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Abbott MJ, Knupp KG. SCN8A modified Delphi commentary. Epilepsia 2024. [PMID: 38943498 DOI: 10.1111/epi.18045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 07/01/2024]
Affiliation(s)
- Megan J Abbott
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Kelly G Knupp
- Department of Pediatrics and Neurology, School of Medicine, University of Colorado, Aurora, Colorado, USA
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Takeguchi R, Akaba Y, Kuroda M, Tanaka R, Tanaka T, Itoh M, Takahashi S. Neurophysiological and brain structural insights into cyclin-dependent kinase-like 5 deficiency disorder: Visual and auditory evoked potentials and MRI analysis. J Neurol Sci 2024; 461:123063. [PMID: 38820769 DOI: 10.1016/j.jns.2024.123063] [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] [Received: 03/26/2024] [Revised: 05/19/2024] [Accepted: 05/23/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE CDKL5 deficiency disorder (CDD), an epileptic encephalopathy for which novel therapeutics are under development, lacks valid and reliable measures of therapeutic efficacy. We aimed to elucidate the neurophysiological and brain structural features of CDD patients and identify objective indicators reflecting the clinical severity. METHODS Twelve CDD patients and 12 healthy controls (HCs) participated. The clinical severity of CDD was scored using the CDD severity assessment (CDD-SA). The participants underwent visual evoked potential (VEP), auditory brainstem response (ABR), structural MRI, and diffusion tensor imaging (DTI) analyses. Measurements from each modality were compared with normal values of age-matched cohorts (VEP and ABR) or statistically compared between CDD patients and HCs (MRI). RESULTS VEP showed a significant correlation between P100 latency and CDD-SA in CDD patients. ABR showed abnormalities in six patients (50%), including prolonged V-wave latency (n = 2), prolonged inter-peak latency between waves I and V (n = 3), and mild hearing loss (n = 4). Structural MRI showed a significant reduction in cortical volume in the left pars triangularis and right cerebellum compared with HCs. DTI showed a widespread decrease in fractional anisotropy and an increase in mean and radial diffusivity compared with HCs. CONCLUSION CDD patients had reduced cortical volume in the left pars triangularis, a brain region crucial for speech, and one-third of patients had mild hearing loss. These changes may be involved in language impairments in CDD patients. Additionally, P100 latency significantly correlated with the clinical severity. These features can be used to assess the clinical severity of CDD.
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Affiliation(s)
- Ryo Takeguchi
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan.
| | - Yuichi Akaba
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan
| | - Mami Kuroda
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan
| | - Ryosuke Tanaka
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan
| | - Teruyuki Tanaka
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Masayuki Itoh
- Department of Mental Retardation and Birth Defect Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Satoru Takahashi
- Department of Pediatrics, Asahikawa Medical University, Hokkaido 078-8510, Japan
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3
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Perinelli MG, Naboni C, Balagura G, Amadori E, Vari MS, Capra V, Lentoiou C, Foiadelli T, Sirchia F, Luparia A, Marseglia G, Ramenghi LA, Striano P. Early Developmental Intervention and Enriched Environment in CDKL5 Developmental and Epileptic Encephalopathy: A Case Report. Neurol Clin Pract 2024; 14:e200287. [PMID: 38660576 PMCID: PMC11042840 DOI: 10.1212/cpj.0000000000200287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/07/2024] [Indexed: 04/26/2024]
Abstract
Objectives CDKL5 developmental and epileptic encephalopathy (CDKL5-DEE) is a rare X-linked dominant genetic disorder. Family-centered Early Intervention (EI) programs, which promote axonal plasticity and synaptic reorganization through exposure to an enriched environment, should be integrated into clinical practice. However, there is presently a dearth of dedicated EI protocols for patients with CDKL5-DEE and cerebral visual impairment (CVI). Methods We present a girl with a deletion of the CDKL5 gene (MIM*300203). At the age of 2 months, the child presented with severe epilepsy. The neurologic examination was abnormal, and she had severe CVI. At the first assessment, at 5 months old, her Developmental Quotient (DQ) on the Griffiths Mental Developmental Scales III (GMDS-III) was equivalent to 3-month-old skills (95% CI). The child was enrolled in an EI program for 6 months. Results At 12 months of age, the DQ score was 91. There has been improvement in the neurovisual functions. The findings from the scales show a gradual improvement in neuromotor and psychomotor development, which is in contrast to the expected outcome of the disease. Discussion The case study shows that a family-centered EI and prompt assessment of CVI can promote and enhance neurodevelopment.
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Affiliation(s)
- Martina Giorgia Perinelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Cecilia Naboni
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Ganna Balagura
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Elisabetta Amadori
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Maria Stella Vari
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Valeria Capra
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Camelia Lentoiou
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Thomas Foiadelli
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Fabio Sirchia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Antonella Luparia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Gianluigi Marseglia
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Luca A Ramenghi
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
| | - Pasquale Striano
- Department of Neurosciences (MGP, GB, LAR, PS), Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa; IRCCS Fondazione Mondino (CN, AL), Pavia; IRCCS Istituto Giannina Gaslini (EA, MSV, VC, LAR, PS), Genoa, Italy; Epilepsy Monitoring Unit (CL), Emergency University Hospital Bucharest, Romania; IRCCS Policlinico San Matteo (TF, FS, GM); and Department of Molecular Medicine (FS), University of Pavia, Italy
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Amin S, Møller RS, Aledo‐Serrano A, Arzimanoglou A, Bager P, Jóźwiak S, Kluger GJ, López‐Cabeza S, Nabbout R, Partridge C, Schubert‐Bast S, Specchio N, Kälviäinen R. Providing quality care for people with CDKL5 deficiency disorder: A European expert panel opinion on the patient journey. Epilepsia Open 2024; 9:832-849. [PMID: 38450883 PMCID: PMC11145618 DOI: 10.1002/epi4.12914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/21/2024] [Indexed: 03/08/2024] Open
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a developmental and epileptic encephalopathy caused by variants in the CDKL5 gene. The disorder is characterized by intractable early-onset seizures, severe neurodevelopmental delay, hypotonia, motor disabilities, cerebral (cortical) visual impairment and microcephaly. With no disease-modifying therapies available for CDD, treatment is symptomatic with an initial focus on seizure control. Another unmet need in the management of people with CDD is the lack of evidence to aid standardized care and guideline development. To address this gap, experts in CDD and representatives from patient advocacy groups from Denmark, Finland, France, Germany, Italy, Poland, Spain, and the United Kingdom convened to form an Expert Working Group. The aim was to provide an expert opinion consensus on how to ensure quality care in routine clinical practice within the European setting, including in settings with limited experience or resources for multidisciplinary care of CDD and other developmental and epileptic encephalopathies. By means of one-to-one interviews around the current treatment landscape in CDD, insights from the Expert Working Group were collated and developed into a Europe-specific patient journey for individuals with CDD, which was later validated by the group. Further discussions followed to gain consensus of opinions on challenges and potential solutions for achieving quality care in this setting. The panel recognized the benefit of early genetic testing, a holistic personalized approach to seizure control (taking into consideration various factors such as concomitant medications and comorbidities), and age- and comorbidity-dependent multidisciplinary care for optimizing patient outcomes and quality of life. However, their insights and experiences also highlighted much disparity in management approaches and resources across different European countries. Development of standardized European recommendations is required to align realistic diagnostic criteria, treatment goals, and management approaches that can be adapted for different settings. PLAIN LANGUAGE SUMMARY: Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a rare condition caused by a genetic mutation with a broad range of symptoms apparent from early childhood, including epileptic seizures that do not respond to medication and severe delays in development. Due to the lack of guidance on managing CDD, international experts and patient advocates discussed best practices in the care of people with CDD in Europe. The panel agreed that early testing, a personalized approach to managing seizures, and access to care from different disciplines are beneficial. Development of guidelines to ensure that care is standardized would also be valuable.
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Affiliation(s)
- Sam Amin
- University Hospitals BristolBristolUK
| | - Rikke S. Møller
- The Danish Epilepsy Centre, FiladelfiaDianalundDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - Angel Aledo‐Serrano
- Vithas Madrid La Milagrosa University HospitalVithas Hospital GroupMadridSpain
| | | | | | | | - Gerhard Josef Kluger
- Epilepsy Center for Children and AdolescentsVogtareuthGermany
- Paracelsus Medical University SalzburgSalzburgAustria
| | | | - Rima Nabbout
- Necker‐Enfants Malades HospitalUniversité Paris Cité, Imagine InstituteParisFrance
| | | | - Susanne Schubert‐Bast
- Center of Neurology and NeurosurgeryEpilepsy Center Frankfurt Rhine‐MainGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
- LOEWE Center for Personalized and Translational Epilepsy Research (CePTER)Goethe‐UniversityFrankfurt am MainGermany
- University Children's HospitalGoethe‐University and University Hospital FrankfurtFrankfurt am MainGermany
| | | | - Reetta Kälviäinen
- University of Eastern Finland and Epilepsy CenterKuopio University HospitalKuopioFinland
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5
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Saldaris JM, Jacoby P, Marsh ED, Suter B, Leonard H, Olson HE, Rajaraman R, Pestana-Knight E, Weisenberg J, Price D, Drummond C, Benke TA, Demarest S, Downs J. Adapting a measure of gross motor skills for individuals with CDKL5 deficiency disorder: A psychometric study. Epilepsy Res 2024; 200:107287. [PMID: 38237219 DOI: 10.1016/j.eplepsyres.2024.107287] [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] [Received: 10/17/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Validated measures capable of demonstrating meaningful interventional change in the CDKL5 deficiency disorder (CDD) are lacking. The study objective was to modify the Rett Syndrome Gross Motor Scale (RSGMS) and evaluate its psychometric properties for individuals with CDD. METHODS Item and scoring categories of the RSGMS were modified. Caregivers registered with the International CDKL5 Clinical Research Network uploaded motor videos filmed at home to a protected server and completed a feedback questionnaire (n = 70). Rasch (n = 137), known groups (n = 109), and intra- and inter-rater reliability analyses (n = 50) were conducted. RESULTS The age of individuals with CDD ranged from 1.5 to 34.1 years. The modified scale, Gross Motor-Complex Disability (GM-CD), comprised 17 items. There were no floor or ceiling effects and inter- and intra-rater reliability were good. Rasch analysis demonstrated that the items encompassed a large range of performance difficulty, although there was some item redundancy and some disordered categories. One item, Prone Head Position, was a poor fit. Caregiver-reported acceptability was positive. Scores differed by age and functional abilities. SUMMARY GM-CD appears to be a suitable remotely administered measure and psychometrically sound for individuals with CDD. This study provides the foundation to propose the use of GM-CD in CDD clinical trials. Longitudinal evaluation is planned.
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Affiliation(s)
- J M Saldaris
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - P Jacoby
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - E D Marsh
- Division of Child Neurology, Children's Hospital of Philadelphia and Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - B Suter
- Department of Pediatrics & Neurology, Baylor College of Medicine, Houston, TX, USA
| | - H Leonard
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - H E Olson
- Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - R Rajaraman
- UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | | | - J Weisenberg
- St. Louis Children's Hospital and Washington University School of Medicine, St Louis, MO, USA
| | - D Price
- NYU Langone Health and Department of Neurology, New York University, New York, NY, USA
| | - C Drummond
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - T A Benke
- University of Colorado, School of Medicine, Depts Pediatrics, Neurology and Pharmacology and Children's Hospital Colorado, Aurora, CO, USA
| | - S Demarest
- University of Colorado, School of Medicine, Depts Pediatrics, Neurology and Pharmacology and Children's Hospital Colorado, Aurora, CO, USA.
| | - J Downs
- Telethon Kids Institute, Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia.
