/2016] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Abstract
The national muscular dystrophy wards database of Japan lists 118 long-term Duchenne muscular dystrophy (DMD) patients who were at least 40 years old as of October 1, 2013. To elucidate the clinical features of DMD patients aged 40 years and older, we obtained gene analysis and muscle biopsy findings, as well as medical condition information. Ninety-four of the registered patients consented to participate, of whom 55 meeting genetic or biochemical criteria confirming DMD were analyzed. The mean age at the time of the study was 43.6 ± 3.0 years, while at the time of independent ambulation loss it was 10.6 ± 1.5 years and at mechanical ventilation introduction it was 24.1 ± 5.5 years. All were receiving continuous ventilation support, 27 with non-invasive positive pressure ventilation and 28 with tracheal intermittent positive pressure ventilation. Thirty-eight were receiving β-blockers or a renin-angiotensin system inhibitor, while 9 were free from those agents. Forty had maintained oral nutrition. The 55 analyzed patients had survived into their 40s by receiving multidisciplinary intervention. Our findings emphasize the need of future studies to investigate disease modifiers and the mechanism of long-term survival. In addition, establishment of a worldwide care standard with focus on quality of life for adult males with DMD is important.
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Affiliation(s)
- Toshio Saito
- Division of Child Neurology, Department of Neurology, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan.
| | - Mitsuru Kawai
- Department of Neurology, National Hospital Organization Higashisaitama Hospital, Hasuda, Saitama, Japan
| | - En Kimura
- National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Katsuhisa Ogata
- Department of Neurology, National Hospital Organization Higashisaitama Hospital, Hasuda, Saitama, Japan
| | - Toshiaki Takahashi
- Department of Neurology, National Hospital Organization Sendai-Nishitaga National Hospital, Sendai, Miyagi, Japan
| | - Michio Kobayashi
- Department of Neurology, National Hospital Organization National Akita Hospital, Yurihonjo, Akita, Japan
| | - Hiroto Takada
- Department of Neurology, National Hospital Organization National Aomori Hospital, Aomori, Japan
| | - Satoshi Kuru
- Department of Neurology, National Hospital Organization National Suzuka Hospital, Suzuka, Mie, Japan
| | - Takashi Mikata
- Department of Neurology, National Hospital Organization National Shimoshizu Hospital, Yotsukaido, Chiba, Japan
| | - Tsuyoshi Matsumura
- Department of Neurology, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Naohiro Yonemoto
- National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Harutoshi Fujimura
- Department of Neurology, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
| | - Saburo Sakoda
- Department of Neurology, National Hospital Organization Toneyama National Hospital, Toyonaka, Osaka, Japan
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Van Ruiten HJA, Marini Bettolo C, Cheetham T, Eagle M, Lochmuller H, Straub V, Bushby K, Guglieri M. Why are some patients with Duchenne muscular dystrophy dying young: An analysis of causes of death in North East England. Eur J Paediatr Neurol 2016; 20:904-909. [PMID: 27524390 DOI: 10.1016/j.ejpn.2016.07.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/08/2016] [Accepted: 07/25/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is the most common inherited muscle disease in children. Recent years have seen an increase in age of survival into adulthood following the introduction of proactive standards of care. We reviewed mortality in DMD in our population in order to identify potential underlying risk factors for premature death and improve clinical care. METHOD A retrospective case note review of all deaths in the DMD population over the last 10 years in North East England. We identified 2 groups of patients: patients who died from underlying cardiac and/or respiratory failure (group 1) and patients who died unexpectedly in the absence of underlying cardio-respiratory failure (group 2). RESULTS Detailed information was available on 21 patients. Mean age of death in group 1 (17 patients) was 23.9 (14.4-39.5) years, in group 2 (4 patients) 14 (12.7-14.9) years. Causes of death in group 2 were acute pneumonia, cardiac arrest, acute respiratory distress and multi-organ failure. Across both groups we identified concerns regarding respiratory failure, inadequate nutrition, non-attendance at appointments, suboptimal coordination of care and decreased psychological wellbeing. In group 2, fat embolism, cardiac arrhythmia and adrenal insufficiency were also potential contributing factors. CONCLUSIONS The main cause of death in DMD in our population remains cardio-respiratory failure. Four patients (19%) died in their teenage years in the absence of severe cardiorespiratory failure. A more thorough understanding of the impact of DMD and its treatment on all organs systems is required to minimise the risk of an untimely death.
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Affiliation(s)
- H J A Van Ruiten
- Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, New Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK; The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - C Marini Bettolo
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - T Cheetham
- Great North Children's Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, New Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - M Eagle
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - H Lochmuller
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - V Straub
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - K Bushby
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK
| | - M Guglieri
- The John Walton Muscular Dystrophy Research Centre, Newcastle University, Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK.