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6
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Ziniel SI, Mackie A, Saldaris J, Leonard H, Jacoby P, Marsh ED, Suter B, Pestana-Knight E, Olson HE, Price D, Weisenberg J, Rajaraman R, VanderVeen G, Benke TA, Downs J, Demarest S. The development, content and response process validation of a caregiver-reported severity measure for CDKL5 deficiency disorder. Epilepsy Res 2023; 197:107231. [PMID: 37751639 PMCID: PMC10760432 DOI: 10.1016/j.eplepsyres.2023.107231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND CDKL5 Deficiency Disorder (CDD) is a severe X-linked developmental and epileptic encephalopathy. Existing developmental outcome measures have floor effects and cannot capture incremental changes in symptoms. We modified the caregiver portion of a CDD clinical severity assessment (CCSA) and assessed content and response-process validity. METHODS We conducted cognitive interviews with 15 parent caregivers of 1-39-year-old children with CDD. Caregivers discussed their understanding and concerns regarding appropriateness of both questions and answer options. Item wording and questionnaire structure were adjusted iteratively to ensure questions were understood as intended. RESULTS The CCSA was refined during three rounds of cognitive interviews into two measures: (1) the CDD Developmental Questionnaire - Caregiver (CDQ-Caregiver) focused on developmental skills, and (2) the CDD Clinical Severity Assessment - Caregiver (CCSA-Caregiver) focused on symptom severity. Branching logic was used to ensure questions were age and skill appropriate. Initial pilot data (n = 11) suggested no floor effects. CONCLUSIONS This study modified the caregiver portion of the initial CCSA and provided evidence for its content and response process validity.
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Affiliation(s)
- Sonja I Ziniel
- University of Colorado School of Medicine Department of Pediatrics, Section of Pediatric Hospital Medicine, 13123 East 16th Avenue, Box 302, Aurora, CO, United States; Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States
| | - Alexandra Mackie
- University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Jacinta Saldaris
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Helen Leonard
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Peter Jacoby
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia
| | - Eric D Marsh
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Bernhard Suter
- Baylor College of Medicine and Texas Children's Hospital, 6701 Fannin St MWT, Suite 1250, Houston, TX 77030, United States
| | - Elia Pestana-Knight
- Cleveland Clinic Neurological Institute, Epilepsy Center, S10-024 9500 Euclid Ave, Cleveland, OH 44195, United States
| | - Heather E Olson
- Boston Children's Hospital Department of Neurology Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, 300 Longwood Ave, Boston, MA, United States
| | - Dana Price
- NYU Langone Comprehensive Epilepsy Center, 223 East 34th Street, New York, NY 10016, United States
| | - Judith Weisenberg
- Washington University School of Medicine Department of Neurology, Division of Pediatric Neurology, 660 South Euclid Ave Campus Box 8111, St. Louis, MO 63110 United States
| | - Rajsekar Rajaraman
- David Geffen School of Medicine and UCLA Mattel Children's Hospital Division of Pediatric Neurology, 10833 Le Conte Ave 22-474 MDCC, Los Angeles, CA 90095 United States
| | - Gina VanderVeen
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Tim A Benke
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States
| | - Jenny Downs
- University of Western Australia Centre for Child Health Research, Telethon Kids Institute, PO Box 855, West Perth, Western Australia 6872, Australia; Curtin University, Curtin School of Allied Health, GPO Box U1987, Perth, Western Australia 6845, Australia
| | - Scott Demarest
- Children's Hospital Colorado Precision Medicine Institute, 13123 East 16th Avenue, Box 155, Aurora, CO 80045 United States; University of Colorado School of Medicine Department of Pediatrics, Section of Neurology, 13123 East 16th Avenue, Box 155, Aurora, CO 80045, United States.
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7
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Neul JL, Benke TA, Marsh ED, Suter B, Silveira L, Fu C, Peters SU, Percy AK. Top caregiver concerns in Rett syndrome and related disorders: data from the US natural history study. J Neurodev Disord 2023; 15:33. [PMID: 37833681 PMCID: PMC10571464 DOI: 10.1186/s11689-023-09502-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVE Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) have enabled the discovery of novel therapeutic approaches that require formal clinical evaluation of efficacy. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top caregiver concerns to guide the development and selection of appropriate clinical trial outcome measures for these disorders. METHODS Caregivers of participants enrolled in the US Natural History Study of RTT and RTT-related disorders (n = 925) were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. RESULTS The top caregiver concerns for classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The frequency of the top caregiver concerns for classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. Caregivers of participants with increased seizure severity often ranked seizures as the first concern, whereas caregivers of participants without active seizures often ranked hand use or communication as the top concern. Comparison across disorders found commonalities in the top caregiver concerns between classic RTT, atypical RTT, MECP2 duplication syndrome, CDKL5 deficiency disorder, and FOXG1 syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. CONCLUSION The top caregiver concerns for individuals with RTT and RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.
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Affiliation(s)
- Jeffrey L Neul
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Timothy A Benke
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Eric D Marsh
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Lori Silveira
- University of Colorado School of Medicine/Children's Hospital Colorado, Aurora, CO, USA
| | - Cary Fu
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarika U Peters
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alan K Percy
- University of Alabama at Birmingham, Birmingham, AL, USA
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8
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Specchio N, Trivisano M, Lenge M, Ferretti A, Mei D, Parrini E, Napolitano A, Rossi-Espagnet C, Talenti G, Longo D, Proietti J, Ragona F, Freri E, Solazzi R, Granata T, Darra F, Bernardina BD, Vigevano F, Guerrini R. CDKL5 deficiency disorder: progressive brain atrophy may be part of the syndrome. Cereb Cortex 2023; 33:9709-9717. [PMID: 37429835 PMCID: PMC10472491 DOI: 10.1093/cercor/bhad235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023] Open
Abstract
The clinical phenotype of Cyclin-Dependent Kinase-Like 5 (CDKL5) deficiency disorder (CDD) has been delineated but neuroimaging features have not been systematically analyzed. We studied brain magnetic resonance imaging (MRI) scans in a cohort of CDD patients and reviewed age at seizure onset, seizure semiology, head circumference. Thirty-five brain MRI from 22 unrelated patients were included. The median age at study entry was 13.4 years. In 14/22 patients (85.7%), MRI in the first year of life was unremarkable in all but two. In 11/22, we performed MRI after 24 months of age (range 2.5-23 years). In 8 out of 11 (72.7%), MRI showed supratentorial atrophy and in six cerebellar atrophy. Quantitative analysis detected volumetric reduction of the whole brain (-17.7%, P-value = 0.014), including both white matter (-25.7%, P-value = 0.005) and cortical gray matter (-9.1%, P-value = 0.098), with a reduction of surface area (-18.0%, P-value = 0.032), mainly involving the temporal regions, correlated with the head circumference (ρ = 0.79, P-value = 0.109). Both the qualitative structural assessment and the quantitative analysis detected brain volume reduction involving the gray and white matter. These neuroimaging findings may be related to either progressive changes due to CDD pathogenesis, or to the extreme severity of epilepsy, or both. Larger prospective studies are needed to clarify the bases for the structural changes we observed.
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Affiliation(s)
- Nicola Specchio
- Clinical and Experimental Neurology, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Marina Trivisano
- Clinical and Experimental Neurology, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Matteo Lenge
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Alessandro Ferretti
- Clinical and Experimental Neurology, Bambino Gesù Children’s Hospital IRCCS, Rome 00165, Italy
| | - Davide Mei
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Elena Parrini
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Antonio Napolitano
- Medical Physics Unit, Enterprise Risk Management, Bambino Gesù Children's Hospital, IRCCS, Rome 00165, Italy
| | - Camilla Rossi-Espagnet
- Functional and Interventional Neuroimaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome 00165, Italy
| | - Giacomo Talenti
- Neuroradiology Unit, Neuroradiology Unit, Azienda Ospedale-Università di Padova, Padova 35128, Italy
| | - Daniela Longo
- Functional and Interventional Neuroimaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome 00165, Italy
| | - Jacopo Proietti
- Child Neuropsychiatry Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona 37121, Italy
| | - Francesca Ragona
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano 20133, Italy
| | - Elena Freri
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano 20133, Italy
| | - Roberta Solazzi
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano 20133, Italy
| | - Tiziana Granata
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano 20133, Italy
| | - Francesca Darra
- Child Neuropsychiatry Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona 37121, Italy
| | - Bernardo Dalla Bernardina
- Child Neuropsychiatry Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona 37121, Italy
| | - Federico Vigevano
- Research Area on Neurology and Neurorehabilitation, Bambino Gesù Children’s Hospital IRCCS, Rome 00050, Italy
| | - Renzo Guerrini
- Neuroscience Department, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
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9
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Neul JL, Benke TA, Marsh ED, Suter B, Silveira L, Fu C, Peters SU, Percy AK. Top Caregiver Concerns in Rett syndrome and related disorders: data from the US Natural History Study. RESEARCH SQUARE 2023:rs.3.rs-2566253. [PMID: 36993737 PMCID: PMC10055548 DOI: 10.21203/rs.3.rs-2566253/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Objective Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) has enabled development of novel therapeutic approaches that are currently undergoing clinical evaluation or are proposed to move into clinical development. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top clinical concerns in order to gain information to guide the development and selection of outcome measures for future clinical trials. Methods Caregivers of participants enrolled in the US Natural History Study of RTT and related disorders were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for Classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. Results The top caregiver concerns for Classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The rank order of the frequency of the top caregiver concerns for Classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. The frequency of caregiver concern for seizures, hand use, and spoken language increased in relation to clinician assessed severity in these clinical domains, showing consistency between clinician assessments and caregiver concerns. Comparison across disorders found commonalities in the top caregiver concerns between Classic RTT, Atypical RTT, MECP2 Duplication Syndrome, CDKL5 Deficiency Disorder, and FOXG1 Syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. Conclusion The top caregiver concerns for individuals with RTT and the RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.
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Affiliation(s)
| | - Timothy A Benke
- University of Colorado School of Medicine: University of Colorado Anschutz Medical Campus School of Medicine
| | | | | | - Lori Silveira
- University of Colorado School of Medicine: University of Colorado Anschutz Medical Campus School of Medicine
| | - Cary Fu
- Vanderbilt University Medical Center
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10
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Cardiac Functional and Structural Abnormalities in a Mouse Model of CDKL5 Deficiency Disorder. Int J Mol Sci 2023; 24:ijms24065552. [PMID: 36982627 PMCID: PMC10059787 DOI: 10.3390/ijms24065552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
CDKL5 (cyclin-dependent kinase-like 5) deficiency disorder (CDD) is a severe neurodevelopmental disease that mostly affects girls, who are heterozygous for mutations in the X-linked CDKL5 gene. Mutations in the CDKL5 gene lead to a lack of CDKL5 protein expression or function and cause numerous clinical features, including early-onset seizures, marked hypotonia, autistic features, gastrointestinal problems, and severe neurodevelopmental impairment. Mouse models of CDD recapitulate several aspects of CDD symptomology, including cognitive impairments, motor deficits, and autistic-like features, and have been useful to dissect the role of CDKL5 in brain development and function. However, our current knowledge of the function of CDKL5 in other organs/tissues besides the brain is still quite limited, reducing the possibility of broad-spectrum interventions. Here, for the first time, we report the presence of cardiac function/structure alterations in heterozygous Cdkl5 +/− female mice. We found a prolonged QT interval (corrected for the heart rate, QTc) and increased heart rate in Cdkl5 +/− mice. These changes correlate with a marked decrease in parasympathetic activity to the heart and in the expression of the Scn5a and Hcn4 voltage-gated channels. Interestingly, Cdkl5 +/− hearts showed increased fibrosis, altered gap junction organization and connexin-43 expression, mitochondrial dysfunction, and increased ROS production. Together, these findings not only contribute to our understanding of the role of CDKL5 in heart structure/function but also document a novel preclinical phenotype for future therapeutic investigation.
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11
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Awad PN, Zerbi V, Johnson-Venkatesh EM, Damiani F, Pagani M, Markicevic M, Nickles S, Gozzi A, Umemori H, Fagiolini M. CDKL5 sculpts functional callosal connectivity to promote cognitive flexibility. Mol Psychiatry 2023:10.1038/s41380-023-01962-y. [PMID: 36737483 DOI: 10.1038/s41380-023-01962-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/02/2023] [Accepted: 01/13/2023] [Indexed: 02/05/2023]
Abstract
Functional and structural connectivity alterations in short- and long-range projections have been reported across neurodevelopmental disorders (NDD). Interhemispheric callosal projection neurons (CPN) represent one of the major long-range projections in the brain, which are particularly important for higher-order cognitive function and flexibility. However, whether a causal relationship exists between interhemispheric connectivity alterations and cognitive deficits in NDD remains elusive. Here, we focused on CDKL5 Deficiency Disorder (CDD), a severe neurodevelopmental disorder caused by mutations in the X-linked Cyclin-dependent kinase-like 5 (CDKL5) gene. We found an increase in homotopic interhemispheric connectivity and functional hyperconnectivity across higher cognitive areas in adult male and female CDKL5-deficient mice by resting-state functional MRI (rs-fMRI) analysis. This was accompanied by an increase in the number of callosal synaptic inputs but decrease in local synaptic connectivity in the cingulate cortex of juvenile CDKL5-deficient mice, suggesting an impairment in excitatory synapse development and a differential role of CDKL5 across excitatory neuron subtypes. These deficits were associated with significant cognitive impairments in CDKL5 KO mice. Selective deletion of CDKL5 in the largest subtype of CPN likewise resulted in an increase of functional callosal inputs, without however significantly altering intracortical cingulate networks. Notably, such callosal-specific changes were sufficient to cause cognitive deficits. Finally, when CDKL5 was selectively re-expressed only in this CPN subtype, in otherwise CDKL5-deficient mice, it was sufficient to prevent the cognitive impairments of CDKL5 mutants. Together, these results reveal a novel role of CDKL5 by demonstrating that it is both necessary and sufficient for proper CPN connectivity and cognitive function and flexibility, and further validates a causal relationship between CPN dysfunction and cognitive impairment in a model of NDD.
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Affiliation(s)
- Patricia Nora Awad
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valerio Zerbi
- Neural Control of Movement Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Neuro-X Institute, School of Engineering (STI), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
- CIBM Center for Biomedical Imaging, Lausanne, Switzerland
| | - Erin M Johnson-Venkatesh
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Francesca Damiani
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Pagani
- Functional Neuroimaging Laboratory, Center for Neuroscience and Cognitive Systems, Istituto Italiano di Tecnologia, Rovereto, Italy
- Autism Center, Child Mind Institute, New York, NY, USA
| | - Marija Markicevic
- Neural Control of Movement Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Sarah Nickles
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alessandro Gozzi
- Functional Neuroimaging Laboratory, Center for Neuroscience and Cognitive Systems, Istituto Italiano di Tecnologia, Rovereto, Italy
| | - Hisashi Umemori
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michela Fagiolini
- F. M. Kirby Neurobiology Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
- Hock E. Tan and K. Lisa Yang Center for Autism Research at Harvard University, Boston, MA, USA.
- International Research Center for Neurointelligence (IRCN), University of Tokyo Institutes for Advanced Study, Tokyo, Japan.
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12
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Operto FF, Pastorino GMG, Viggiano A, Dell’Isola GB, Dini G, Verrotti A, Coppola G. Epilepsy and Cognitive Impairment in Childhood and Adolescence: A Mini-Review. Curr Neuropharmacol 2023; 21:1646-1665. [PMID: 35794776 PMCID: PMC10514538 DOI: 10.2174/1570159x20666220706102708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/22/2022] Open
Abstract
Managing epilepsy in people with an intellectual disability remains a therapeutic challenge and must take into account additional issues such as diagnostic difficulties and frequent drug resistance. Advances in genomic technologies improved our understanding of epilepsy and raised the possibility to develop patients-tailored treatments acting on the key molecular mechanisms involved in the development of the disease. In addition to conventional antiseizure medications (ASMs), ketogenic diet, hormone therapy and epilepsy surgery play an important role, especially in cases of drugresistance. This review aims to provide a comprehensive overview of the mainfactors influencing cognition in children and adolescents with epilepsy and the main therapeutic options available for the epilepsies associated with intellectual disability.
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Affiliation(s)
- Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Grazia Maria Giovanna Pastorino
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
| | - Andrea Viggiano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, SA, Italy
| | | | - Gianluca Dini
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of Perugia, Giorgio Menghini Square, 06129 Perugia, Italy
| | - Giangennaro Coppola
- Child and Adolescent Neuropsychiatry Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, SA, Italy
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13
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CDKL5 deficiency causes epileptic seizures independent of cellular mosaicism. J Neurol Sci 2022; 443:120498. [PMID: 36417806 DOI: 10.1016/j.jns.2022.120498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/06/2022] [Accepted: 11/12/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In a study using a mouse model of CDKL5 deficiency disorder (CDD), seizures are specific to female mice heterozygous for Cdkl5 mutations and not observed in hemizygous knockout males or homozygous knockout females. The aim of this study was to examine whether the clinical phenotype of patients with CDD can be impacted by the type of genetic variant. METHODS Eleven CDD patients (six females and five males) were included in this study. The molecular diagnosis of hemizygous male patients was performed using digital PCR and their clinical phenotypes were compared with those of patients with mosaic or heterozygous CDKL5 variants. The severity of clinical phenotypes was graded by using CDKL5 Developmental Score and the adapted version of the CDKL5 Clinical Severity Assessment. The effect of cellular mosaicism on the severity of CDD was studied by comparing the clinical characteristics and comorbidities between individuals with hemizygous and mosaic or heterozygous CDKL5 variants. RESULTS One of the five male patients was mosaic for the CDKL5 variant. All patients developed seizures irrespective of their genetic status of the pathogenic variant. However, cellular mosaicism of CDKL5 deficiency was associated with lesser severity of other comorbidities such as feeding, respiratory, and visual functional impairments. SIGNIFICANCE This study provided evidence that cellular mosaicism of CDKL5 deficiency was not necessarily required for developing epilepsy. CDD patients not only exhibited clinical features of epilepsy but also exhibited the developmental consequences arising directly from the effect of the CDKL5 pathogenic variant.
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14
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Berg AT, Kaat AJ, Gaebler-Spira D. Measuring the inch stones for progress: Gross motor function in the developmental and epileptic encephalopathies. Epilepsy Behav 2022; 137:108953. [PMID: 36368092 DOI: 10.1016/j.yebeh.2022.108953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Developmental and epileptic encephalopathies (DEE) entail moderate to profound impairments in gross motor skills and mobility, which are poorly quantified with clinical outcomes assessments (COA) used in neuro-typical populations. We studied the motor domain of the Adaptive Behavior Assessment System-3 for ages 0-5 years (ABAS) used outside of its intended age range with a focus on raw scores. METHODS In a cross-sectional survey, 117 parents of children with a variety of DEEs (ages 1-35 years, median = 9) completed the motor domain section of the ABAS. Floor and ceiling effects and associations with epilepsy-related factors were assessed with appropriate parametric and nonparametric statistical techniques. The sensitivity of the ABAS and additional measures of mobility borrowed from the cerebral palsy literature (Functional Activities Questionnaire (FAQ-22) walking level (FAQ-WL)) to different levels of the Functional Mobility Scale was determined. RESULTS ABAS motor scores corresponded to a median age equivalent of 20.5 months (Inter-Quartile Range (IQR) 8-34). Most raw scores corresponded to standardized scores > 2 standard deviations below the ABAS standardization sample mean. ABAS raw scores demonstrated minimal floor and ceiling effects (<5%). In linear regression models, scores increased with age under 6 years (p < 0.0001) but flattened out thereafter. Scores varied substantially by DEE group (p < 0.001) and decreased with higher convulsive seizure frequency (<0.0001) and number of seizure medications (p < 0.001). ABAS and other motor scores were sensitive to important differences in mobility as represented by the FMS at 5 yards. Further, they correlated with declines in mobility function from 5 to 500 yards. SIGNIFICANCE An out-of-range COA with raw scores may provide a measure of motor ability and mobility sensitive within the range of moderate to profound impairment seen in patients with DEE. This approach could shorten the time to appropriate COA development and ensure timely clinical trial readiness for novel therapies for rare DEEs.
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Affiliation(s)
- Anne T Berg
- COMBINEDBrain, Nashville, TN, United States; Northwestern Feinberg School of Medicine, Department of Neurology, Chicago, IL, United States.
| | - Aaron J Kaat
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Deborah Gaebler-Spira
- Shirley Ryan Ability Lab, Chicago, IL, United States; Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, United States; Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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15
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Faubel RJ, Santos Canellas VS, Gaesser J, Beluk NH, Feinstein TN, Wang Y, Yankova M, Karunakaran KB, King SM, Ganapathiraju MK, Lo CW. Flow blockage disrupts cilia-driven fluid transport in the epileptic brain. Acta Neuropathol 2022; 144:691-706. [PMID: 35980457 DOI: 10.1007/s00401-022-02463-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 01/28/2023]
Abstract
A carpet of ependymal motile cilia lines the brain ventricular system, forming a network of flow channels and barriers that pattern cerebrospinal fluid (CSF) flow at the surface. This CSF transport system is evolutionary conserved, but its physiological function remains unknown. Here we investigated its potential role in epilepsy with studies focused on CDKL5 deficiency disorder (CDD), a neurodevelopmental disorder with early-onset epilepsy refractory to seizure medications and the most common cause of infant epilepsy. CDKL5 is a highly conserved X-linked gene suggesting its function in regulating cilia length and motion in the green alga Chlamydomonas might have implication in the etiology of CDD. Examination of the structure and function of airway motile cilia revealed both the CDD patients and the Cdkl5 knockout mice exhibit cilia lengthening and abnormal cilia motion. Similar defects were observed for brain ventricular cilia in the Cdkl5 knockout mice. Mapping ependymal cilia generated flow in the ventral third ventricle (v3V), a brain region with important physiological functions showed altered patterning of flow. Tracing of cilia-mediated inflow into v3V with fluorescent dye revealed the appearance of a flow barrier at the inlet of v3V in Cdkl5 knockout mice. Analysis of mice with a mutation in another epilepsy-associated kinase, Yes1, showed the same disturbance of cilia motion and flow patterning. The flow barrier was also observed in the Foxj1± and FOXJ1CreERT:Cdkl5y/fl mice, confirming the contribution of ventricular cilia to the flow disturbances. Importantly, mice exhibiting altered cilia-driven flow also showed increased susceptibility to anesthesia-induced seizure-like activity. The cilia-driven flow disturbance arises from altered cilia beating orientation with the disrupted polarity of the cilia anchoring rootlet meshwork. Together these findings indicate motile cilia disturbances have an essential role in CDD-associated seizures and beyond, suggesting cilia regulating kinases may be a therapeutic target for medication-resistant epilepsy.