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Villa CR, Kaddourah A, Mathew J, Ryan TD, Wong BL, Goldstein SL, Jefferies JL. Identifying evidence of cardio-renal syndrome in patients with Duchenne muscular dystrophy using cystatin C. Neuromuscul Disord 2016; 26:637-642. [PMID: 27542440 DOI: 10.1016/j.nmd.2016.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/25/2016] [Indexed: 11/16/2022]
Abstract
Patients with Duchenne muscular dystrophy (DMD) develop dilated cardiomyopathy and are at risk for kidney injury. Creatinine based estimated glomerular filtration rate (eGFR) is limited by low muscle mass with low serum creatinine levels in DMD. We assessed the relationship between cardiac function, modified Schwartz eGFR and cystatin C eGFR in patients with DMD. Ninety-three patients with DMD were screened for renal dysfunction in an outpatient neuromuscular clinic. Patients with new nephrotoxic medications, recent hospitalization or decompensated heart failure were excluded from the analysis. Eleven (12%) patients had evidence of renal dysfunction identified by cystatin C eGFR, while no patients had renal dysfunction by Schwartz eGFR. There was no significant correlation between cystatin C eGFR and age (r = -0.2, p = 0.11), prednisone dose (r = 0.06, p = 0.89) or deflazacort dose (r = -0.01, p = 0.63). There was a significant correlation between left ventricular ejection fraction and cystatin C GFR among patients with chronic left ventricular dysfunction (r = 0.46, p < 0.01), but not normal function (r = -0.07, p = 0.77). There was no significant correlation between left ventricular ejection fraction and Schwartz eGFR among patients with (r = 0.07, p = 0.59) or without (r = -0.27, p = 0.07) chronic left ventricular dysfunction. Cystatin C eGFR correlates with cardiac dysfunction in patients with DMD, thus providing novel evidence of cardio-renal syndrome in this population. Routine monitoring of renal function is recommended in patients with DMD.
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Affiliation(s)
- Chet R Villa
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Ahmad Kaddourah
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jacob Mathew
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D Ryan
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Brenda L Wong
- Division of Pediatric Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John L Jefferies
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Affiliation(s)
- Jeanne James
- From the Department of Pediatrics, Heart Institute, The Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Robbins
- From the Department of Pediatrics, Heart Institute, The Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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Finsterer J, Stöllberger C. Heart Disease in Disorders of Muscle, Neuromuscular Transmission, and the Nerves. Korean Circ J 2016; 46:117-34. [PMID: 27014341 PMCID: PMC4805555 DOI: 10.4070/kcj.2016.46.2.117] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 10/30/2015] [Accepted: 11/24/2015] [Indexed: 12/31/2022] Open
Abstract
Little is known regarding cardiac involvement (CI) by neuromuscular disorders (NMDs). The purpose of this review is to summarise and discuss the major findings concerning the types, frequency, and severity of cardiac disorders in NMDs as well as their diagnosis, treatment, and overall outcome. CI in NMDs is characterized by pathologic involvement of the myocardium or cardiac conduction system. Less commonly, additional critical anatomic structures, such as the valves, coronary arteries, endocardium, pericardium, and even the aortic root may be involved. Involvement of the myocardium manifests most frequently as hypertrophic or dilated cardiomyopathy and less frequently as restrictive cardiomyopathy, non-compaction, arrhythmogenic right-ventricular dysplasia, or Takotsubo-syndrome. Cardiac conduction defects and supraventricular and ventricular arrhythmias are common cardiac manifestations of NMDs. Arrhythmias may evolve into life-threatening ventricular tachycardias, asystole, or even sudden cardiac death. CI is common and carries great prognostic significance on the outcome of dystrophinopathies, laminopathies, desminopathies, nemaline myopathy, myotonias, metabolic myopathies, Danon disease, and Barth-syndrome. The diagnosis and treatment of CI in NMDs follows established guidelines for the management of cardiac disease, but cardiotoxic medications should be avoided. CI in NMDs is relatively common and requires complete work-up following the establishment of a neurological diagnosis. Appropriate cardiac treatment significantly improves the overall long-term outcome of NMDs.
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Affiliation(s)
| | - Claudia Stöllberger
- 2 Medical Department with Cardiology and Intensive Care Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria
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Afzal MZ, Reiter M, Gastonguay C, McGivern JV, Guan X, Ge ZD, Mack DL, Childers MK, Ebert AD, Strande JL. Nicorandil, a Nitric Oxide Donor and ATP-Sensitive Potassium Channel Opener, Protects Against Dystrophin-Deficient Cardiomyopathy. J Cardiovasc Pharmacol Ther 2016; 21:549-562. [PMID: 26940570 DOI: 10.1177/1074248416636477] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/30/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Dystrophin-deficient cardiomyopathy is a growing clinical problem without targeted treatments. We investigated whether nicorandil promotes cardioprotection in human dystrophin-deficient induced pluripotent stem cell (iPSC)-derived cardiomyocytes and the muscular dystrophy mdx mouse heart. METHODS AND RESULTS Dystrophin-deficient iPSC-derived cardiomyocytes had decreased levels of endothelial nitric oxide synthase and neuronal nitric oxide synthase. The dystrophin-deficient cardiomyocytes had increased cell injury and death after 2 hours of stress and recovery. This was associated with increased levels of reactive oxygen species and dissipation of the mitochondrial membrane potential. Nicorandil pretreatment was able to abolish these stress-induced changes through a mechanism that involved the nitric oxide-cyclic guanosine monophosphate pathway and mitochondrial adenosine triphosphate-sensitive potassium channels. The increased reactive oxygen species levels in the dystrophin-deficient cardiomyocytes were associated with diminished expression of select antioxidant genes and increased activity of xanthine oxidase. Furthermore, nicorandil was found to improve the restoration of cardiac function after ischemia and reperfusion in the isolated mdx mouse heart. CONCLUSION Nicorandil protects against stress-induced cell death in dystrophin-deficient cardiomyocytes and preserves cardiac function in the mdx mouse heart subjected to ischemia and reperfusion injury. This suggests a potential therapeutic role for nicorandil in dystrophin-deficient cardiomyopathy.
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Affiliation(s)
- Muhammad Z Afzal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Melanie Reiter
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Courtney Gastonguay
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jered V McGivern
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Xuan Guan
- Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Zhi-Dong Ge
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David L Mack
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Martin K Childers
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Allison D Ebert
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer L Strande
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
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