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Affiliation(s)
- Regina J Faubel
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA
| | - Veronica S Santos Canellas
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA
| | - Jenna Gaesser
- Division of Child Neurology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA
| | - Nancy H Beluk
- Division of Radiology, University of Pittsburgh, Pittsburgh, PA, 15260, USA
| | - Tim N Feinstein
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA
| | - Yong Wang
- Laboratory for Fluid Physics, Pattern Formation and Biocomplexity, Max Planck Institute for Dynamics and Self-Organization, Am Faßberg 17, 37077, Göttingen, Germany
| | - Maya Yankova
- Department of Molecular Biology and Biophysics, And Electron Microscopy Facility, University of Connecticut Health Center, Farmington, CT, 06030-3305, USA
| | - Kalyani B Karunakaran
- Supercomputer Education and Research Centre, Indian Institute of Science, Bangalore, 560012, India
| | - Stephen M King
- Department of Molecular Biology and Biophysics, And Electron Microscopy Facility, University of Connecticut Health Center, Farmington, CT, 06030-3305, USA
| | - Madhavi K Ganapathiraju
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA
| | - Cecilia W Lo
- Department of Developmental Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15201, USA.
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16
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Medici G, Tassinari M, Galvani G, Bastianini S, Gennaccaro L, Loi M, Mottolese N, Alvente S, Berteotti C, Sagona G, Lupori L, Candini G, Baggett HR, Zoccoli G, Giustetto M, Muotri A, Pizzorusso T, Nakai H, Trazzi S, Ciani E. Expression of a Secretable, Cell-Penetrating CDKL5 Protein Enhances the Efficacy of Gene Therapy for CDKL5 Deficiency Disorder. Neurotherapeutics 2022; 19:1886-1904. [PMID: 36109452 PMCID: PMC9723029 DOI: 10.1007/s13311-022-01295-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 12/14/2022] Open
Abstract
Although delivery of a wild-type copy of the mutated gene to cells represents the most effective approach for a monogenic disease, proof-of-concept studies highlight significant efficacy caveats for treatment of brain disorders. Herein, we develop a cross-correction-based strategy to enhance the efficiency of a gene therapy for CDKL5 deficiency disorder, a severe neurodevelopmental disorder caused by CDKL5 gene mutations. We created a gene therapy vector that produces an Igk-TATk-CDKL5 fusion protein that can be secreted via constitutive secretory pathways and, due to the cell-penetration property of the TATk peptide, internalized by cells. We found that, although AAVPHP.B_Igk-TATk-CDKL5 and AAVPHP.B_CDKL5 vectors had similar brain infection efficiency, the AAVPHP.B_Igk-TATk-CDKL5 vector led to higher CDKL5 protein replacement due to secretion and penetration of the TATk-CDKL5 protein into the neighboring cells. Importantly, Cdkl5 KO mice treated with the AAVPHP.B_Igk-TATk-CDKL5 vector showed a behavioral and neuroanatomical improvement in comparison with vehicle or AAVPHP.B_CDKL5 vector-treated Cdkl5 KO mice. In conclusion, we provide the first evidence that a gene therapy based on a cross-correction approach is more effective at compensating Cdkl5-null brain defects than gene therapy based on the expression of the native CDKL5, opening avenues for the development of this innovative approach for other monogenic diseases.
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Affiliation(s)
- Giorgio Medici
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Marianna Tassinari
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Giuseppe Galvani
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Stefano Bastianini
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Laura Gennaccaro
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Manuela Loi
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Nicola Mottolese
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Sara Alvente
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Chiara Berteotti
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Giulia Sagona
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128, Pisa, Italy
- Department of Neuroscience, Drug Research and Child Health (NEUROFARBA), University of Florence, 50139, Psychology, Italy
| | - Leonardo Lupori
- Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, 56128, Pisa, Italy
- Scuola Normale Superiore, 56126, Pisa, Italy
| | - Giulia Candini
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Helen Rappe Baggett
- Departments of Molecular and Medical Genetics and Molecular Immunology and Microbiology Oregon Health & Science University, OR, 97239, Portland, USA
| | - Giovanna Zoccoli
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy
| | - Maurizio Giustetto
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, OR, 10126, Turin, Italy
| | - Alysson Muotri
- School of Medicine, Department of Pediatrics/Rady Children's Hospital, University of California San Diego, San Diego, USA
- Department of Cellular & Molecular Medicine, Kavli Institute for Brain and Mind, Archealization Center (ArchC), Center for Academic Research and Training in Anthropogeny (CARTA), La Jolla, CA, 92037, USA
| | - Tommaso Pizzorusso
- Scuola Normale Superiore, 56126, Pisa, Italy
- Institute of Neuroscience, National Research Council, 56126, Pisa, Italy
| | - Hiroyuki Nakai
- Departments of Molecular and Medical Genetics and Molecular Immunology and Microbiology Oregon Health & Science University, OR, 97239, Portland, USA
- Division of Neuroscience, Oregon National Primate Research Center, Beaverton, OR, 97006, USA
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy.
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Science, University of Bologna, 40126, Bologna, Italy.
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Knowles JK, Helbig I, Metcalf CS, Lubbers LS, Isom LL, Demarest S, Goldberg EM, George AL, Lerche H, Weckhuysen S, Whittemore V, Berkovic SF, Lowenstein DH. Precision medicine for genetic epilepsy on the horizon: Recent advances, present challenges, and suggestions for continued progress. Epilepsia 2022; 63:2461-2475. [PMID: 35716052 PMCID: PMC9561034 DOI: 10.1111/epi.17332] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/14/2022] [Accepted: 06/14/2022] [Indexed: 01/18/2023]
Abstract
The genetic basis of many epilepsies is increasingly understood, giving rise to the possibility of precision treatments tailored to specific genetic etiologies. Despite this, current medical therapy for most epilepsies remains imprecise, aimed primarily at empirical seizure reduction rather than targeting specific disease processes. Intellectual and technological leaps in diagnosis over the past 10 years have not yet translated to routine changes in clinical practice. However, the epilepsy community is poised to make impressive gains in precision therapy, with continued innovation in gene discovery, diagnostic ability, and bioinformatics; increased access to genetic testing and counseling; fuller understanding of natural histories; agility and rigor in preclinical research, including strategic use of emerging model systems; and engagement of an evolving group of stakeholders (including patient advocates, governmental resources, and clinicians and scientists in academia and industry). In each of these areas, we highlight notable examples of recent progress, new or persistent challenges, and future directions. The future of precision medicine for genetic epilepsy looks bright if key opportunities on the horizon can be pursued with strategic and coordinated effort.
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Affiliation(s)
- Juliet K. Knowles
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Institute of Clinical Molecular Biology, University of Kiel, Kiel, Germany
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Cameron S. Metcalf
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Laura S. Lubbers
- Citizens United for Research in Epilepsy, Chicago, Illinois, USA
| | - Lori L. Isom
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott Demarest
- Department of Pediatrics and Neurology, University of Colorado, School of Medicine, Aurora, Colorado, USA
| | - Ethan M. Goldberg
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alfred L. George
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Sarah Weckhuysen
- Division of Neurology, University Hospital Antwerp, Antwerp, Belgium
- Applied and Translational Neurogenomics Group, Vlaams Instituut voor Biotechnologie Center for Molecular Neurology, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
- μNEURO Research Center of Excellence, University of Antwerp, Antwerp, Belgium
| | - Vicky Whittemore
- Division of Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Rockville, Maryland, USA
| | - Samuel F. Berkovic
- Epilepsy Research Centre, Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel H. Lowenstein
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
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18
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Cohen SR, Helbig I, Kaufman MC, Schust Myers L, Conway L, Helbig KL. Caregiver assessment of quality of life in individuals with genetic developmental and epileptic encephalopathies. Dev Med Child Neurol 2022; 64:957-964. [PMID: 35229292 PMCID: PMC10305579 DOI: 10.1111/dmcn.15187] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 02/06/2023]
Abstract
AIM To summarize quality of life (QoL) and its determinants, including disease severity, in individuals with developmental and epileptic encephalopathies (DEEs) through a tailored questionnaire. METHOD A questionnaire containing 89 items addressing demographic characteristics, genetic diagnosis, clinical features, and QoL was distributed to primary caregivers of individuals with DEEs through patient advocacy organizations. Composite scores were generated from the mean values of QoL items, grouped into domain scores. RESULTS Out of 176 received responses, the most common genetic diagnoses reported were SCN2A (n=42/173, 24%), SLC6A1 (n=28/173, 16%), SCN1A (n=22/173, 13%), and KCNQ2 (n=21/173, 12%). Composite QoL scores centered around a mean score of 61.67 of 100 (SD 17.10). QoL scores were strongly associated with the number of days minimally disrupted by seizures, medication side effects, genetic diagnosis, and community type. The mean QoL scores for individuals with DEEs was significantly lower than for individuals with Rett syndrome, cerebral palsy, autism spectrum disorder, and Down syndrome. INTERPRETATION QoL in DEEs can be assessed through a standardized instrument. QoL only partially overlaps with objective measurements of disease severity and may represent an independent outcome measure in precision medicine trials.
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Affiliation(s)
- Stacey R Cohen
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ingo Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics (DBHi), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael C Kaufman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biomedical and Health Informatics (DBHi), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Laura Conway
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Katherine L Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Epilepsy NeuroGenetics Initiative (ENGIN), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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19
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Ak M, Akturk Z, Bowyer K, Mignon L, Pasupuleti S, Glaze DG, Suter B, Pehlivan D. Assessing the Burden on Caregivers of MECP2 Duplication Syndrome. Pediatr Neurol 2022; 133:1-8. [PMID: 35716604 DOI: 10.1016/j.pediatrneurol.2022.05.008] [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: 12/21/2021] [Revised: 03/23/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND MECP2 duplication syndrome (MDS) is a rare neurogenetic disorder characterized by severe neurodevelopmental disorder, refractory epilepsy, recurrent infections, and functional gastrointestinal problems. Because of the significant clinical problems and lifelong disability of children with this disorder we hypothesized that the burden on parents/caregivers of these children is significant. However, there are no reports of the impact on caregivers of individuals with MDS. METHODS We developed and validated a burden scale to investigate the challenges of caregivers of children and adults with MDS and identified factors contributing to the burden on caregivers. We developed a Health Insurance Portability and Accountability Act-compliant patient registry for families with MDS and delivered caregiver burden survey through the registry. RESULTS Of 237 completed surveys, 101 were eligible for the study. We identified increased levels of self-perceived anxiety, depression, and emotional exhaustion in caregivers that correlated with higher burden scores. Epilepsy was the only clinical feature that caused a higher burden in caregivers of individuals with MDS. In addition, a higher burden was found in Hispanic caregivers. The duration of care negatively correlated with burden score. CONCLUSIONS This is the first study to investigate the burden on caregivers of individuals with MDS and identify several factors contributing to increased burden. Addressing these concerns has the potential to improve the health of individuals with MDS and contribute to the well-being of their caretakers.
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Affiliation(s)
- Muharrem Ak
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Zekeriya Akturk
- Institute of General Practice and Health Services Research, School of Medicine, Technical University of Munich, Munich, Germany
| | | | | | - Sasidhar Pasupuleti
- Bioinformatics Core, Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas
| | - Daniel G Glaze
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Blue Bird Circle Rett Center, Texas Children's Hospital, Houston, Texas
| | - Bernhard Suter
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Blue Bird Circle Rett Center, Texas Children's Hospital, Houston, Texas
| | - Davut Pehlivan
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Blue Bird Circle Rett Center, Texas Children's Hospital, Houston, Texas.
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20
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Sofia F. Quality of lives matter in developmental and epileptic encephalopathy. Dev Med Child Neurol 2022; 64:935. [PMID: 35315520 DOI: 10.1111/dmcn.15219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
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21
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Amin S, Monaghan M, Aledo-Serrano A, Bahi-Buisson N, Chin RF, Clarke AJ, Cross JH, Demarest S, Devinsky O, Downs J, Pestana Knight EM, Olson H, Partridge CA, Stuart G, Trivisano M, Zuberi S, Benke TA. International Consensus Recommendations for the Assessment and Management of Individuals With CDKL5 Deficiency Disorder. Front Neurol 2022; 13:874695. [PMID: 35795799 PMCID: PMC9251467 DOI: 10.3389/fneur.2022.874695] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
CDKL5 Deficiency Disorder (CDD) is a rare, X-linked dominant condition that causes a developmental and epileptic encephalopathy (DEE). The incidence is between ~ 1:40,000 and 1:60,000 live births. Pathogenic variants in CDKL5 lead to seizures from infancy and severe neurodevelopmental delay. During infancy and childhood, individuals with CDD suffer impairments affecting cognitive, motor, visual, sleep, gastrointestinal and other functions. Here we present the recommendations of international healthcare professionals, experienced in CDD management, to address the multisystem and holistic needs of these individuals. Using a Delphi method, an anonymous survey was administered electronically to an international and multidisciplinary panel of expert clinicians and researchers. To provide summary recommendations, consensus was set, a priori, as >70% agreement for responses. In the absence of large, population-based studies to provide definitive evidence for treatment, we propose recommendations for clinical management, influenced by this proposed threshold for consensus. We believe these recommendations will help standardize, guide and improve the medical care received by individuals with CDD.
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Affiliation(s)
- Sam Amin
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Marie Monaghan
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Angel Aledo-Serrano
- Epilepsy Program, Department of Neurology, Ruber Internacional Hospital, Madrid, Spain
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Necker Enfants Malades, Université de Paris, Paris, France
| | - Richard F. Chin
- Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom
| | - Angus J. Clarke
- University Hospital of Wales, Cardiff University, Cardiff, United Kingdom
| | - J. Helen Cross
- Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Scott Demarest
- Departments of Pediatrics and Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Orrin Devinsky
- Department of Neurology, New York University, New York, NY, United States
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Elia M. Pestana Knight
- Cleveland Clinic Epilepsy Center, Cleveland Clinic Learner College of Medicine, Cleveland, OH, United States
| | - Heather Olson
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | | | - Graham Stuart
- Bristol Heart Institute, Bristol Royal Hospital for Children, University of Bristol, Bristol, United Kingdom
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sameer Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
- College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom
| | - Tim A. Benke
- Department of Pediatrics, Pharmacology, Neurology, and Otolaryngology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
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22
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Leonard H, Downs J, Benke TA, Swanson L, Olson H, Demarest S. CDKL5 deficiency disorder: clinical features, diagnosis, and management. Lancet Neurol 2022; 21:563-576. [PMID: 35483386 PMCID: PMC9788833 DOI: 10.1016/s1474-4422(22)00035-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 12/19/2021] [Accepted: 01/18/2022] [Indexed: 12/25/2022]
Abstract
CDKL5 deficiency disorder (CDD) was first identified as a cause of human disease in 2004. Although initially considered a variant of Rett syndrome, CDD is now recognised as an independent disorder and classified as a developmental epileptic encephalopathy. It is characterised by early-onset (generally within the first 2 months of life) seizures that are usually refractory to polypharmacy. Development is severely impaired in patients with CDD, with only a quarter of girls and a smaller proportion of boys achieving independent walking; however, there is clinical variability, which is probably genetically determined. Gastrointestinal, sleep, and musculoskeletal problems are common in CDD, as in other developmental epileptic encephalopathies, but the prevalence of cerebral visual impairment appears higher in CDD. Clinicians diagnosing infants with CDD need to be familiar with the complexities of this disorder to provide appropriate counselling to the patients' families. Despite some benefit from ketogenic diets and vagal nerve stimulation, there has been little evidence that conventional antiseizure medications or their combinations are helpful in CDD, but further treatment trials are finally underway.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia.
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia; Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Tim A Benke
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Pharmacology, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA; Department of Otolaryngology, University of Colorado at Denver, Aurora, CO, USA
| | - Lindsay Swanson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Heather Olson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Scott Demarest
- Department of Neurology, Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado at Denver, Aurora, CO, USA; Department of Neurology, University of Colorado at Denver, Aurora, CO, USA
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23
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Rare diseases - rare outcomes: Assessing communication abilities for the developmental and epileptic encephalopathies. Epilepsy Behav 2022; 128:108586. [PMID: 35158285 DOI: 10.1016/j.yebeh.2022.108586] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Developmental and epileptic encephalopathies (DEE) entail moderate to profound communication and other impairments that are poorly measured by typical clinical outcomes assessments (COA). We examined the potential of alternative approaches, specifically, the use of raw scores and COAs outside of their intended age ranges. METHODS In a cross-sectional survey, 120 parents of children with Dravet Syndrome, Lennox-Gastaut syndrome, KCNQ2-DEE, KCNB1-DEE, and SCN2A-DEE (ages 1-35 years) completed the Adaptive Behavior Assessment System-3 for ages 0-5 years, modified checklist for autism (mCHAT), communication and social behavior scales (CSBS), communication matrix (CM), and several parent-reported classifiers of communication. Adaptive Behavior Assessment System communication and social raw scores were the primary and adjunctive outcomes. Floor and ceiling effects, dispersion and convergence with related measures were assessed with appropriate parametric and nonparametric statistical techniques. RESULTS Median chronological age (CA) was 8.7 years (Interquartile range (IQR): 5.3-13.5). Adaptive Behavior Assessment Systemcommunication and social age equivalents were 12.5 months (IQR 7.5-28) and 16.5 months (IQR 9-31). Most raw scores corresponded to standardized scores indicating performance <3 standard deviations below the general population mean. Adaptive Behavior Assessment System raw scores demonstrated minimal floor and ceiling effects (<1-2.5%). In linear regression models, scores correlated with age under 6 years (communication, p = 0.001; social, p = 0.003) but significantly flattened out thereafter. Scores varied substantially by DEE group (both p < 0.001) and decreased with higher convulsive seizure frequency (communication, p = 0.01, social, p = 0.02). There was good convergence with mCHAT, CSBS, and CM scores (all r > 0.8). SIGNIFICANCE Raw scores and out-of-range COAs may provide measures that are sensitive at the very limited levels of functioning typical of profoundly impaired, older patients with DEEs. To ensure that targeted trial outcomes are responsive to meaningful change, development of these approaches will be essential to clinical trial readiness for novel therapies for rare DEEs.
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24
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Ramirez JM, Karlen-Amarante M, Wang JDJ, Huff A, Burgraff N. Breathing disturbances in Rett syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:139-151. [PMID: 36031301 PMCID: PMC10029146 DOI: 10.1016/b978-0-323-91532-8.00018-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Rett Syndrome is an X-linked neurological disorder characterized by behavioral and neurological regression, seizures, motor deficits, and dysautonomia. A particularly prominent presentation includes breathing abnormalities characterized by breathing irregularities, hyperventilation, repetitive breathholding during wakefulness, obstructive and central apneas during sleep, and abnormal responses to hypoxia and hypercapnia. The condition and pathology of the respiratory system is further complicated by dysfunctions of breathing-motor coordination, which is reflected in dysphagia. The discovery of the X-linked mutations in the MECP2 gene has transformed our understanding of the cellular and molecular mechanisms that are at the root of various clinical phenotypes. However, the genotype-phenotype relationship is complicated by various factors which include not only X-inactivation but also consequences of the intermittent hypoxia and oxidative stress associated with the breathing abnormalities.
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Affiliation(s)
- Jan-Marino Ramirez
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, United States; Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, United States.
| | - Marlusa Karlen-Amarante
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, United States
| | - Jia-Der Ju Wang
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, United States
| | - Alyssa Huff
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, United States
| | - Nicholas Burgraff
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA, United States
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25
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Saby JN, Mulcahey PJ, Zavez AE, Peters SU, Standridge SM, Swanson LC, Lieberman DN, Olson HE, Key AP, Percy AK, Neul JL, Nelson CA, Roberts TPL, Benke TA, Marsh ED. Electrophysiological biomarkers of brain function in CDKL5 deficiency disorder. Brain Commun 2022; 4:fcac197. [PMID: 35974796 PMCID: PMC9374482 DOI: 10.1093/braincomms/fcac197] [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: 01/05/2022] [Revised: 05/05/2022] [Accepted: 08/02/2022] [Indexed: 11/14/2022] Open
Abstract
CDKL5 deficiency disorder is a debilitating developmental and epileptic encephalopathy for which no targeted treatment exists. A number of promising therapeutics are under development for CDKL5 deficiency disorder but a lack of validated biomarkers of brain function and clinical severity may limit the ability to objectively assess the efficacy of new treatments as they become available. To address this need, the current study quantified electrophysiological measures in individuals with CDKL5 deficiency disorder and the association between these parameters and clinical severity. Visual and auditory evoked potentials, as well as resting EEG, were acquired across 5 clinical sites from 26 individuals with CDKL5 deficiency disorder. Evoked potential and quantitative EEG features were calculated and compared with typically developing individuals in an age- and sex-matched cohort. Baseline and Year 1 data, when available, were analysed and the repeatability of the results was tested. Two clinician-completed severity scales were used for evaluating the clinical relevance of the electrophysiological parameters. Group-level comparisons revealed reduced visual evoked potential amplitude in CDKL5 deficiency disorder individuals versus typically developing individuals. There were no group differences in the latency of the visual evoked potentials or in the latency or amplitude of the auditory evoked potentials. Within the CDKL5 deficiency disorder group, auditory evoked potential amplitude correlated with disease severity at baseline as well as Year 1. Multiple quantitative EEG features differed between CDKL5 deficiency disorder and typically developing participants, including amplitude standard deviation, 1/f slope and global delta, theta, alpha and beta power. Several quantitative EEG features correlated with clinical severity, including amplitude skewness, theta/delta ratio and alpha/delta ratio. The theta/delta ratio was the overall strongest predictor of severity and also among the most repeatable qEEG measures from baseline to Year 1. Together, the present findings point to the utility of evoked potentials and quantitative EEG parameters as objective measures of brain function and disease severity in future clinical trials for CDKL5 deficiency disorder. The results also underscore the utility of the current methods, which could be similarly applied to the identification and validation of electrophysiological biomarkers of brain function for other developmental encephalopathies.
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Affiliation(s)
| | | | - Alexis E Zavez
- Orphan Disease Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sarika U Peters
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Shannon M Standridge
- Cincinnati Children’s Hospital Medical Center, Division of Neurology and University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Lindsay C Swanson
- Department of Neurology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - David N Lieberman
- Department of Neurology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Heather E Olson
- Department of Neurology, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Alexandra P Key
- Department of Hearing and Speech Sciences, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Alan K Percy
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Jeffrey L Neul
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Charles A Nelson
- Laboratories of Cognitive Neuroscience, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, Cambridge, MA 02115, USA
- Graduate School of Education, Harvard University, Cambridge, MA 02115, USA
| | - Timothy P L Roberts
- Division of Radiology Research, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Timothy A Benke
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO 80045, USA
- Department of Neurology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO 80045, USA
- Department of Pharmacology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO 80045, USA
- Department of Otolaryngology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Eric D Marsh
- Correspondence to: Eric D. Marsh, MD Division of Child Neurology Abramson Research Building, Room 502E 3615 Civic Center Boulevard Philadelphia, PA 19104, USA E-mail:
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26
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Leonard H, Junaid M, Wong K, Aimetti AA, Pestana Knight E, Downs J. Influences on the trajectory and subsequent outcomes in CDKL5 deficiency disorder. Epilepsia 2021; 63:352-363. [PMID: 34837650 DOI: 10.1111/epi.17125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study investigated the effect of seizure and medication burden at initial contact with the International CDKL5 Disorder Database on subsequent development and clinical severity and compared quality of life among those whose development progressed, remained stable, or regressed between baseline and follow-up. METHODS The effects of seizure and medication burden at baseline (high or low) on the CDKL5 Disorder Severity Scores and CDKL5 Developmental Score (CDS) at follow-up were assessed using linear and negative binomial regressions, respectively, with adjustment for age at baseline, gender, and follow-up duration with and without genotype. Seizure and medication burden were defined by average daily seizure count (high, ≥5/day; low, <5/day) and number of antiseizure medications (high, ≥3/day; low, <3/day), respectively. The effects of change in CDS over time (improved, stable, or deteriorated) on Quality of Life Inventory-Disability (QI-Disability) total and domain scores at follow-up were assessed in those aged at least 3 years at follow-up using linear regression models with adjustment for baseline CDS, gender, and follow-up duration. RESULTS The expected follow-up CDS was lower for individuals with high compared to low seizure burden at baseline (β = -.49, 95% confidence interval [CI] = -.84 to -.13). The average total QI-Disability score was 5.6 (95% CI = -.2 to 11.5) points higher among those with improved compared with stable or deteriorating CDS and 8.5 (95% CI = 3.1-13.8) points lower for those with deteriorating compared to stable or improved CDS. SIGNIFICANCE Our finding that later development showed slight improvement in those with better earlier seizure control even after adjustment for genotype suggests that the trajectory for an individual child is not necessarily predetermined and could possibly be influenced by optimal seizure management. This has implications for children's quality of life.
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Affiliation(s)
- Helen Leonard
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,Faculty of Health and Medical Sciences, Centre of Child Health Research, University of Western Australia, Nedlands, Western Australia, Australia
| | - Mohammed Junaid
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
| | | | - Elia Pestana Knight
- Pediatric Epilepsy Section, Epilepsy Center, Cleveland Clinic, Neurological Institute, Cleveland, Ohio, USA
| | - Jenny Downs
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia
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Brock D, Fidell A, Thomas J, Juarez-Colunga E, Benke TA, Demarest S. Cerebral Visual Impairment in CDKL5 Deficiency Disorder Correlates With Developmental Achievement. J Child Neurol 2021; 36:974-980. [PMID: 34547934 PMCID: PMC9853471 DOI: 10.1177/08830738211019284] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder is a rare neurodevelopmental disorder characterized by infantile-onset refractory epilepsy, profound developmental delays, and cerebral visual impairment. Although there is evidence that the presence of cerebral visual impairment in CDKL5 deficiency disorder is common, the potential impact of cerebral visual impairment severity on developmental attainment has not been explored directly. Focusing on a cohort of 46 children with CDKL5 deficiency disorder, examination features indicative of cerebral visual impairment were quantified and compared to developmental achievement. The derived cerebral visual impairment severity score was inversely correlated with developmental attainment, bolstering the supposition that cerebral visual impairment severity may provide a useful early biomarker of disease severity and prognosis. This study demonstrates the utility of a cerebral visual impairment score to better capture the range of cerebral visual impairment severity in the CDKL5 deficiency disorder population and further elucidates the interaction between cerebral visual impairment and developmental outcomes.
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Affiliation(s)
- Dylan Brock
- Children’s Hospital Colorado, Department of Child Neurology, Anschutz Medical Campus, Aurora, CO, USA,University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
| | - Andrea Fidell
- Children’s Hospital Colorado, Department of Child Neurology, Anschutz Medical Campus, Aurora, CO, USA,University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
| | - Jacob Thomas
- University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Juarez-Colunga
- University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
| | - Tim A. Benke
- Children’s Hospital Colorado, Department of Child Neurology, Anschutz Medical Campus, Aurora, CO, USA,University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Demarest
- Children’s Hospital Colorado, Department of Child Neurology, Anschutz Medical Campus, Aurora, CO, USA,University of Colorado Denver School of Medicine, Anschutz Medical Campus, Anschutz Medical Campus, Aurora, CO, USA
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Saldaris J, Weisenberg J, Pestana-Knight E, Marsh ED, Suter B, Rajaraman R, Heidary G, Olson HE, Devinsky O, Price D, Jacoby P, Leonard H, Benke TA, Demarest S, Downs J. Content Validation of Clinician-Reported Items for a Severity Measure for CDKL5 Deficiency Disorder. J Child Neurol 2021; 36:998-1006. [PMID: 34378447 PMCID: PMC8458223 DOI: 10.1177/08830738211019576] [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] [Indexed: 12/31/2022]
Abstract
CDKL5 deficiency disorder (CDD) results in early-onset seizures and severe developmental impairments. A CDD clinical severity assessment (CCSA) was previously developed with clinician and parent-report items to capture information on a range of domains. Consistent with US Food and Drug Administration (FDA) guidelines, content validation is the first step in evaluating the psychometric properties of an outcome measure. The aim of this study was to validate the content of the clinician-reported items in the CCSA (CCSA-Clinician). Eight neurologists leading the USA CDD Center of Excellence clinics were interviewed using the "think aloud" technique to critique 26 clinician-reported items. Common themes were aggregated, and a literature search of related assessments informed item modifications. The clinicians then participated in 2 consensus meetings to review themes and finalize the items. A consensus was achieved for the content of the CCSA-Clinician. Eight of the original items were omitted, 11 items were added, and the remaining 18 items were revised. The final 29 items were classified into 2 domains: functioning and neurologic impairments. This study enabled refinement of the CCSA-Clinician and provided evidence for its content validity. This preliminary validation is essential before field testing and further validation, in order to advance the instrument toward clinical trial readiness.
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Affiliation(s)
| | - Judith Weisenberg
- St. Louis Children’s Hospital and Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Eric D. Marsh
- Division of Neurology, Children’s Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bernhard Suter
- Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Gena Heidary
- Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Heather E. Olson
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Orrin Devinsky
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Dana Price
- NYU Langone Health and Department of Neurology, New York University, New York, New York, USA
| | - Peter Jacoby
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, Perth, Western Australia, Australia,The University of Western Australia, Perth, Western Australia, Australia
| | - Tim A. Benke
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott Demarest
- Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, Perth, Western Australia, Australia,The School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
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29
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Galvani G, Mottolese N, Gennaccaro L, Loi M, Medici G, Tassinari M, Fuchs C, Ciani E, Trazzi S. Inhibition of microglia overactivation restores neuronal survival in a mouse model of CDKL5 deficiency disorder. J Neuroinflammation 2021; 18:155. [PMID: 34238328 PMCID: PMC8265075 DOI: 10.1186/s12974-021-02204-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background CDKL5 deficiency disorder (CDD), a severe neurodevelopmental disorder characterized by early onset epilepsy, intellectual disability, and autistic features, is caused by mutations in the CDKL5 gene. Evidence in animal models of CDD showed that absence of CDKL5 negatively affects neuronal survival, as well as neuronal maturation and dendritic outgrowth; however, knowledge of the substrates underlying these alterations is still limited. Neuroinflammatory processes are known to contribute to neuronal dysfunction and death. Recent evidence shows a subclinical chronic inflammatory status in plasma from CDD patients. However, to date, it is unknown whether a similar inflammatory status is present in the brain of CDD patients and, if so, whether this plays a causative or exacerbating role in the pathophysiology of CDD. Methods We evaluated microglia activation using AIF-1 immunofluorescence, proinflammatory cytokine expression, and signaling in the brain of a mouse model of CDD, the Cdkl5 KO mouse, which is characterized by an impaired survival of hippocampal neurons that worsens with age. Hippocampal neuron survival was determined by DCX, NeuN, and cleaved caspase-3 immunostaining in Cdkl5 KO mice treated with luteolin (10 mg/kg), a natural anti-inflammatory flavonoid. Since hippocampal neurons of Cdkl5 KO mice exhibit increased susceptibility to excitotoxic stress, we evaluated neuronal survival in Cdkl5 KO mice injected with NMDA (60 mg/kg) after a 7-day treatment with luteolin. Results We found increased microglial activation in the brain of the Cdkl5 KO mouse. We found alterations in microglial cell morphology and number, increased levels of AIF-1 and proinflammatory cytokines, and activation of STAT3 signaling. Remarkably, treatment with luteolin recovers microglia alterations as well as neuronal survival and maturation in Cdkl5 KO mice, and prevents the increase in NMDA-induced cell death in the hippocampus. Conclusions Our results suggest that neuroinflammatory processes contribute to the pathogenesis of CDD and imply the potential usefulness of luteolin as a treatment option in CDD patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-021-02204-0.
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Affiliation(s)
- Giuseppe Galvani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Nicola Mottolese
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Laura Gennaccaro
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Manuela Loi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Giorgio Medici
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Marianna Tassinari
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Claudia Fuchs
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy.
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126, Bologna, Italy.
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30
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Palmer EE, Howell K, Scheffer IE. Natural History Studies and Clinical Trial Readiness for Genetic Developmental and Epileptic Encephalopathies. Neurotherapeutics 2021; 18:1432-1444. [PMID: 34708325 PMCID: PMC8608984 DOI: 10.1007/s13311-021-01133-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 02/04/2023] Open
Abstract
The developmental and epileptic encephalopathies (DEEs) are the most severe group of epilepsies. They usually begin in infancy or childhood with drug-resistant seizures, epileptiform EEG patterns, developmental slowing or regression, and cognitive impairment. DEEs have a high mortality and profound morbidity; comorbidities are common including autism spectrum disorders. With advances in genetic sequencing, over 400 genes have been implicated in DEEs, with a genetic cause now identified in over 50% patients. Each genetic DEE typically has a broad genotypic-phenotypic spectrum, based on the underlying pathophysiology. There is a pressing need to improve health outcomes by developing novel targeted therapies for specific genetic DEE phenotypes that not only improve seizure control, but also developmental outcomes and comorbidities. Clinical trial readiness relies firstly on a deep understanding of phenotype-genotype correlation and evolution of a condition over time, in order to select appropriate patients for clinical trials. Understanding the natural history of the disorder informs assessment of treatment efficacy in terms of both clinical outcome and biomarker utility. Natural history studies (NHS) provide a high quality, integrated, comprehensive approach to understanding a complex disease and underpin clinical trial design for novel therapies. NHS are pre-planned observational studies designed to track the course of a disease and identify demographic, genetic, environmental, and other variables, including biomarkers, that correlate with the disease's evolution and outcomes. Due to the rarity of individual genetic DEEs, appropriately funded high-quality DEE NHS will be required, with sustainable frameworks and equitable access to affected individuals globally.
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Affiliation(s)
- Elizabeth E Palmer
- School of Women's and Children's Health, UNSW, Sydney, NSW, Australia
- Sydney Children's Hospital Network, Sydney, NSW, Australia
| | - Katherine Howell
- Department of Neurology, Royal Children's Hospital, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Florey Institute for Neuroscience and Mental Health, Melbourne, VIC, Australia
| | - Ingrid E Scheffer
- Department of Neurology, Royal Children's Hospital, Parkville, VIC, Australia.
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
- Epilepsy Research Centre, Department of Medicine, University of Melbourne, Austin Health, Melbourne, VIC, Australia.
- Florey Institute for Neuroscience and Mental Health, Melbourne, VIC, Australia.
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31
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Brock DC, Demarest S, Benke TA. Clinical Trial Design for Disease-Modifying Therapies for Genetic Epilepsies. Neurotherapeutics 2021; 18:1445-1457. [PMID: 34595733 PMCID: PMC8609073 DOI: 10.1007/s13311-021-01123-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 02/04/2023] Open
Abstract
Although trials with anti-seizure medications (ASMs) have not shown clear anti-epileptogenic or disease-modifying activity in humans to date, rapid advancements in genomic technology and emerging gene-mediated and gene replacement options offer hope for the successful development of disease-modifying therapies (DMTs) for genetic epilepsies. In fact, more than 26 potential DMTs are in various stages of preclinical and/or clinical development for genetic syndromes associated with epilepsy. The scope of disease-modification includes but is not limited to effects on the underlying pathophysiology, the condition's natural history, epilepsy severity, developmental achievement, function, behavior, sleep, and quality of life. While conventional regulatory clinical trials for epilepsy therapeutics have historically focused on seizure reduction, similarly designed trials may prove ill-equipped to identify these broader disease-modifying benefits. As we look forward to this pipeline of DMTs, focused consideration should be given to the challenges they pose to conventional clinical trial designs for epilepsy therapeutics. Just as DMTs promise to fundamentally alter how we approach the care of patients with genetic epilepsy syndromes, DMTs likewise challenge how we traditionally construct and measure the success of clinical trials. In the following, we briefly review the historical and preclinical frameworks for DMT development for genetic epilepsies and explore the many novel challenges posed for such trials, including the choice of suitable outcome measures, trial structure, timing and duration of treatment, feasible follow-up period, varying safety profile, and ethical concerns.
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Affiliation(s)
- Dylan C Brock
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
- Children's Hospital Colorado, Aurora, CO, 80045, USA.
| | - Scott Demarest
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
- Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Tim A Benke
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
- Departments of Neurology, Pharmacology, and Otolaryngology, University of Colorado School of Medicine, CO, 80045, Aurora, USA
- Children's Hospital Colorado, Aurora, CO, 80045, USA
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32
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Gennaccaro L, Fuchs C, Loi M, Pizzo R, Alvente S, Berteotti C, Lupori L, Sagona G, Galvani G, Gurgone A, Raspanti A, Medici G, Tassinari M, Trazzi S, Ren E, Rimondini R, Pizzorusso T, Giovanna Z, Maurizio G, Elisabetta C. Age-Related Cognitive and Motor Decline in a Mouse Model of CDKL5 Deficiency Disorder is Associated with Increased Neuronal Senescence and Death. Aging Dis 2021; 12:764-785. [PMID: 34094641 PMCID: PMC8139207 DOI: 10.14336/ad.2020.0827] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/27/2020] [Indexed: 01/02/2023] Open
Abstract
CDKL5 deficiency disorder (CDD) is a severe neurodevelopmental disease caused by mutations in the X-linked CDKL5 gene. Children affected by CDD display a clinical phenotype characterized by early-onset epilepsy, intellectual disability, motor impairment, and autistic-like features. Although the clinical aspects associated with CDKL5 mutations are well described in children, adults with CDD are still under-characterized. Similarly, most animal research has been carried out on young adult Cdkl5 knockout (KO) mice only. Since age represents a risk factor for the worsening of symptoms in many neurodevelopmental disorders, understanding age differences in the development of behavioral deficits is crucial in order to optimize the impact of therapeutic interventions. Here, we compared young adult Cdkl5 KO mice with middle-aged Cdkl5 KO mice, at a behavioral, neuroanatomical, and molecular level. We found an age-dependent decline in motor, cognitive, and social behaviors in Cdkl5 KO mice, as well as in breathing and sleep patterns. The behavioral decline in older Cdkl5 KO mice was not associated with a worsening of neuroanatomical alterations, such as decreased dendritic arborization or spine density, but was paralleled by decreased neuronal survival in different brain regions such as the hippocampus, cortex, and basal ganglia. Interestingly, we found increased β-galactosidase activity and DNA repair protein levels, γH2AX and XRCC5, in the brains of older Cdkl5 KO mice, which suggests that an absence of Cdkl5 accelerates neuronal senescence/death by triggering irreparable DNA damage. In summary, this work provides evidence that CDKL5 may play a fundamental role in neuronal survival during brain aging and suggests a possible worsening with age of the clinical picture in CDD patients.
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Affiliation(s)
- Laura Gennaccaro
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Claudia Fuchs
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Manuela Loi
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Riccardo Pizzo
- 2Department of Neuroscience, University of Turin, Turin, Italy
| | - Sara Alvente
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Chiara Berteotti
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Leonardo Lupori
- 3BIO@SNS lab, Scuola Normale Superiore di Pisa, Pisa, Italy.,4Institute of Neuroscience, National Research Council, Pisa, Italy
| | - Giulia Sagona
- 4Institute of Neuroscience, National Research Council, Pisa, Italy.,5Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence, Florence, Italy.,6Department of Developmental Neuroscience, IRCCS Stella Maris Foundation, Pisa, Italy
| | - Giuseppe Galvani
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Antonia Gurgone
- 2Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Giorgio Medici
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Marianna Tassinari
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Stefania Trazzi
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Elisa Ren
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Roberto Rimondini
- 7Department of Medical and Clinical Sciences, University of Bologna, Bologna, Italy
| | - Tommaso Pizzorusso
- 3BIO@SNS lab, Scuola Normale Superiore di Pisa, Pisa, Italy.,4Institute of Neuroscience, National Research Council, Pisa, Italy.,5Department of Neuroscience, Psychology, Drug Research and Child Health NEUROFARBA, University of Florence, Florence, Italy
| | - Zoccoli Giovanna
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giustetto Maurizio
- 2Department of Neuroscience, University of Turin, Turin, Italy.,8National Institute of Neuroscience-Italy, Turin, Italy
| | - Ciani Elisabetta
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
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Loi M, Gennaccaro L, Fuchs C, Trazzi S, Medici G, Galvani G, Mottolese N, Tassinari M, Rimondini Giorgini R, Milelli A, Ciani E. Treatment with a GSK-3β/HDAC Dual Inhibitor Restores Neuronal Survival and Maturation in an In Vitro and In Vivo Model of CDKL5 Deficiency Disorder. Int J Mol Sci 2021; 22:5950. [PMID: 34073043 PMCID: PMC8198396 DOI: 10.3390/ijms22115950] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 01/03/2023] Open
Abstract
Mutations in the X-linked cyclin-dependent kinase-like 5 (CDKL5) gene cause a rare neurodevelopmental disorder characterized by early-onset seizures and severe cognitive, motor, and visual impairments. To date there are no therapies for CDKL5 deficiency disorder (CDD). In view of the severity of the neurological phenotype of CDD patients it is widely assumed that CDKL5 may influence the activity of a variety of cellular pathways, suggesting that an approach aimed at targeting multiple cellular pathways simultaneously might be more effective for CDD. Previous findings showed that a single-target therapy aimed at normalizing impaired GSK-3β or histone deacetylase (HDAC) activity improved neurodevelopmental and cognitive alterations in a mouse model of CDD. Here we tested the ability of a first-in-class GSK-3β/HDAC dual inhibitor, Compound 11 (C11), to rescue CDD-related phenotypes. We found that C11, through inhibition of GSK-3β and HDAC6 activity, not only restored maturation, but also significantly improved survival of both human CDKL5-deficient cells and hippocampal neurons from Cdkl5 KO mice. Importantly, in vivo treatment with C11 restored synapse development, neuronal survival, and microglia over-activation, and improved motor and cognitive abilities of Cdkl5 KO mice, suggesting that dual GSK-3β/HDAC6 inhibitor therapy may have a wider therapeutic benefit in CDD patients.
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Affiliation(s)
- Manuela Loi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Laura Gennaccaro
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Claudia Fuchs
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Giorgio Medici
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Giuseppe Galvani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Nicola Mottolese
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | - Marianna Tassinari
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
| | | | - Andrea Milelli
- Department for Life Quality Studies, University of Bologna, 47921 Rimini, Italy;
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Piazza di Porta San Donato 2, 40126 Bologna, Italy; (M.L.); (L.G.); (C.F.); (S.T.); (G.M.); (G.G.); (N.M.); (M.T.)
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Reviewing Evidence for the Relationship of EEG Abnormalities and RTT Phenotype Paralleled by Insights from Animal Studies. Int J Mol Sci 2021; 22:ijms22105308. [PMID: 34069993 PMCID: PMC8157853 DOI: 10.3390/ijms22105308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Rett syndrome (RTT) is a rare neurodevelopmental disorder that is usually caused by mutations of the MECP2 gene. Patients with RTT suffer from severe deficits in motor, perceptual and cognitive domains. Electroencephalogram (EEG) has provided useful information to clinicians and scientists, from the very first descriptions of RTT, and yet no reliable neurophysiological biomarkers related to the pathophysiology of the disorder or symptom severity have been identified to date. To identify consistently observed and potentially informative EEG characteristics of RTT pathophysiology, and ascertain areas most worthy of further systematic investigation, here we review the literature for EEG abnormalities reported in patients with RTT and in its disease models. While pointing to some promising potential EEG biomarkers of RTT, our review identify areas of need to realize the potential of EEG including (1) quantitative investigation of promising clinical-EEG observations in RTT, e.g., shift of mu rhythm frequency and EEG during sleep; (2) closer alignment of approaches between patients with RTT and its animal models to strengthen the translational significance of the work (e.g., EEG measurements and behavioral states); (3) establishment of large-scale consortium research, to provide adequate Ns to investigate age and genotype effects.
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35
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Gennaccaro L, Fuchs C, Loi M, Roncacè V, Trazzi S, Ait-Bali Y, Galvani G, Berardi AC, Medici G, Tassinari M, Ren E, Rimondini R, Giustetto M, Aicardi G, Ciani E. A GABA B receptor antagonist rescues functional and structural impairments in the perirhinal cortex of a mouse model of CDKL5 deficiency disorder. Neurobiol Dis 2021; 153:105304. [PMID: 33621640 DOI: 10.1016/j.nbd.2021.105304] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/25/2022] Open
Abstract
CDKL5 (cyclin-dependent kinase-like 5) deficiency disorder (CDD) is a severe neurodevelopmental encephalopathy characterized by early-onset epilepsy and intellectual disability. Studies in mouse models have linked CDKL5 deficiency to defects in neuronal maturation and synaptic plasticity, and disruption of the excitatory/inhibitory balance. Interestingly, increased density of both GABAergic synaptic terminals and parvalbumin inhibitory interneurons was recently observed in the primary visual cortex of Cdkl5 knockout (KO) mice, suggesting that excessive GABAergic transmission might contribute to the visual deficits characteristic of CDD. However, the functional relevance of cortical GABAergic circuits abnormalities in these mutant mice has not been investigated so far. Here we examined GABAergic circuits in the perirhinal cortex (PRC) of Cdkl5 KO mice, where we previously observed impaired long-term potentiation (LTP) associated with deficits in novel object recognition (NOR) memory. We found a higher number of GABAergic (VGAT)-immunopositive terminals in the PRC of Cdkl5 KO compared to wild-type mice, suggesting that increased inhibitory transmission might contribute to LTP impairment. Interestingly, while exposure of PRC slices to the GABAA receptor antagonist picrotoxin had no positive effects on LTP in Cdkl5 KO mice, the selective GABAB receptor antagonist CGP55845 restored LTP magnitude, suggesting that exaggerated GABAB receptor-mediated inhibition contributes to LTP impairment in mutants. Moreover, acute in vivo treatment with CGP55845 increased the number of PSD95 positive puncta as well as density and maturation of dendritic spines in PRC, and restored NOR memory in Cdkl5 KO mice. The present data show the efficacy of limiting excessive GABAB receptor-mediated signaling in improving synaptic plasticity and cognition in CDD mice.
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Affiliation(s)
- Laura Gennaccaro
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Claudia Fuchs
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Manuela Loi
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Vincenzo Roncacè
- Department for Life Quality Studies, University of Bologna, Bologna, Italy
| | - Stefania Trazzi
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Yassine Ait-Bali
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Giuseppe Galvani
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | | | - Giorgio Medici
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Marianna Tassinari
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Elisa Ren
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy
| | - Roberto Rimondini
- Department of Medical and Clinical Sciences, University of Bologna, Bologna, Italy
| | - Maurizio Giustetto
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Giorgio Aicardi
- Department for Life Quality Studies, University of Bologna, Bologna, Italy.
| | - Elisabetta Ciani
- Department of Biomedical and Neuromotor Science, University of Bologna, Bologna, Italy.
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36
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Terzic B, Cui Y, Edmondson AC, Tang S, Sarmiento N, Zaitseva D, Marsh ED, Coulter DA, Zhou Z. X-linked cellular mosaicism underlies age-dependent occurrence of seizure-like events in mouse models of CDKL5 deficiency disorder. Neurobiol Dis 2021; 148:105176. [PMID: 33197557 PMCID: PMC7856307 DOI: 10.1016/j.nbd.2020.105176] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/08/2020] [Indexed: 11/29/2022] Open
Abstract
CDKL5 deficiency disorder (CDD) is an infantile, epileptic encephalopathy presenting with early-onset seizures, intellectual disability, motor impairment, and autistic features. The disorder has been linked to mutations in the X-linked CDKL5, and mouse models of the disease recapitulate several aspects of CDD symptomology, including learning and memory impairments, motor deficits, and autistic-like features. Although early-onset epilepsy is one of the hallmark features of CDD, evidence of spontaneous seizure activity has only recently been described in Cdkl5-deficient heterozygous female mice, but the etiology, prevalence, and sex-specificity of this phenotype remain unknown. Here, we report the first observation of disturbance-associated seizure-like events in heterozygous female mice across two independent mouse models of CDD: Cdkl5 knockout mice and CDKL5 R59X knock-in mice. We find that both the prevalence and severity of this phenotype increase with aging, with a median onset around 28 weeks of age. Similar seizure-like events are not observed in hemizygous knockout male or homozygous knockout female littermates, suggesting that X-linked cellular mosaicism is a driving factor underlying these seizure-like events. Together, these findings not only contribute to our understanding of the effects of CDKL5 loss on seizure susceptibility, but also document a novel, pre-clinical phenotype for future therapeutic investigation.
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Affiliation(s)
- Barbara Terzic
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Yue Cui
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Andrew C Edmondson
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Sheng Tang
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Child Neurology and CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nicolas Sarmiento
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Daria Zaitseva
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Eric D Marsh
- Departments of Neuroscience, Neurology, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Child Neurology and CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Douglas A Coulter
- Departments of Neuroscience, Neurology, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Division of Child Neurology and CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Zhaolan Zhou
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.
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37
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MacKay CI, Wong K, Demarest ST, Benke TA, Downs J, Leonard H. Exploring genotype-phenotype relationships in the CDKL5 deficiency disorder using an international dataset. Clin Genet 2020; 99:157-165. [PMID: 33047306 DOI: 10.1111/cge.13862] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/20/2020] [Accepted: 10/09/2020] [Indexed: 12/24/2022]
Abstract
Characterized by early-onset seizures, global developmental delay and severe motor deficits, CDKL5 deficiency disorder is caused by pathogenic variants in the cyclin-dependent kinase-like 5 gene. Previous efforts to investigate genotype-phenotype relationships have been limited due to small numbers of recurrent mutations and small cohort sizes. Using data from the International CDKL5 Disorder Database we examined genotype-phenotype relationships for 13 recurrent CDKL5 variants and the previously analyzed historic variant groupings. We have applied the CDKL5 Developmental Score (CDS) and an adapted version of the CDKL5 Clinical Severity Assessment (CCSA), to grade the severity of phenotype and developmental outcomes for 285 individuals with CDKL5 variants. Comparisons of adapted CCSA and CDS between recurrent variants and variant groups were performed using multiple linear regression adjusting for age and sex. Individuals with the missense variant, p.Arg178Trp, had the highest mean adapted CCSA and lowest mean developmental scores. Other variants producing severe phenotypes included p.Arg559* and p.Arg178Gln. Variants producing milder phenotypes included p.Arg134*, p.Arg550*, and p.Glu55Argfs*20. There are observed differences in phenotype severity and developmental outcomes for individuals with different CDKL5 variants. However, the historic variant groupings did not seem to reflect differences in phenotype severity or developmental outcomes as clearly as analyzed by individual variants.
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Affiliation(s)
- Conor I MacKay
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Kingsley Wong
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Scott T Demarest
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics and Neurology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Tim A Benke
- Children's Hospital Colorado, Aurora, Colorado, USA.,Departments of Pediatrics, Pharmacology, Neurology and Otolaryngology, University of Colorado at Denver, Aurora, Colorado, USA
| | - Jenny Downs
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
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38
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Cutri-French C, Armstrong D, Saby J, Gorman C, Lane J, Fu C, Peters SU, Percy A, Neul JL, Marsh ED. Comparison of Core Features in Four Developmental Encephalopathies in the Rett Natural History Study. Ann Neurol 2020; 88:396-406. [PMID: 32472944 DOI: 10.1002/ana.25797] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Rett syndrome, CDKL5-deficiency disorder, FOXG1 disorder, and MECP2 duplication disorder are developmental encephalopathies with shared and distinct features. Although they are historically linked, no direct comparison has been performed. The first head-to-head comparison of clinical features in these conditions is presented. METHODS Comprehensive clinical information was collected from 793 individuals enrolled in the Rett and Rett-Related Disorders Natural History Study. Clinical features including clinical severity, regression, and seizures were cross-sectionally compared between diagnoses to test the hypothesis that these are 4 distinct disorders. RESULTS Distinct patterns of clinical severity, seizure onset age, and regression were present. Individuals with CDKL5-deficency disorder were the most severely affected and had the youngest age at seizure onset (2 months), whereas children with MECP2 duplication syndrome had the oldest median age at seizure onset (64 months) and lowest severity scores. Rett syndrome and FOGX1 were intermediate in both features. Smaller head circumference correlates with increased severity in all disorders and earlier age at seizure onset in MECP2 duplication syndrome. Developmental regression occurred in all Rett syndrome participants (median = 18 months) but only 23 to 34% of the other disorders. Seizure incidence prior to the baseline visit was highest for CDKL5 deficiency disorder (96.2%) and lowest for Rett syndrome (47.5%). Other clinical features including seizure types and frequency differed among groups. INTERPRETATION Although these developmental encephalopathies share many clinical features, clear differences in severity, regression, and seizures warrant considering them as unique disorders. These results will aid in the development of disease-specific severity scales, precise therapeutics, and future clinical trials. ANN NEUROL 2020;88:396-406.
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Affiliation(s)
- Clare Cutri-French
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dallas Armstrong
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joni Saby
- Division of Radiology Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Casey Gorman
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jane Lane
- Department of Pediatrics, Civitan International Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cary Fu
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarika U Peters
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan Percy
- Department of Pediatrics, Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey L Neul
- Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric D Marsh
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Child Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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39
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Fu C, Armstrong D, Marsh E, Lieberman D, Motil K, Witt R, Standridge S, Nues P, Lane J, Dinkel T, Coenraads M, von Hehn J, Jones M, Hale K, Suter B, Glaze D, Neul J, Percy A, Benke T. Consensus guidelines on managing Rett syndrome across the lifespan. BMJ Paediatr Open 2020; 4:e000717. [PMID: 32984552 PMCID: PMC7488790 DOI: 10.1136/bmjpo-2020-000717] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/19/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Rett syndrome (RTT) is a severe neurodevelopmental disorder with complex medical comorbidities extending beyond the nervous system requiring the attention of health professionals. There is no peer-reviewed, consensus-based therapeutic guidance to care in RTT. The objective was to provide consensus on guidance of best practice for addressing these concerns. METHODS Informed by the literature and using a modified Delphi approach, a consensus process was used to develop guidance for care in RTT by health professionals. RESULTS Typical RTT presents early in childhood in a clinically recognisable fashion. Multisystem comorbidities evolve throughout the lifespan requiring coordination of care between primary care and often multiple subspecialty providers. To assist health professionals and families in seeking best practice, a checklist and detailed references for guidance were developed by consensus. CONCLUSIONS The overall multisystem issues of RTT require primary care providers and other health professionals to manage complex medical comorbidities within the context of the whole individual and family. Given the median life expectancy well into the sixth decade, guidance is provided to health professionals to achieve current best possible outcomes for these special-needs individuals.
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Affiliation(s)
- Cary Fu
- Pediatrics and Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dallas Armstrong
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Marsh
- Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lieberman
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen Motil
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Children's Nutrition Research Center, USDA ARS, Houston, Texas, USA
| | - Rochelle Witt
- Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shannon Standridge
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paige Nues
- International Rett Syndrome Foundation, Cincinnati, Ohio, USA
| | - Jane Lane
- Civitan International Research Center, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Tristen Dinkel
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Jana von Hehn
- Rett Syndrome Research Trust, New York, New York, USA
| | - Mary Jones
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Katie Hale
- Pediatric Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Bernhard Suter
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel Glaze
- Pediatrics and Neurology, Baylor College of Medicine, Houston, Texas, USA.,Neurology, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey Neul
- Vanderbilt Kennedy Center, Nashville, Tennessee, USA.,Pediatrics, Pharmacology, and Special Education, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alan Percy
- Pediatrics, Neurology, Neurobiology, Genetics, and Psychology, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy Benke
- Neurology, Children's Hospital Colorado, Aurora, Colorado, USA.,Pediatrics, Pharmacology, Neurology, Otolaryngology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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40
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Kadam SD, Sullivan BJ, Goyal A, Blue ME, Smith-Hicks C. Rett Syndrome and CDKL5 Deficiency Disorder: From Bench to Clinic. Int J Mol Sci 2019; 20:ijms20205098. [PMID: 31618813 PMCID: PMC6834180 DOI: 10.3390/ijms20205098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 12/18/2022] Open
Abstract
Rett syndrome (RTT) and CDKL5 deficiency disorder (CDD) are two rare X-linked developmental brain disorders with overlapping but distinct phenotypic features. This review examines the impact of loss of methyl-CpG-binding protein 2 (MeCP2) and cyclin-dependent kinase-like 5 (CDKL5) on clinical phenotype, deficits in synaptic- and circuit-homeostatic mechanisms, seizures, and sleep. In particular, we compare the overlapping and contrasting features between RTT and CDD in clinic and in preclinical studies. Finally, we discuss lessons learned from recent clinical trials while reviewing the findings from pre-clinical studies.
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Affiliation(s)
- Shilpa D Kadam
- The Hugo Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Brennan J Sullivan
- The Hugo Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA.
| | - Archita Goyal
- The Hugo Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA.
| | - Mary E Blue
- The Hugo Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Constance Smith-Hicks
- The Hugo Moser Research Institute at Kennedy Krieger, Baltimore, MD 21205, USA.
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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